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Hygiene Chap 24

The skin, functions, factors affecting, age related skin changes, assessment terms

Risk factors for Hygiene Care

Assessment and care of the feet, eyes, ears, and nose and mouth – know procedures for skills related to these areas (Padlet content and lab)

Infection control and hygiene

Katz index of ADL’s (Ch 3- p.45)

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1) Subjective data - history, nail care practices, and their treatments.
2) Objective - inspection, contour and cleanliness, appearance (manicured and trimmed), red or cracks

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1) No real NANDA labels, but things related to nail care.
- Impaired tissue related to ingrown nails
- Risk for infection

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subjective data:
pain or discomfort
how often they clean their feet in the home setting.

objective:
dry/ cracked skin
swelling
pressure ulcers
redness
open wounds

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We cant clip the patient's nails unless we have an order, so we need to file them:
- Soak before filing
- We do not cut or file callused areas
- remove hangnails, clean under the nail with hangwood stick
- We file straight across rounding the corner slightly to prevent scratching. Paying close attention to not file too deeply in the corners to cause ingrown nails

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There are no NOC outcomes that relate specifically to nail care.
1) Demonstrate proper nail care
2) Seek a podiatrist for toenail care
3) Do not neglect self care

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Assessment (nonjudgmental, respectful manner    ->many people are insecure about their skin) 

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Assessment (nonjudgmental, respectful manner    ->many people are insecure about their skin) 

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Subjective Data:
Ask patient about their usual bathing and skin care practices & preferences, as well as:

* Past and current skin problems, & effects on the patient’s life

* Prescription and over-the-counter (OTC) or herbal skin remedies being used

* Allergic skin reactions to food, medications, plants, skin care products, and so on

* History of diseases or other factors known to cause skin problems, including decreased mobility, decreased circulation, incontinence, inadequate nutrition, or deficient knowledge

Objective Data:
Inspect each area of the skin in an orderly, head-to-toe manner, noting
* overall cleanliness, condition, color, texture, turgor, hydration, and temperature.
Observe for
* rashes, lumps, lesions, and cracking.
Look for
* drainage from wounds or around tubes.
Observe for the following changes in skin color:

* Pallor in a light-skinned person may appear as pale skin without underlying pink tones. In a dark-skinned person, observe for an ashen gray or yellow color.

* Erythema is redness of the skin related to vasodilation and inflammation. It is difficult to see in dark-skinned people, so you may discover it by palpating the skin for areas of increased warmth.

* Jaundice:  yellow discoloration of the skin(impaired liver function). Best seen in the sclerae of the eyes.

* Cyanosis: bluish coloring of the skin (caused by dec peripheral circulation or decreased oxygenation of the blood) may be related to cardiac, pulmonary, or peripheral vascular problems.
In dark-skinned patients, you can best see cyanosis by examining the conjunctivae, tongue, buccal mucosa, and palms and soles for a dull dark color.

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The patient can clean and care for their dentures daily.

The patient can self perform oral hygiene as evidenced by proper oral care routine of brushing, flossing, and using mouthwash.

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Impaired Dentition related to the inability to manage mouthcare as evidenced by Inflammation of the gums

Mouth Pain related to mouth lesions as evidenced by bleeding and inflammation of the gums

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risk for infection r/t ingrown toenail AMB pain, redness, and swelling

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Subjective data- History of problems, diseases, or therapies that will affect the hair (chemotherapy). The hair products used, care they take for hair and scalp, patients physical ability to clean hair (impaired mobility)

Objective data- inspect condition and cleanliness or hair. Inspect for lesions, dandruff, pediculosis, and alopecia.

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- Subjective: history of periodontal diseases, do they have dentures, eating habits / hydration levels, tobacco and alcohol use, cavities, oral hygiene patterns

-Objective: dry lips, oral mucosa, lesions or bleeding of the gums, missing or decaying teeth, stomatitis, unusual odors

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Eyes

Assessment

Inspect eyes for redness, lesions, swelling, crusting, excessive tearing, and discharge

Check to see if pt wears glasses or contacts, if so ask questions R/T it (ie when they use them, how bad their vision is without them, how often they wear them, and cleaning protocols)

Diagnosis

Risk for infection r/t improper hand washing and improper lens cleaning

Risk for injury r/t not cleaning contact lenses properly

Planning outcomes

Pt demonstrates proper cleaning of contact lenses

Eyes appear clean and healthy

Intervention

For unconscious pt you would keep the eyes lubricated with saline or artificial tears, eye care should be done every 2-4 hours

Caring for contact lenses and eyeglasses

Eyeglasses need to be cleaned at least once a day

Keep free of infectious microorganisms

Education

Teach cleaning and disinfecting measures to clients as needed

Teaching the importance as to why everything should be kept clean

To always wash your hands before touching the eyes or the lenses

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For Impaired Skin (or Tissue) Integrity—Bathing, Cutaneous Stimulation, Perineal Care, Pressure Management, Skin Surveillance, and Wound Care

For Risk for Impaired Skin Integrity—Add to the above: Bed Rest Care, Circulatory Precautions, Pressure Ulcer Prevention, and Positioning

bathing

back massage

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Individualized goals/outcome statements you might write for a patient with skin problems include the following:

Skin will remain intact and free of secretions.

Skin will remain free of lesions.

Patient will follow a regimen to improve skin dryness.

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retrieve doctors order to remove ingrown toenail.
gently file away rough or sharp edges using a nail file, best to do after a shower or bath.
is clipping toenails, use clean nail clippers designated for patient to prevent contact transmitted infections.
feet should be washed everyday
cleaned and dried especially well in between toes.
use moisturizer  daily, but avoid in between the toes.
nonslip socks should be applied and changed daily after proper foot care.

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Why should you not apply lotion between the toes?

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Why should you not apply lotion between the toes?

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moisture, warm, dark wet environment = risk for infection

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List at least three factors that cause dry mouth.

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List at least three factors that cause dry mouth.

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mouth breathing
medications, radiation
NPO, NGT
smoking, alcohol
Dehydration, oxygen
Seasonal
Oral airways

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Risk for Impaired Skin Integrity.

Impaired Skin Integrity

Problem : Skin integrity
Etiology : r/t chemical injury, moisture, excretions , secretions , developmental age, alteration in metabolism , hormonal change, immunodeficiency , alteration in skin turgor, sensation

Signs or symptoms: redness, bleeding, localized area hot to touch, vascular trauma, radiation agent, arterial puncture

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Outcome:
Oral mucous membranes will remain pink, moist, and intact. Patient demonstrates proper technique for brushing and flossing teeth.

Intervention:
Provide necessary oral hygiene supplies, educate patient on proper oral hygiene, assist with keeping the mouth clean and moist, sideline patient when unconscious to brush teeth.

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- People with diabetes or circulatory issues we should file only.
- Teach client to inspect nails carefully
- Encourage using moisturizer
- Avoid biting nails
- Poor nail care can lead to infection

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Risk for Infection r/t Alteration in skin integrity/broken skin AEB open wounds on patients scalp.

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Assessment: Client function (conscious or unconscious, debilitated patients with NG tube)
Diagnosis: risk for infection. Risk for interfered respirations due to secretions. Risk for skin breakdown related to NG tube.
Outcomes/ Interventions: Remove secretions by gently inserting a moistened cotton-tipped applicator into the nostrils or use suction if needed. Provide special skin care and lubricant where the NG tube touches the nares.

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- Teach the client to avoid food high in sugar as sugar can cause tooth decay
- Instruct and tell the patient how important it is to have dental checkups and cleanings
-Teach the patient about the importance of oral hygiene and how it prevents gum disease and other dental issues

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patient will be able to demonstrate proper hygiene after teachings daily within three days.
teach client how to properly wash feet and clip toenails to avoid further risk of infections.

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Keep hair and scalp clean. Keep hair and scalp free from infections, infestations, and dryness

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Ears

Assessment

Assess for excess cerumen, any drainage, and hearing loss

Healthy ears require limited self care

Diagnosis

Risk for hearing loss r/t excess wax build up

Risk for infection

Risk for rupturing eardrum r/t pushing a cotton swab to far

Intervention

Clean the auricle and remove wax from canal with the tip of a moistened washcloth or disposable wipe, if this doesn't remove the excess wax obtain a prescription for cerumenolytic drops and water irrigation

Make sure to handle and store hearing aid properly

Cleaning and replacement of batteries

Hearing aids should be replaced every 5-10 years

Education

Teach proper care of cleaning the ears

Teaching the importance of good ear care to prevent hearing loss and damage

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Patients should also be encouraged to comb or brush their hair a couple of times a day and wash as needed to prevent build up of oils and dry skin.

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- importance of drying skin
-good hydration,
-apply skin lotion after bath and after wash hands ( no lotion between the toes)
-instructed patient and caregiver on preventing skin tears. In terms of prevention, protective arm sleeves are helpful.
-changing a patient's position
-Avoid scratches, punctures, and other injuries.
- Nutrition
- mobilization to improve circulation

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Apply the shampoo and massage it into the hair. Using the jug, rinse the patient’s hair with water. Apply conditioner, if required by the patient, and rinse the hair again. Check, regularly, the patient is comfortable and can maintain their position.

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Eyes should be cleansed from the inner to outer canthus to avoid dragging debris into the nasolacrimal duct.

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What are important principles while making an occupied bed?

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What are important principles while making an occupied bed?

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Rails up,

Bed lowest position when leaving pt
Hip height when providing care, wide base of support

Don't soil clean linens
Have supplies
Assistance prn
Body mechanics

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What precautions should you take while providing hygiene care?

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What precautions should you take while providing hygiene care?

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Standard precautions @ minimum
Others prn

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What are ways to provide oral care that decrease infection ?

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What are ways to provide oral care that decrease infection ?

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Unconscious
Critically ill
Dependent/Confused
side lying
Assessment
Brushing 2 minutes
Toothette swabs prn
Vaseline/chapstick

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What changes take place in the skin as a person ages?

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What changes take place in the skin as a person ages?

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Wrinkling, thinning, dry, reduced ability to heal - collagen, impaired sweating
With age, both layers of the skin become thinner and more fragile. As collagen and elastin fibers in the dermis deteriorate, the skin becomes wrinkled. Sebaceous and sweat gland activity decreases, causing the skin to become dry, scaly, and itchy, and temperature regulation in hot weather becomes more difficult. As the number and activity of hair follicles and pigment cells (melanocytes) diminish, hair becomes thin, turns gray or white, and grows more slowly. Nails thicken and growth decreases. These changes increase the risk for skin problems.