Presentation on theme: "FALL, 2010. Science of the establishment and maintenance of health Contributes to psychological and physiological well-being Promotes comfort, improves."— Presentation transcript:
Completely independent 0 Requires use of assistive device 1 Requires help from 1 person 2 Requires help from 1 person and equipment 3 Totally dependent 4
Bathing/Hygiene Self-Care Deficit Dressing/Grooming Self-Care Deficit Toileting Self-Care Deficit Total Self-Care Deficit RELATED TO: (Examples) Decreased or lack of motivation Weakness and/or fatigue Impaired transfer ability Perceptual or cognitive ability
Instruct UAP regarding: Patient’s limitations and restrictions Use of assistive devices Specific safety precautions to follow Maintenance of tubes and bandages Required observations during bathing Need to collect a specimen?
Protective Barrier Regulates Body Temperature Secretes Sebum Excretes Sweat Transmits sensations Facilitates absorption of Vitamin D
Health Status Dampness Dehydration Insufficient circulation Nutritional status Skin diseases Jaundice (itchy and dry skin) Immobility Nursing Diagnosis: Risk for impaired skin integrity
Developmental Stage Infants Fragile, easily injured Children Need adults to provide or supervise Adolescents Oily skin/acne Older adult Thinner, more fragile skin Drier, scaly, itchy skin Impaired temperature regulation Hair and nails grow more slowly
BATHING Removes perspiration and bacteria, increases circulation, stimulates depth of respirations, provides sensory input, strengthens nurse-patient relationship, promotes relaxation and comfort, provides opportunity for assessment
Cleaning Baths OPPORTUNIY FOR Shower Tub Self/Help Partial Bed Bath Assisted Bed Bath Complete Bed Bath Therapeutic Baths Sitz Soaks Cool or tepid water baths
Oral Care-Halitosis, Dental caries, Gingivitis, Periodontal disease, Stomatitis, Glossitis, Cheilosis, Oral Malignancies Hair Care-Dandruff, Pediculosis, Alopecia Eye, Ear and Nose Care Perineal Care Unconscious clients Dementia clients **See page 451-452 Wilkinson and Van Leuven text for more details
Foot and Nail Care OPPORTUNITY FOR Corns Calluses Tinea pedis Ingrown toenail Foot odor Plantar wart Pressure ulcers Color, drainage, edema, cracks, capillary refill?
Room temperature comfortable? Siderails up as indicated? Bed position? Bed wheels locked? Bed linens clean and free of wrinkles? Patient’s call device within reach? Overbed table clean and uncluttered? Uncluttered walking space? Unpleasant odors? What else may I do for you?