1. FALL, 2010

2.  Science of the establishment and maintenance of health  Contributes to psychological and physiological well-being  Promotes comfort, improves self- image and decreases infection and disease

3.  Personal preferences-normal routine-assistive devices needed  Culture and religion or spirituality  Economic status or living environment  Developmental level  Knowledge level  Allergies

4.  Bathing/Hygiene  Dressing/Grooming  Toileting  Pain?  Limited mobility?  Sensory deficits?  Cognitive impairment?  Emotional disturbances?

5.  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

6.  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

7.  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?

8.  Protective Barrier  Regulates Body Temperature  Secretes Sebum  Excretes Sweat  Transmits sensations  Facilitates absorption of Vitamin D

9.  Health Status  Dampness  Dehydration  Insufficient circulation  Nutritional status  Skin diseases  Jaundice (itchy and dry skin)  Immobility Nursing Diagnosis: Risk for impaired skin integrity

10.  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

11.  Pallor  Erythema  Jaundice  Cyanosis  Pruritis  Dry skin  Maceration  Excoriation  Abrasion  Pressure Ulcers  Acne

12.  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

13.  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

14.  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

15.  Foot and Nail Care OPPORTUNITY FOR  Corns  Calluses  Tinea pedis  Ingrown toenail  Foot odor  Plantar wart  Pressure ulcers  Color, drainage, edema, cracks, capillary refill?

17.  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?

18.  http://www.youtube.com/watch?v=hYXYcOH T6aE http://www.youtube.com/watch?v=hYXYcOH T6aE