1. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Chapter 39 Hygiene

2. 2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Scientific Knowledge Base Physical hygiene is necessary for comfort, safety, and well-being. Ill patients require assistance with personal hygiene. Several factors influence a patient’s hygiene practices, such as culture and age. Good hygiene techniques promote normal structure and function of tissues. Apply knowledge of pathophysiology to provide preventive hygiene care.

3. 3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study  Mrs. Winkler is a 58-year-old white woman admitted recently to an assisted-living nursing facility. She has a medical history of multiple sclerosis (MS) and diabetes mellitus plus a family history of coronary artery disease.  Mrs. Winkler uses a wheelchair for mobility. She has recently become weaker (in both upper and lower extremities), is unable to push the chair herself, and requires assistance in transferring to and from the chair.

4. 4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. The Skin  Functions include  Protection, secretion, excretion, temperature regulation, and sensation  Two layers  Epidermis: shields underlying tissue  Dermis: contains bundles of collagen, nerve fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles  Subcutaneous: tissue lies just beneath the skin; contains blood vessels, nerves, lymph, and loose connective tissue filled with fat cells

5. 5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. The Feet, Hands, and Nails  Feet, hands, and nails require special attention to prevent infection.  The hand in contrast to the foot is used for manipulation rather than for support.  The condition of a patient’s hands and feet influences his or her ability to perform hygiene care.  The normal nail is transparent, smooth, and convex, with a pink nail bed and a white tip.

6. 6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. The Oral Cavity  Cavity is lined with mucous membranes.  Normal oral mucosa is light pink, soft, moist, smooth, and without lesions.  Medications, exposure to radiation, and mouth breathing can impair salivary secretion.  Xerostomia—dry mouth  Gingivitis—inflammation of the gums  Dental caries—tooth decay

7. 7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Jamie Johnson is a 20-year-old nursing student assigned to the nursing facility. She is single and works part-time in a skilled nursing facility near her home. Jamie knows how important it is for patients to feel comfortable and to have their basic needs met.  To provide basic hygiene, Jamie needs to learn about what is important for Mrs. Winkler’s comfort. When hygiene needs are not fulfilled, patients experience complications such as oral lesions and infections.

8. 8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Hair  Growth, distribution, and pattern indicate general health status.  Hormonal changes, nutrition, emotional stress, physical stress, aging, infection, and other illnesses can affect the hair.  Sun, chemicals, hair products, permanents, and straightening and coloring agents can also affect the hair.

9. 9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Eyes, Ears, and Nose  When hygiene care is provided, the eyes, ears, and nose require careful attention.  Clean the sensitive sensory tissues in a way that prevents injury and discomfort for a patient, such as by taking care to not get soap in his or her eyes.  The sense of smell is an important aid to appetite.

10. 10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Jamie needs to review the effect of dependency on the patient’s self-esteem and to review ways to give patients opportunities to maintain self-care needs. At an optimal level of functioning with assistance, Mrs. Winkler is at risk for potential self-care deficits, impaired skin integrity, impaired oral mucosa, and altered health maintenance.  During hygiene care, Jamie interacts with Mrs. Winkler to assess her readiness to learn and to teach health promotion practices.

11. 11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Knowledge Base  Factors influence a patient’s personal hygiene.  Use communication skills to promote the therapeutic relationship.  Hygiene care is never routine.  During hygiene, assess:  Emotional status  Health promotion practices  Health care education needs

12. 12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Factors Influencing Hygiene Social patterns Ethnic, social, and family influences on hygiene patterns Personal preferences Dictate hygiene practices Body image A person’s subjective concept of his or her body appearance Socioeconomic status Influences the type and extent of hygiene practices used

13. 13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Factors Influencing Hygiene (cont’d) Health beliefs and motivation Motivation is the key factor in hygiene. Cultural variables People from diverse cultures practice different hygiene rituals. Developmental stage Affects the patient’s ability to perform hygiene care Physical condition May lack physical energy and dexterity to perform self-care

14. 14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Factors Influencing Hygiene (cont’d)  Developmental stage  Skin (sensitive neonate skin, active glands in puberty, thinning and drying with age)  Feet and nails (dry skin, systemic disease footwear problems, chronic foot problems)  Mouth Teeth (teething, caries, gum disease, edentulous)  Hair (shaving, puberty, aging)  Eyes, ears, nose

15. 15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Critical Thinking Integrate nursing knowledge. Consider developmental and cultural influences. Think creatively. Be nonjudgmental and confident. Draw on your own experiences. Rely on professional standards.

16. 16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 1. You are caring for a non–English-speaking male patient. When preparing to assist him with personal hygiene, you should A. Use soap and water on all types of skin. B. Ensure that culture and ethnicity influence hygiene practices. C. Shave facial hair to make the patient more comfortable. D. Know that all patients need to be bathed daily.

17. 17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Before entering Mrs. Winkler’s room, Jamie reviews knowledge about the effects of chronic illness on body image and independence, principles of communication and the pathophysiology for MS, diabetes, and oral lesions.  Previous clinical experience has taught Jamie that patients need to have an opportunity to determine how nurses implement nursing care.

18. 18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Assessment  Explore the patient’s viewpoint.  Assess:  Patients at risk for hygiene problems Self-Care AbilitySkinFeet and Nails Oral cavityHair and hair care Eyes, ears, and nose Use of sensory aids Hygiene care practices Cultural influences

19. 19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Assessment

20. 20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Jamie learns that Mrs. Winkler likes to have her face and hands washed first and then her teeth brushed before breakfast. But then, she tells Jamie that it is really not important.  Mrs. Winkler says, “I am not going to have breakfast today because my mouth is sore. I took my dentures out yesterday. They hurt my mouth too much. I guess I just can’t wear them anymore.” Jamie determines that assisting Mrs. Winkler with oral care is a priority.

21. 21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Diagnosis  Common diagnoses associated with hygiene:  Activity intolerance  Bathing self-care deficit  Dressing self-care deficit  Impaired physical mobility  Impaired oral mucous membrane  Ineffective health maintenance  Risk for infection  Use the patients’ actual alteration or the alteration for which they are at risk.

22. 22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Mrs. Winkler states that she wants to be able to wear her teeth and to feel clean.  Mrs. Winkler reports mouth pain and sores.  Jamie’s examination reveals reddened oral mucosa, red sores and patchy white lesions, a thick coating on the gums and tongue, and some bleeding from swollen tissues.  Mrs. Winkler states that she has trouble holding her arms above her waist and trouble holding small things like her brush because her muscles are so weak.

23. 23Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Planning  Goals and outcomes  Partner with the patient and family  Measurable, achievable, individualized  Set priorities based on assistance required, extent of problems, nature of diagnoses  Teamwork and collaboration  Health care team members  Family  Community agencies

24. 24Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Goals:  Knowledge: illness care Mrs. Winkler will verbalize preventive and routine oral and denture care by the time of discharge.  Oral hygiene Mrs. Winkler will have return of intact oral mucosa within 1 week.

25. 25Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation Use caring to reduce anxiety, promote comfort. Administer meds for symptoms before hygiene. Be alert for patient’s anxiety or fear. Assist and prepare patients to perform hygiene as independently as possible. Teach techniques and signs of problems. Inform patients about community resources.

26. 26Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation (cont’d)  Health promotion  Make instructions relevant.  Adapt instruction to patient’s facilities and resources.  Teach the patient ways to avoid injury.  Reinforce infection control practices.  Acute, restorative, and continuing care  Hygiene measures vary by patient needs and health care setting.

27. 27Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation (cont’d)  Consider normal grooming routines, and individualize care.  Bathing and skin care  Therapeutic: sitz, medicated  Complete bed bath, shower  Partial bed bath Bag baths Perineal care  Back rub  Foot and nail care

28. 28Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Bath Guidelines Provide privacy. Maintain safety. Maintain warmth. Promote independence. Anticipate needs.

29. 29Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation  Oral hygiene  Brushing removes particles, plaque, and bacteria; massages the gums; and relieves unpleasant odors and tastes.  Flossing removes tartar at the gum line.  Rinsing removes particles and excess toothpaste.  Patients with special needs: diabetes, artificial airways, unconscious, chemotherapy

30. 30Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Care of Dentures

31. 31Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation  Hair and scalp care  Brushing and combing Distributes oil Prevents tangling, as does braiding Obtain permission before braiding or cutting. Procedures for head lice  Shampooing  Shaving  Mustache and beard care

32. 32Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Shampooing Hair of Patient Who Is Bed-Bound

33. 33Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Shaving

34. 34Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 2. A young girl with long hair is experiencing a problem with matting. The most appropriate action to take would be A. Cutting the matted hair away. B. Braiding the hair to reduce tangles. C. Using a grease-type product to tame the hair. D. Keeping the hair oil free by applying powder every morning.

35. 35Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation  Care of the eyes, ears, and nose:  Basic eye care  Eyeglasses  Contact lenses  Artificial eyes  Ear care  Hearing aid care  Nasal care

36. 36Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Removal of a Prosthetic Eye

37. 37Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Hearing Aids: In the Canal

38. 38Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Hearing Aids: In the Ear

39. 39Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Hearing Aids: Behind the Ear

40. 40Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation  Patient’s room environment  Maintaining comfort: temperature, noise, lighting, ventilation, odors  Beds Features: raising, adjusting, side rails Clean, comfortable, and safe  Bed making Occupied Unoccupied

41. 41Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Room Equipment

42. 42Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Foot Boots

43. 43Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Communication

44. 44Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Linen Care

45. 45Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Surgical or Recovery Bed

46. 46Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  What interventions are appropriate for restoration of oral health?  What is the rationale supporting each intervention?  Example intervention: Remove, clean, and do not replace dentures except for meals (if desired).  Rationale: This promotes healing during cases of mild to moderate stomatitis.

47. 47Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Evaluation  Evaluate during and after each intervention.  Observe for changes in patient’s behavior.  Consider the patient’s perspective.  Often it takes time, repeated measures, and a combination of interventions for improvement.  Expected outcomes met?  Patient’s expectations met?  Ask questions to determine appropriate changes to interventions.

48. 48Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Jamie asks Mrs. Winkler about reporting of symptoms.  Mrs. Winkler states she now knows that her oral discomfort and sores are related to how she cares for her dentures, and that she will report these symptoms if they recur.  Achievement of outcome is shown because Mrs. Winkler is able to participate in prevention of oral problems by reporting symptoms indicating a problem.

49. 49Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Safety Guidelines  Communicate clearly with team members.  Incorporate patient’s priorities.  Move from the cleanest to less clean areas.  Use clean gloves for contact with nonintact skin, mucous membranes, secretions, excretions, or blood.  Test the temperature of water or solutions.  Use principles of body mechanics and safe patient handling.  Be sensitive to the invasion of privacy.