1. PRINCIPLES OF HYGIENE Michele Archdale

2. Risks of Hospitalisation Functional Decline Iatrogenic Illnesses Cognitive Impairment Mood Disorders Immobility/Gait Disorders Malnutrition Restraints 2

3. FUNCTIONAL DECLINE – older patients “Older patients often experience a loss of independent physical functioning during the course of an acute illness requiring hospitalisation” Patient’s potentially will become dependent in one or more ADLs 3

4. It is our role to assist our clients with achieving optimum health and independence, Assisting with ADL’s is a large part of that process. 4

5. WHAT ARE ADL’S? *ACTIVITIES OF DAILY LIVING * 5

6. ACTIVITIES OF DAILY LIVING Self Care- – - dressing / undressing – - grooming, hygiene, elimination. Mobility- – - sleep patterns – - exercise – - housework – -ability to move around safely – -specific difficulties 6

7. HYGIENE Hygiene needs are individualised depending on the patient’s level of dependence for assistance Level of illness Cultural diversity Normal practices Emotional state

8. PURPOSE OF NURSE PROVIDED HYGIENE Remove microorganisms Do a head to toe physical assessment Increase circulation – Peripheral to central – arms and legs inwards – Return to heart Improve self image Provide comfort

9. HYGIENE includes: Cleansing of patient Communicating with the patient Bedmaking Room straightening Emptying garbage Removal of used supplies, dishes, flowers, newspapers, etc. Assessing patency of and cleansing equipment Placement of necessary supplies

10. Hygiene involves cleansing of the: Skin Mouth Teeth Hair Nails Eyes Ears Nose Perineal Area Feet

11. PRIORITIES OF HYGIENE Depends upon Patient’s general physical condition Individual hygiene requirements Preferences and requests from the patient The number of patients you are caring for Remember that some types of hygiene are necessary for the patient’s wellbeing – even if it may cause some discomfort.

12. SKIN Regulates body temperature First line of defense against harm Antibacterial and antifungal Transmits sensations Signs of problems Redness (erythema) Wet or damp Not intact

13. NURSING ASSESSMENT WHILE BATHING History Relationship Color and condition of skin Pain on movement Level of consciousness Injuries Scars Skin dryness Presence of moles Weight loss or gain

14. NURSING INTERVENTIONS General health important Intact skin – Caution in movement – Don’t overbathe elderly Protein in diet Avoid periods of moisture – Change frequently – Dry carefully – Rinse soap Sun screen important – Especially with certain medications

15. PATIENTS AT RISK FOR SKIN PROBLEMS Altered level of consciousness Altered nutrition Immobility Dehydration Altered sensation Secretions on skin Mechanical devices, casts, restraints Altered venous circulation

16. GENERAL PRINCIPLES Client safety Nurse safety Work in time constraints & be organised Allow privacy and dignity – Only body part being washed is uncovered – Curtain is closed Change water, washcloths, towels, linen as needed Call bell available

17. CONFIDENTIALITY In providing hygiene, may find very personal details Report on “need to know” basis Tell instructor; decide together on what to take further Must break confidentiality if signs of abuse

18. PATIENT PREFERENCES Try to involve patient in care If too ill, we must do all Give control over soap, deodorant, mouthwash, nail length, water temperature Must work within time constraints Be very cautious with delegation of care to others Must carefully assess refusal of bathing; speak to Team Leader.

19. BATH REFUSAL What is real problem? Power issue? Fatigue? Visitors? Assessment Patient continent? Skin care? Level of exertion? Comfort education and negotiation

20. ATTENTION TO BODY IMAGE ISSUES Body image is the meaning that the person attaches to body part Person may have radical changes in body image You may be one of first to see this How nurse responds to body image changes sets tone to last a lifetime

21. SOCIOCULTURAL FACTORS It is common to bathe daily; not all cultures do Economics is an influence Different cultures shave different body parts and hair on head differently Some cultures wear items not to be removed in bath – examples: wigs, headdressings, amulets, turbans, religious medals or shawls Male nurse only or female nurse only may be necessary in some cultures

22. SOCIOCULTURAL FACTORS In some cultures, male relative may not allow male nurse alone with woman patient In some cultures, autonomy of patient is paramount; in others, family makes decisions for care Level of education may influence care Legal and presumptive relationships – Gay and lesbian partners – Teen friends of emancipated minors Nurse accepts all who lovingly participate

23. POVERTY OR HOMELESSNESS Influences hygiene May have body parasites May have unhealed/untreated wounds Dental issues Clotting problems from alcohol Drug entry sites, abscesses

24. KNOWLEDGE LEVEL May need teaching regarding: – Front to back perineal care – Brushing gum line, not just teeth – Special foot care for circulatory problems – Skin inspections by dermatologist

25. Hospital acquired infection Also called iatrogenic Patient illness brought on simply by being in the hospital and being exposed to organisms not found outside the health care setting

26. Hospital acquired infection Hands washed with antiseptic soap and friction Short fingernails; artificial nails now being forbidden Soiled linen kept off uniform Gloves – if client has open or draining wound or is incontinent – if nurse has skin breaks on hands No sharing supplies without proper sanitation

27. SAFETY  Electrical supplies must be checked by engineering department prior to use; and not left near pan of water ◦ hair dryers ◦ electric shavers  Bed raised to working height and lowered when finished  Side rails up for patients requiring  All spilled water immediately wiped  Caution with use of powder  Caution with use of latex

28. SHAVING Shaving reflects level of caring Safety razor not used on certain patients – Those on anticoagulant drugs – Those with liver disease causing clotting disorders – Confused patients – Suicidal patients Use electric razor after engineer check If using hair depilatory, always test area first

29. SAFETY All patients will need attention to water temperature Patients with impaired level of consciousness will need special care – gentle eye care, possibly patching – frequent mouth care – proper positioning – care to bed linen – water temperature

30. PATIENTS RECEIVING CHEMOTHERAPY Special mouth care – nausea – oral thrush or stomatitis Special hair care Rest periods

31. PATIENTS RECEIVING RADIATION THERAPY Do not wash off markings No bath salts No heating pads or hot water bottles

32. UNCONSCIOUS PATIENT Maintain normal range of movement Maintain patient safety Patient lifts with 2 or more staff members Regular mouth care with head to side and semi dry swabs Priority to perineal care and incontinence

33. FATIGUE AS A FACTOR Nurse’s job to monitor patient tolerance – Respiratory response – Heart rate – Can patient tolerate being flat? Do they need to sit upright? – Confusion level – Shower less taxing than bed bath – May be easier on patient to be up in chair than rolled side to side

34. DEVELOPMENTAL LEVEL: NEWBORNS Do not place under running water Do not submerge until umbilical cord drops off Dry carefully, especially the head Dress warmly following a bath – dependent on room temperature.

35. DEVELOPMENTAL LEVEL: YOUNG CHILDREN Children can drown in 2 inches of water; never leave alone during bathing Teach parents about fluoride No milk or juice bottles in bed Wipe off teeth after eating with soft cloth

36. DEVELOPMENTAL ISSUES: CHILDREN Children may have natural parents, stepparents, four sets of grandparents, all involved in care For decision making, some cultures must ask father, some must ask grandmother

37. DEVELOPMENTAL LEVEL: ADOLESCENTS Modesty essential Normal clothes, not gowns Bed pans not acceptable Allow decision making No tampons in the hospital

38. DEVELOPMENTAL LEVEL: OLDER ADULTS Heat insensitivity; can burn easily Foot care Skin very fragile

39. STUDENT NURSE ISSUES Be aware of inappropriate behavior or comments Personal space of patient – Undress, examine, wash and groom stranger – Incontinence can cause discomfort – Sexuality may be an issue Patient really asking “Am I still desirable despite my illness?” Take a break if uncomfortable; tell facilitator, preceptor Attraction? Ask for patient change

40. STUDENT NURSE ISSUES Your safety and well being is our job Care of your back Lifting and bending appropriately Protected against infection transmission Tell facilitator, preceptor if pregnant or immunosuppressed Ask for help (physical and emotional) Learn assessment skills

41. THERAPEUTIC BATHING (not common) Physician ordered; nurse suggestion Water temperature usually 100-115 F Medications are ordered to be put in water Time usually 20 minutes Don’t leave patients alone – Be very clear delegating

42. TYPES OF THERAPEUTIC BATHS Saline – 0.9% NaCl Normal body consistency for wound care and irrigations Pinetarsol bath additive for itching Iodine for antibacterial action (Ask about allergies)

43. SHOWERING PREPARATION Check patient case notes for any mobilization restrictions Organize your supplies first Consider if pain medication is needed first Remember patient dignity/privacy Keep curtains/doors closed Dry carefully – Pat dry Include oral care, shampoo, and shave Don’t ever leave them alone in shower

44. BEDBATH / SPONGEBATH Change linen as needed Do range of motion as needed Do oral care, hair care, and give back rub Leave bed in low position, rails up, and call bell in place. Tidy room. Replace wet linen with fresh Report and chart findings

45. BEDBATH Wash head to toe, front to back, distal to proximal, clean to dirty. Physical assessment as you are washing; must also loosen and secure lines as moving and turning patient Change wash clothes for different areas Change water if cold or soiled or very soapy Some put oil in bath water of elderly Talk and make conversation – relax a potentially difficult situation

46. WHO BATHES PATIENT? More complexly ill, higher level of caregiver – In ICU, registered nurse – In General Wards, nurse – In intensive care nursery, nurse – In nursing home, may be nursing assistant, nurse but nurse is responsible for training and delegating

47. BACK RUB Purpose - Pressure Area Care – Relaxation – Circulation – Pain relief Assess skin integrity on back Assess all bony prominences Always done as part of good nursing care

48. BACK OR BODY MASSAGE Warm lotion first Use continuous strokes Does not include back of calves Ensure privacy is maintained Not too firm

49. PERINEAL CARE Professionalism always Not deferred in cases needing nursing assessment Female – Always clean to dirty (urethra to rectum) – Use absorbent pads for females menstruating (no tampons) – If large breasts, need to dry underneath carefully Male – Assess for circumcision If not, cleanse under foreskin and replace

50. FOOT CARE Soak feet as part of bath Clean toes and toenails Teach as you go Range of motion of legs Feet of diabetic patients and patients with vascular disease are inspected carefully; Never cut toenails of these patients Many facilities have podiatrist visits

51. NAIL & HAND CARE Observe circulation; color, capillary refill time Observe color, sensation, and movement (CSM) Polish removed to observe color and use pulse oximeter Assess for clubbing sign of long term lack of oxygen Assess for rings too tight or too loose

52. MOUTH CARE – ORAL HYGIENE Examine with gloves and light, especially smokers Use only water soluble lubricants Unconscious patient has no gag reflex, position on side for care May have gum hyperplasia (bleeding gums) from medication May have teeth staining from medication Teach about brushing and flossing

53. CARE OF DENTURES Assess for fit If removed, keep in covered cup with water Label cup with patient’s name Keep in bedside table Pad sink when cleaning Use cool water

54. HAIR CARE Culture may influence care – Hmong – do not touch without permission – Muslim and Orthodox Jew – May keep covered, wear wig – Sikh – Does not cut – Different parts of body have hair shaved

55. HAIR CARE Hair is combed daily and shampooed prn Dredlocks & braids not to be undone to shampoo – Patients may use hair oil on these Both wet and dry shampoo available Send to operating room or surgical procedure with clean hair and shaven (see surgeon’s standing orders)

56. EYE CARE Contact lenses usually removed Stored in saline liquid; case labeled Also label and safeguard glasses in drawer Clean inner to outer canthus Patient must be able to blink to protect cornea Never use cotton near eyes Treat each eye separately Eyes considered sterile Care of artificial eye similar to dentures

57. EARS Allow nothing sharp in ears Hearing aids now very small in size – don’t lose! Label case Cerumen (wax) in ears may need softening and removing Speak directly to patient’s face if hard of hearing - deaf

58. ASSESSING TUBES AND LINES Oxygen – stays on during bath, check connections, liters per minute, cleanliness of prongs or mask, water if used, plugged in if concentrator IV lines – use special gown, don’t open lines to change gown, look at IV site, rate and solution Urinary catheter – draining, unkinked, bag below bladder Enteral tubes – in place, running or draining properly, or clamped properly Dressings – Clean and dry, drains properly working Does anything need to be emptied, changed or cleaned? Ensure your patient is not lying on tubing or equipment

59. BEDMAKING Make bed for patient comfort If incontinent, wash, rinse, dry, change linen Use aids to relieve pressure points – heel, elbow protectors – bed frame with trapeze – frame to keep covers off feet – special beds and mattresses Position as ordered

60. NURSE SAFETY IN BEDMAKING Raise bed to working height Face patient Bend knees Conserve steps Don’t lift alone Side rails as ordered Lower bed and place call bell when leaving

61. CHARTING How patient tolerated bath Any unusual findings What was done about findings Comparative progress