Hygiene

Hygiene Schedule In Acute Care

Early Morning or A.M. Care

Morning or After Breakfast Care

Afternoon Care

HS Care

Skin Care Assessment- Inspection/ Palpation

Determine need for hygiene Observe color (Table 32-9,pg 689),

texture, thickness, turgor, temperature, hydration

Skin Lesions (Box 32-8, pg.692) Recognize common skin problems

(Table 38-2, pg.1009)

Skin Care Nursing Diagnoses

Impaired Skin IntegrityAltered Peripheral Tissue PerfusionBathing/Hygiene Self-Care Deficit

Planning Goals- Cleanliness, stimulation of

circulation, range of motion, improved self-esteem, and reduction of body odors

Skin Care Implementation

Bathing

Perineal Care

Back Rubs

Perineal Care Assessment- Listen for problems, smell,

know at risk clients

Indications for Care- Urinary or fecal incontinence, excessive secretions, skin irritation, clients at risk because of indwelling catheters, perineal surgery, or childbirth

Goal of Care- Comfort, promote healing, prevent or eliminate odor or infection

Back Rub Goal- Promote relaxation and

stimulate circulation

Cautions Contraindications Never massage arms and legs

Nail and Foot Care Assessment

Circulation Abnormalities or problems (Table 38-3,pg

1011) Gait Pulses Nails Special considerations- diabetic clients

Nail and Foot Care Nursing Diagnoses

Pain Impaired Skin Integrity Self-Care Deficit

Plan and Implementation Foot and nail care given during bath

Diabetic Client Foot Care Need meticulous care daily

Do not cut corns or calluses or use commercial removers

Always dry well between toes, use powder when necessary

Avoid doing or wearing anything that impairs circulation

Wear clean socks daily Well fitting shoes, no bare feet

Hair Care Assessment

Examine condition of hair and scalp Determine ability to do self care Problems/ abnormalities (Table 38-4, pg.1012)

Dandruff Ticks Pediculosis Capitis Pediculosis Corporis Pediculosis Pubis Alopecia

Hair Care Diagnosis

Dressing/ Self-Care Deficits Impaired Skin Integrity Pain Body Image Disturbance

Planning and Implementation Brushing and combing Shampooing Shaving Mustache and beard care

Eye Care Assessment

Scaliness underlying eyebrow Eyelids- edema, lesions, secretions Eyelashes- styes, irritating lashes

(entropian,ectropian) Lacrimal Sac- Sclera or conjunctiva Pupil- Size, shape, light response Eye movement Contacts, eyeglasses, or artificial eye

Eye Care Implementation

Basic care Unconscious client Eyeglasses Contact lenses Artificial eyes

Ear Care Assessment

Exam external ear

Implementation Clean during bath Cautions Assess gross hearing

Nose Care Assessment

Exam nasal mucosa Position of nasal septum Difficulty breathing from nose

Implementation Nasal secretions Suctioning

Client’s room Maintain comfortable room environment

Temperature, ventilation, noises, lighting, controlling stimuli Room equipment

Overbed table, night stand, chairs, bed, lights, special equip. Common bed positions

Know common bed positions (Table 38-6, page 1054) Room accessories

Water pitcher, glass, tissue, lotion, toothpaste, wash basin, etc Bed-making

Basic principles of asepsis- Keep linen away from uniform, never fan linen, place nothing on the floor, if clean linen touches floor get new linen

Use good body mechanics Be able to make occupied and unoccupied beds (open/closed)

SummaryEvaluation of client’s hygiene is

based on the client’s expression of a sense of comfort, relaxation, well-being, and an understanding of personal hygiene techniques