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Unit five Mr. Ahmad Ata1 RN,CNS,MSN Lecture Objectives At the end of this lecture the student will able to: 1. 2. 3. 4. 5. 6. Know about hygiene, hygiene measure. Know about common problem of the skin. Describe common kind of hygiene. Ability to identify patients with self care deficit related hygiene. Ability to communicate and interact effectively with patients Commitment to safety and quality 2 Introduction Personal hygiene practices well vary widely among persons. Well people are ordinarily responsible for their own hygiene. In some cases the nurse assist well person through teaching to develop personal habits the person may lack. 3 Definition: Hygiene: is self care by which people attended to such function as bathing, oral care, grooming hair, cleaning fingernails, genital area, ear and eye care. 4 Hygiene involves cleansing of the: Skin Mouth Teeth Hair Nails Eyes Ears Nose Perineal Area Feet 5 Hygiene Cleansing by nurse is part of historical giving of care The more ill patient, the more skill needed in providing the hygiene care. Cleansing skin is first line of defense against organisms 6 Kinds of hygiene may nurses described: 1. Early morning care: Assist patient with toileting. Provide comfort measure to refresh patient to prepare for day. Wash face and hands. Provide mouth care. 2. Morning care: After breakfast, nurse completes morning care: Toileting Oral care Bathing Back massage Hair care, cosmetics Dressing Positioning for comfort Refreshing or changing bed linens Tidying up bedside 7 Kinds of hygiene may nurses described: 3. After noon care: Ensure patient’s comfort after lunch: Offer assistance with toileting, hand washing, oral care Straighten bed linens Help patients with mobility to reposition themselves 4. Hours of sleep care: Before patient retires: Offer assistance with toileting, washing, and oral care Offer a back massage Change any soiled bed linens or clothing Position patient comfortably Ensure that call light and other objects patient requires are within reach 5. As needed care: is provided required by client. 8 Factor influencing individual hygiene: culture. Religion. Environment. Development level. Health status. Personal preferences 9 Etiologies of self care deficit Visual impairment. Activity intolerance or weakness. Pain or discomfort. Mental impairment. Therapeutic procedures. Skeletal impairment. 10 Functional level of the patient may described as following: Total dependent. Partial dependent. Independent. 11 PURPOSE OF NURSE PROVIDED HYGIENE Remove microorganisms Do physical assessment Increase circulation Improve self image Provide comfort 12 Skin: Definition: is the largest organ that cover all surface of the body. The skin contains: Epidermis. Dermis. Subcutaneous layer. 13 14 1) Epidermis 1. Keratinocyte the most important cell in the epidermis become filled with a tough fibrous protien called keratin. They make up more than 90% of the epidermal cells 2. Melanocyte contribute color to the skin and serve to decrease the amount of ultraviolet light that can penetrate into deeper layers of the skin. 15 Cell Types 3. Langerhans cell : it plays limited role in immunological reaction that effect the skin and may serve defense mechanism for the body. 4. Merkel cells - combines with disclike sensory nerve endings to make Merkel’s discs 16 2) Dermis It is some time called true skin , it is composed of a thin papillary and thicker reticular layer. It may exceed 4mm on the soles and palms . At various level in the dermis , there are muscle fibers, sweet gland, hair follicles and many blood vessels. 17 Functions of the skin 1) Protection: A) from micro organism. B) from dehydration. C) from ultraviolet. D) mechanical trauma. E) pain F) heat and cold 18 Functions of the skin 2) Sensation: the widespread of the millions of different somatic sensory receptors that detect stimuli. 3) Excretion by regulating the volume and chemical content of sweat. 4) Vitamin D production . 5) Immunity (langerhan’s cell). 6) Regulation of body temperature. 19 Assessment: Cleanliness. Color. Temperature. Moisture. Sensation. Turgor Texture. 20 NURSING ASSESSMENT WHILE BATHING History Relationship Color and condition of skin Pain on movement Level of consciousness Injuries Scars Skin turgor Nevi Wt loss or gain 21 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 22 Practices related skin care: 1) Bathing: practice that use soap and water to remove sweet, oil, dirt, and microorganism from skin. Type of bathing: 1. Tube bath. 2. Partial bath. 3. Bed bath. 23 1. Tube Bath: For all clients who are independent and there no safly risk. Nurse should encourage clients to take shower independent. Most bath room are equipped with rails and handle to promote client safety. 2. Partial bath: Washing only body area that are directly cause odor ( face, hand, axillae, perineal area). Partial bathing done at sink or with basin at bed side. 24 Perineum: area around the genital and rectum, its required special cleaning technique. When perineal care: After vaginal delivery. Gynecological or rectal surgery. Urine, stool. 25 3. Bed bath: Washing with a basin of water at the bed side. For client who cannot take shower independently. 26 3. Bed bath Wash head to toe, front to back, distal to proximal 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 Use powder in your hand, very sparingly not with respiratory patients or those with allergies 27 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 light in place. Straighten room. Report and chart findings 28 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 29 Purposes of bathing: Provides Cleanse of skin. Acts as skin conditioner. Helping in relaxation patient. Promote circulation. Serve as musculoskeletal exercise. Promote comfort. Improve body image. 30 2) Shaving: To remove unwanted body hair. 3) Oral hygiene: Practice used to clean the mouth includes: Tooth brushes and flossing. Denture care. 4) Hair care: hair grooming, shampooing and identify patient usual hair practice and styling preferences 31 5) Bed making: 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 32 Diagnosis: Self care deficit (bathing, grooming, and dressing) R/T pain. Knowledge deficit R/T lack of experience. Self esteem disturbance R/T body odor. 33 Implementation: Avoid long shape finger nails, jewelry may be irritant skin. Maintain nutrition to prevent skin dryness. Reduce moisturing in the irritant area such as axilla and between toes by apply corn starch. Maintain level of cleanliness. 34 Causes of skin alteration: Thin and obese people. Fluid loss. Excessive perspiration jaundice. Age. Poor circulation. 35 Hair: Hair is composed of column of dead keratinized. Its consists of shaft and root. Hair covers the whole body part but its distribution, color, texture, differ according to: 1. Location. 2. Age . 3. Gender. 36 Hair Hair color is determined by the amount and type of melanin present. Melanocytes become less active with age. Gray hair is a mixture of pigmented and non-pigmented hairs. Red hair results from a a modified type of melanin that contains iron. Alopecia is the term for hair loss. 37 Culture may influence HAIR care: – do not touch without permission Muslim – May keep covered, wear wig Sikh – Does not cut Hmong 38 Importance of hair: Appearance. Prevent heat loss. Protection. Assessment: Alopecia, dandruff, lice, scabies, hirsutism. Diagnosis: Self care deficit grooming R/T activity intolerance. Risk for infection R/T scalp laceration. Implementation: Brushing, shampooing that stimulate circulation and distribute the oil. 39 Nail : Nails made of keratin. Parts of nail: Nail root. Nail body. Nail bed. Clupping fingers: is condition in which the angle between the nail and nail bed is 180 degree may cause by long term lack of oxygen. Koilonychias: is condition of nails which is like spoon shape may be caused by iron deficiency anemia. 40 Parts of Nail 41 Assessment : 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 Cut nails straight across and file smooth; Do not go down into corners Assess for rings too tight or too loose 42 Teeth Each tooth has three parts: 1. Crown: is exposed parts of the tooth which is out side of gum. 2. Root: is embedded in the jaw and covered by bony tissue called cementum. 3. Pulp: is the center of the tooth contains the blood vessels and nerves. Teeth begin to erupt at six month to two year. Deciduous teeth (temporary teeth). Permanent teeth. Adults have 28 – 32 permanent teeth depending on wisdom teeth. 43 Assessment 1. Caries: erode tooth enamel because of accumulation of sugur, bacteria. 2. Tartar: is avisible, hard deposite of plague and dead bactria. 3. Pyorrhea: the teeth are loose and pus is evident when the gums are pressed. 4. Periodontal disease: gums appear spongy and bleeding. 5. Halitosis: bad breathing. 44 Diagnosis: Self care deficit. Altered oral mucosa. Implementation: Good oral hygiene. Brushing and flossing the teeth. Caring of artificial denture. 45 Mouth care Examine with gloves and light, especially smokers Use only water soluble lubricants If feeding tubes present, assess for parotitis Unconscious patient has no gag reflex, position on side for care May have gum hyperplasia from meds May have teeth staining from meds May have accumulated debris in mouth called sordes Teach about brushing and flossing 46 Care of eyes: Clean from inner to outer conthus with wet, warm cotton ball or compress. Use artificial tear solution or normal saline every four hour, if blink reflex is absent. Care for eye glass, contact lens. 47 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 48 Ear and nose: Wash external ear with wash cloth covered finger . Clean nose by having patient blow. If indicated use nasal suction with bulb syringe. Remove crusted secretion around nose and apply moisturing gill. 49 50