Hygiene and Wound care

What factors influence hygiene?

• personal preferences

• culture/religion/spirituality

• economic status/living environment

• developmental level

• knowledge and cognitive levels

Which health status and Care ability affects hygeine?

- Pain (chronic disease)

- Limited Mobility

- Sensory Deficits

- Cognitive Impairments

- Emotional & Mental health status

How should you asses the client: Hygiene?

- Health Hx

- Cognitive Ability

- Physical Function

- Sensory Status

- Mobility

- Pain

- Special needs

- any other factors...

How should you plan for the client: Hygiene?

- routine

- assistance

- equipment

- culture

What are the types of hygiene care that can be provided?

- hourly rounding

- early morning care

- AM (morning) care

- PM (afternoon) care

- HS (hour of sleep) care

What are the functions of the skin?

protection

regulation

sensation

secretion

excretion

vitamin D formation

What affects the skin?

dampness

dehydration

nutritional status

insufficient circulation

skin diseases

jaundice

lifestyle and choices

What are common foot problems?

Corn

Calluses

Tinea Pedis

Ingrown toenail

Foot odor

Plantar Warts

Bunion

What is a corn?

a callus on a toe

what is a callus?

An area of skin with a thickened epidermis

What is tinea pedis?

athlete's foot, fungal infection

What is an ingrown toenail?

occurs when the edge of the toenail grows deeply into the nail groove & penetrates the surrounding tissue

what are plantar warts?

deep, painful papillomas on the soles of the feet

what is a bunion?

structual deformity of the hallux bone

what are risk factors for oral problems?

history

finances

pregnancy

nutrition

medications

oral conditions

what are the common problems of the mouth?

Halitosis

Dental Caries

Gingivitis

Periodontal disease

Stomatitis

Glossitis

Cheilosis

Oral Malignancies

what is halitosis?

bad breath

what are dental caries?

tooth decay, cavities

What is gingivitis?

inflammation of the gums

What is peridontal disease?

Inflammation of soft tissue of bones in teeth/infection of tongue or floor of mouth

what is stomatitis?

inflammation of the oral mucosa

what is glossitis?

inflammation of the tongue (red and swollen), beefy tongue

What is cheilosis?

cracks at the corner of the mouth

what is dandruff?

an excess of keratinized cells shed from the scalp

flaking

What is pediculosis?

lice

What is alopecia?

hair loss

What is included in the eye assessment?

Appearance

Location

Color

Drainage

Pain

Sensitivity

Artificial

what is involved in the ear assessment?

Appearance

Cerumen

Drainage

Location

Sensitivity

Hearing Aids

What is cerumen?

ear wax

what is involved in the assessment of the nose?

Appearance

Location

Patency

Drainage

What things should you check to ensure the safety of a patient in their room?

Scan the room

Equipment

Windows

Temperature

Location, location, location

Mattresses and linen

Bed making

what is the largest organ in the body?

Skin (integumentary system)

what is the body's first line of defense?

skin, protects the internal body from the outside world

what do langerhans cells in the skin do?

sense and kill pathogens that are found on the skin

What is enamel?

first line of defense for the teeth

protects teeth from plaque and pathogens

*coating is the hardest material in the human body

what does regularly washing the skin do?

remove: oil, dead skin cells, and bacteria that causes skin breakdown

who is at higher risk of skin breakdown?

Patients who are prone to incontinence

what are nails made up of?

keratin

what do the nail protect?

the distal ends of the fingers and toes

What does handwashing do?

prevents infection

decreases transmission of germs

can be performed with soap and water/ alcohol based sanitizer

what does health promotion do?

bring awareness to health problems

produce positive behavior changes: prevention and change in beliefs about illness

encourages increased utilization of health services

what essential role does hygiene play?

keeps every client healthy

why might an older client refuse showering/bathing?

- illness,

- pain with mobility

-fear of water

-fear of falling

-fear of temperature of water

-difficulty getting in and out of the shower or bath.

why might a patient who had had a stroke have difficulty performing personal hygiene?

motor function loss

Where might the bariatric client have deep skin folds?

abdominal region

groin

gluteus maximus

under the breast

behind the knees

elbows

ankles

neck

how do the skin folds of bariatric patients affect their hygiene?

they affect their ability to perform proper hygiene care

what might clients with dementia do in terms of bathing?

refuse a bath

causing skin breakdown and odor

what are the benefits of bathing?

washes away dirt, sweat, and bacteria

enhances circulation and client comfort

what are the negatives of "bath basins"?

contaminated with pathogens and could aid in the transfer of hospital pathogens

what does washing the hair with shampoo do?

removes oil and hair care products from hair shft

cleans the skin of the scalp

what should clients who are at a high risk for infection do for their feet?

closely monitor them

do not soak them in water (ex: pedicures)

what do long nails have vs short nails?

greater # of pathogens

why is perineal care performed?

to avoid infections, odor, and irritation in the perineum

what can inadequate oral hygiene cause?

tooth decay = dental caries(cavitites)

peridontal gum disease

what have tooth decay and periodontal gum disease been associated with?

heart disease

cancer

diabetes

What does the Braden Scale evaluate?

sensory perception, moisture, activity, mobility, nutrition, friction and shearing

low # = high risk

how are pressure injuries classified?

stages I-IV

according to amount of skin and tissue damage

how can the nurse decrease pt's skin breakdown?

-regular skin assessments

-observations of environmental factors

-diligent implementation of prevention measures

How are wounds classified?

acute or chronic

based on origin and healing progression

what does holistic skin care adress?

tissue injury prevention

comprehensive plan covering client's: hygiene, nutrition, hydration, and circulation needs

what two main components do the prevention of pressure injuries focus on?

identification of clients at risk

implementation of interventions that are designed to reduce their risk

Surgical site infections may be?

superficial and localized

or extend deep into the tissues

what are major complications of wounds?

infections

dehiscence

evisceration

bleeding/hemorrhage

What is dehiscence?

A separation of the wound incision

what is evisceration?

protrusion of visceral organs through a wound opening

what is the skin's integrity influenced by?

age

immobility

cancer

what are the main functions of the skin?

provide a barrier against injury, infection, UV radiation, and fluctuations in temp changes

what does skin frailty refer to?

at risk, vulnerable skin

factors such as: age, decreased mobility, and malnutrition may exacerbate vulnerability

what is an important part of the nursing role: skin?

maintaining skin integrity

what does wound care include?

-irrigation

-various types of debridement: surgical, enzymatic, and biologic

-dressing changes

what are wound dressings classified as: 2 types?

wet or dry

how should you determine what dressing to use?

dressings depend on:

wound base, healing rate, and amount of exudate

what is used when there is a large amount of drainage?

wound drains

-open or closed

-dependent of surgery and surgeons preference

what are the most often identified risk factors for pressure injury development?

immobility

malnutrition

impaired perfusion

sensory impairment

what relationship do hair braids and pressure injuries have?

tight hair braids next to the scalp can increase the risk of pressure injury development

what are the age related variations that affect skin integrity?

Impaired Mobility

Nutrition

Hydration

Diminished Sensation

Impaired Circulation

Medications

Moisture

Fever

Infection

Lifestyle

what are examples of open wounds?

Abrasions, lacerations, puncture wounds, surgical incisions

what are examples of closed wounds?

Contusion (bruise)

Hematoma

Sprain

what are the different types of wound healing?

regenerative/ epithelial

primary intention healing

secondary intention healing

tertiary intention healing

what is regenerative/epithelial healing?

affects only dermis and epidermis

ex: abrasions, partial thickness wounds

body heals itself

what is primary intention healing?

edges are proximate. (come back together)

ex: surgical incision

edges are sutured back together

what is secondary intention healing?

extensive tissue loss, edge are NOT proximate

heals from the inside out

heal slower, more scar tissue, more prone to infection

what is tertiary intention healing?

granulation tissue are brought together

edges are sutured together at a later date

what are the phases of healing?

-Inflammatory phase

-Proliferative phase

-Maturation phase

what is the inflammatory phase of healing?

-vasoconstriction

-vasodilation

-leukocytosis

-phagocytosis

what is the proliferative phase of healing?

3-24 days

epithelial cells rapidly regenerate and migrate to replace damaged cells

granulation (scar) wound resurfaces (wound to scab). appears as dry, pink tissue

what is the maturation phase of healing?

This phase begins several weeks after injury and is normally completed within 2 years.

The maturation phase is characterized by:

Cellular differentiation continues, scar tissue forms, scar remodeling occurs.

what are the types of wound closures?

Adhesive strips

Sutures

Surgical Staples

Surgical glue

what are the types of advanced wound healing?

surgical

hyperbaric oxygen therapy (HBOT)

platelet-delivered growth factor

What is serous exudate drainage?

watery

very little cellular matter

straw colored fluid

from clean wounds

What is serosanguineous drainage?

Pale, pink, watery; mixture of clear and red fluid

What is purosanguineous exudate?

red tinged pus

What is sanguineous drainage?

Bright red; indicates active bleeding

What is purulent exudate?

Pus: indicates a bacterial infection

what are the complications of wound healing?

Hemorrhage

Infection

Dehiscence

Evisceration

Fistula formation

what causes pressure ulcers?

pressure, friction, shear, moisture

where are pressure ulcers more likely to occur?

-back of head

-shoulders

-greater trochanter

-elbow

-hip

-lower back and buttocks

-heel

-inner knees

what are the intrinsic factors of pressure injuries?

Immobility

Impaired sensation

Stroke

Coma

Poor nutrition

Edema

Aging

Fever

Septicemia

what are the extrinsic factors of pressure injuries?

Friction

Shearing

Moisture

Compression

what are the stages of pressure wounds?

stage 1= erythema, non-blanchable

stage 2= partial thickness skin loss

stage 3= full thickness skin loss

stage 4=full thickness skin and tissue loss

unstageable