Hygiene

FACILITATING HYGIENE

OBJECTIVES (CH. 31)

  • Discuss skin anatomy, physiology, and condition.

  • Identify factors influencing personal hygiene practices.

  • Explain the nursing process as it relates to personal hygiene and skin care.

  • Explain how personal hygiene relates to health and well-being.

  • Discuss delegation of hygiene activities to unlicensed assistive personnel (UAP).

  • Discuss the nurse's role in determining a client's self-care ability.

  • Describe normal and abnormal assessment findings of the skin, feet, nails, mouth, hair, eyes, ears, and nose.

  • State the importance and purpose of bathing.

ANATOMY & PHYSIOLOGY OF SKIN

The Integumentary System

  • Components: Skin, hair, nails, sweat glands, sebaceous glands.

  • Main Functions of the Skin:

    • Protection: Acts as a barrier against infection and environmental damage.

    • Sensation: Houses nerve endings that sense touch, temperature, and pain.

    • Regulation: Helps regulate body temperature and maintains fluid balance.

    • Secretion/Excretion: Removes waste products through sweat and sebum.

    • Vitamin D Formation: Synthesizes vitamin D when exposed to sunlight.

    • Immune Response: Provides a first line of defense in immune function.

  • Layers of Skin:

    • Epidermis: Outer layer; renewed every 3-4 weeks.

    • Dermis: Middle layer; contains connective tissues and organs.

    • Hypodermis (Subcutaneous Layer): Deep layer; insulates and stores nutrients.

The Epidermis

  • Characteristics:

    • Continuously shed; replaced every 3-4 weeks.

    • Serves as a semi-permeable barrier against moisture, chemicals, microbes, and UV light.

    • Protects the body from environmental factors and prevents excessive water loss.

The Dermis

  • Characteristics:

    • Lies beneath the epidermis.

    • Contains connective tissue, nerve endings, sweat/oil glands, immune cells, hair follicles, and blood vessels.

    • Provides flexibility and strength to the skin.

The Hypodermis

  • Characteristics:

    • Composed of fat and connective tissue, providing protection.

    • Functions as an insulator against heat and cold, and stores nutrients.

FACTORS AFFECTING SKIN HEALTH STATUS

  • Dampness: Prolonged moisture can cause skin breakdown.

  • Dehydration: Leads to dry skin and increased susceptibility to injury.

  • Insufficient Circulation: Impairs skin health and overall healing processes.

  • State of Health: Overall health status can impact skin integrity.

  • Skin Diseases: Conditions like jaundice, diaper rash, and dry skin affect hygiene.

IMPORTANCE OF BATHING

Purposes of Bathing

  • Health: Primary goal to remove excess oils, perspiration, and bacteria through mechanical cleansing.

  • Social Interaction: Establishes and maintains social norms and interactions.

  • Pleasure and Relaxation: Enhances emotional wellbeing and physical comfort.

TYPES OF SCHEDULED HYGIENE CARE

  • Routine Hygiene in In-Patient Facility:

    • Early Morning Care: Upon awakening; wash face, hands, and provide mouth care.

    • A.M. Care: After breakfast; includes bathing, toileting, hair, skin care, and bed making.

    • P.M. Care: Afternoon; involves toileting, hand washing, oral care, and preparing for visitors.

    • H.S. Care: Before sleep; includes relaxation activities and preparing the environment for sleep.

    • P.R.N. Care: Hygiene measures as needed; change bed linens and clothes, oral care every 2 hours.

DELEGATING HYGIENE CARE

  • **Assess Prior to Delegating: **

    • Evaluate the client’s limitations and the amount of assistance needed.

    • Instruct unlicensed assistive personnel (UAP) regarding the care of tubes, assistive devices, and observations to be made during hygiene care.

    • Note: The nurse remains ultimately responsible for the care provided.

FACTORS INFLUENCING HYGIENIC PRACTICES

Personal Preferences

  • Different bathing options include:

    • Shower

    • Bed Bath

    • Bath in a Bag

    • Tub Bath

Cultural, Religion, or Spirituality

  • Family beliefs and practices significantly influence hygiene preferences. North American hygiene practices may differ from other cultures.

Economic Status and Living Environment

  • Economic factors can affect access to hygiene supplies and the hygiene environment itself.

Developmental Level

  • Infants and Young Children: May require different hygiene practices and monitoring.

  • Older Children and Adolescents: Hygiene practices are often influenced by social dynamics and peer interactions.

  • Older Adults: Aging can affect skin integrity and hygiene needs.

Knowledge and Cognitive Levels

  • Varying levels of knowledge and understanding of hygiene may lead to different hygiene practices and requirements for assistance.

CASE STUDY

  • A scenario involving an assessment of an 89-year-old patient with limited mobility, dirty living conditions, and sensory challenges; illustrates the need for a thoughtful approach regarding hygiene care and assessment.

NURSING PROCESS FOR SKIN CARE & PERSONAL HYGIENE

Assessment of Skin

  • Bathing presents an optimal opportunity to assess skin condition.

  • Nurses must complete skin assessments but can selectively involve UAP for reporting abnormalities.

Subjective Data Collection

  • Information relating to routine skin care, past skin issues, product use, allergies, and existing skin diseases is gathered.

Objective Data Collection

  • Conduct a thorough head-to-toe inspection of the skin focusing on cleanliness, color, texture, turgor, hydration, temperature, and abnormalities such as rashes or lesions.

Significant Color Changes in Skin Assessment

  • Pallor: Pale appearance often resulting from anemia or low blood flow; identifiable in light-skinned and ashen in darker skin.

  • Erythema: Redness due to inflammation, which may be less visible in darker skin types.

  • Jaundice: Yellow coloration, best observed in the part of the eyes; indicates liver problems.

  • Cyanosis: Bluish coloring due to oxygen deprivation; assess primarily in mucosal areas.

Common Skin Problems

  • Pruritus: Itching, typically leading to irritation or injury due to scratching.

  • Dry Skin: Vulnerable to cracking and itching, increasing injury risk.

  • Maceration: Softening of the skin from prolonged moisture exposure.

  • Excoriation: Damage to superficial skin layers from repeated scratching.

  • Abrasion: Loss of epidermal layers due to friction; often on bony prominences.

  • Pressure Ulcers (Decubitus Ulcers): Injury resulting from pressure and poor circulation.

  • Acne: Inflammation of sebaceous glands common in adolescents.

  • Burns: Damage caused by thermal, chemical, or electrical sources.

BRADEN SCORE - For Predicting Pressure Sore Risk

  • Utilizes sensory perception, moisture, activity, mobility, nutrition, and friction/shear assessment for determining risk levels.

    • Each category has a scoring system:

    • Sensory Perception:

      • 1 (Completely Limited)

      • 2 (Very Limited)

      • 3 (Slightly Limited)

      • 4 (No Impairment)

    • Moisture:

      • 1 (Constantly Moist)

      • 2 (Often Moist)

      • 3 (Occasionally Moist)

      • 4 (Rarely Moist)

    • Activity:

      • 1 (Bedfast)

      • 2 (Chairfast)

      • 3 (Walks Occasionally)

      • 4 (Walks Frequently)

    • Mobility:

      • 1 (Immobile)

      • 2 (Very Limited)

      • 3 (Slightly Limited)

      • 4 (No Limitations)

    • Nutrition:

      • 1 (Very Poor)

      • 2 (Probably Inadequate)

      • 3 (Adequate)

      • 4 (Excellent)

    • A total score of 12 or less indicates high risk for pressure sores.

NURSING PROCESS FOR SKIN CARE & PERSONAL HYGIENE - ORAL CAVITY

Goals of Oral Care

  • Maintain integrity of mucous membranes, teeth, gums, and prevent decay/disease.

  • Education needed on routine check-ups, nutrition, and daily care routines.

Risk Factors for Oral Problems

  • History of periodontal disease, lack of access to dental care, pregnancy, poor nutrition, and affecting medications.

Common Problems of the Mouth

  • Dental Caries (Cavities)

  • Periodontal Disease

  • Halitosis (Bad Breath)

  • Gingivitis

  • Stomatitis

  • Glossitis

  • Cheilosis

  • Oral Malignancies

  • Geographic Tongue

Assessing Oral Cavity

  • Identify routines and needs for assistance in care. Special attention needed for unconscious, dementia, or denture patients.

EYES, EARS, & NOSE

Eyes

  • Assess for redness, discharge, and overall eye health, including contact use and presence of artificial eyes.

  • Cleaning: Clean eyes from inner to outer canthus as needed.

Ears

  • Require minimal routine care; excessive wax may impede hearing.

  • Teach avoidance of rigid objects in ears & proper care of hearing aids.

Nose

  • Generally requires no special care; advise gentle nose blowing for secretions.

HAIR

  • Hair aids in temperature regulation and personal image.

  • Encourage patient participation in hair care and respect cultural differences concerning hair treatment.

NAIL AND FOOT CARE

  • Assess feet for cleanliness, odor, integrity, and color; document usual care routines for the patient.

  • Diabetic Patients: Must be assessed carefully due to potential for complications.

  • Do not cut or trim client’s nails without proper consent.

PERINEAL & VAGINAL CARE

  • Frequent cleaning is crucial in the perineal area to prevent infections, especially in cases of incontinence or drainage; consider cultural preferences.

  • Always wear gloves and wash from front to back.

CATHETER CARE

  • Integrated into daily bathing routine to minimize infection risk; requires special attention around the meatus and during bowel movements.

CLIENT COMFORT MEASURES

  • Maintain privacy during hygiene practices, ensure a warm environment, and utilize proper water temperatures (110-115°F).

  • Massage may be beneficial for circulation unless contraindicated.

COMMON TYPES OF BATHS

  • Assist Bath: Focus on hard-to-reach areas.

  • Partial Bath: Involves only necessary cleaning.

  • Bed Bath: Full bathing in bed.

  • Bag or Packaged Bath, Shower, Tub Bath, Therapeutic Bath

  • Sitz Bath and Disposable Bath Wipes.

BED MAKING

General Principles

  • Ensure efficient and safe processes within hygiene protocols.

  • Remove soiled linens directly into hampers without contact with floors.

Unoccupied Bed Making

  • Assemble necessary linens and avoid shaking or fanning them.

Occupied Bed Making

  • Care must be taken not to entangle tubes or kink lines when handling linens.

  • Utilize sliding or rolling techniques for safety and comfort.

NURSING PROCESS: HYGIENE (ADPIE)

Steps Include:

  • Assess: Gather comprehensive health history and current information.

  • Diagnose: Identify a problem list related to hygiene needs.

  • Plan: Develop goals and action plans for hygiene interventions.

  • Implement: Carry out the planned interventions including a variety of personal hygiene practices.

  • Evaluate: Review and document client outcomes and satisfaction with care.

NURSING DIAGNOSIS NANDA DIAGNOSIS

  • Include:

    • Bathing/Hygiene Self-Care Deficit

    • Impaired Swallowing

    • Impaired Skin Integrity

    • Risk for Infection

    • Knowledge deficit

    • Ineffective Health Maintenance

    • Impaired Physical Mobility

Related Factors

  • Include sensory, mobility, or motivational deficits among others.

PLANNING OUTCOMES/EVALUATION

  • Example outcomes might include clean feeling, intact skin/mucosal membranes, demonstrating correct skin care, and following regimens for improvement.

IMPLEMENTATION STRATEGIES

  • Incorporate bathing, back massages, oral care, hair, and other hygiene activities as appropriate.

EVALUATION CRITERIA

  • Assess the client’s tolerance to procedures, and document participation, mobility, skin conditions, and any abnormalities throughout care processes.

IN SUMMARY

  • Hygiene is critical in nursing practice, ensuring patient cleanliness promotes improved health outcomes and comfort.