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NEEDS: HUMAN THE NURSING PROCESS APPLIED SECTION 6 UNIT 1 -UNIT 2 -UNIT 3 -UNIT 4 -UNIT 5 -UNIT 6 -UNIT 7 -UNIT 8 -UNIT 9 -UNIT 10 -- HYGIENE ORAL HYGIENE NUTRITION IN THE HEALTHCARE SETTING SLEEP COMFORT OXYGENATION INTAKE AND OUTPUT MEASUREMENT URINARY ELIMINATION ELIMINATION NEEDS: URETHRAL CATHETERIZATION ELIMINATION NEEDS: BOWEL ELIMINATION BAKERSFIELD COLLEGE LICENSED VOCATIONAL NURSING PROGRAM 1ST SEMESTER FUNDAMENTALS HUMAN NEEDS THE NURSING PROCESS APPLIED UNIT 1 - HYGIENE INTRODUCTION Good personal hygiene is important in prompting a person s self-esteem and in preventing illness. It is the nurse s responsibility to determine a client s ability to perform self-care measures and to provide hygiene measures according to the client s needs and preferred practices. In addition, it is important that the nurse provide client teaching to maintain or improve the client s hygiene habits. OBJECTIVES Upon completion of this unit, the student will be able to: A. Theory 1. Define selected terms associated with client hygiene. 2. Identify common skin problems and related interventions. 3. Describe the care provided by the nurse for each of the hygienic care schedules. 4. Describe the types of bathing techniques used depending on a client s physical condition. 6. Explain shy if is important for the diabetic client to understand good foot care. 7. Describe the methods used for cleaning and cutting the nails. 8. List common hair and scalp problems and describe related nursing interventions. 9. Explain the rationale for assessing client s hair care practice. 10. Identify two groups of clients for whom it is preferable to use an electric razor for shaving. 11. Describe the special care given for the unconscious client. 12. Discuss how to assess the needs of clients requiring eye, ear, and nose care. 13. Describe how to control the room environment for the client s well-being. 14. Describe the hospital room equipment and accessories. 15. Given a step in the bed making procedure, state the appropriate rationale for that step. ASSIGNMENT A. Read Chapter 39- Potter & Perry Critical Thinking Exercises # 1 & 2 and Review Questions B. Study Guide for Chapter 39 CHAPTER 39 HYGIENE A WIDE VARIETY OF CLIENTS WHO REQUIRE ASSISTANCE WITH PERSONAL HYGIENE OR THOSE WHO MUST LEARN PROPER HYGIENE TECHNIQUES DEPEND ON THE NURSE TO ASSIST THEM. HYGIENE IS THE SCIENCE OF HEALTH I. HYGENIC CARE SCHEDULE IN THE ACUTE CARE SETTING A. EARLY MORNING CARE OR A.M.CARE B. MORNING OR AFTER BREAKFAST CARE C. AFTERNOON CARE D. HS CARE SKIN CARE A. ASSESSMENT BY INSPECTION AND PALPATION B. NURSING DIAGNOSES; EXAMPLES RELATED TO SKIN NANDA APPROVED Impaired skin integrity Altered peripheral tissue perfusion Bathing/hygiene self-care deficit Impaired tissue integrity PLANNING Planned to meet the goals of: Cleanliness, stimulation of circulation, range of motion, improved self esteem, and reduction of body odors IMPLEMENTATION BATHING PERINEAL CARE BACK RUBS III. PERINEAL CARE -- THE CLEANSING OF THE EXTERNAL GENITALIA AND SURROUNDING AREA. MOST CLIENTS ARE CAPABLE OF SELF-CARE A. B. C. IV. ASSESSMENT INDICATIONS FOR CARE Those clients at risk for developing an infection PURPOSES OF PERI-CARE II. C. D. BACK RUB -- PROVIDES HEALING WITH THE LAYING ON OF HANDS. IT PROMOTES RELAXATION, RELIEVES MUSCULAR TENSION AND STIMULATES CIRCULATION A. V. CAUTIONS NAIL AND FOOT CARE -- PREVENTS INFECTION, ODORS, AND INJURY TO TISSUES A. B. C. ASSESSMENT NURSING DIAGNOSIS INCLUDE PAIN, IMPAIRED SKIN INTEGRITY, SELF-CARE DEFICIT PLAN AND IMPLEMENTATION -- THE NURSE CAN PROVIDE FOOT AND NAIL CARE DURING THE BATH 1. 2. 3. 4. 5. 6. D. extremely hard nails require a podiatrist requires soaking inspect feet daily file toenails straight across soak hands apply lotion to feet and hands THE DIABETES MELLITUS CLIENTS 1. do not cut corns or calluses 2. always dry toes well 3. avoid wearing constricting stockings, elastic 4. wear clean socks daily 5. always wear shoes COMMON FOOT AND NAIL PROBLEMS Table 38-3 Callus portion thickened of epidermis consists of mass or horny, keratotic cells; caused by local friction or pressure Corns -- keratosis is caused by friction and pressure from ill-fitting of loose shoes Plantar Warts -- usually appears of sole of foot; caused by papilloma virus Athlete s Foot (Tinea Pedis) -- fungal infection of the foot, can spread to other body parts and freq. recurs; very contagious Ingrown Nails -- toenail or fingernail grows inward into soft tissue around nail; painful Ram s Horn Nails -- unusually long and curved nails; easy to damage nail while cutting E. Paronychia -- inflammation of tissue surrounding nail, occurs after hangnail or other injury; easily infected Foot Odors -- result of excess perspiration promoting microorganism growth VI. HAIR CARE HAIR AND SCALP CARE IS IMPORTANT FOR OVERALL HEALTH AND BODY IMAGE A. B. ASSESSMENT COMMON HAIR AND SCALP PROBLEMS: 1. DANDRUFF scaling of scalp with itching 2. 3. TICKS -- small, grayish brown parasites burrow into skin and suck blood PEDICULOSIS (lice) -- tiny, grayish-white parasite insects that infest mammals a. PEDICULOSIS CAPITIS (head lice) - parasite found on scalp attached to hair strands hard to remove; easily spread b. c. PEDICULOSIS CORPORIS (body lice) - parasites tend to cling to clothing, not easily seen; itches PEDICULOSIS PUBIS (crab lice) parasites found in pubic hair. Crab lice are grayish white with red legs; spread through bed linen, & sexual contact 4. C. ALOPECIA (hair loss) pattern baldness; hair loss, occurs in all races NURSING DIAGNOSIS Dressing/grooming self-deficit, impaired skin integrity, pain, body image disturbance, or potential for infection PLAN AND IMPLEMENTATION -- GOALS FOR CLIENT INCLUDE HAIR AND SCALP WILL BE CLEAN AND HEALTHY. CLIENT WILL ACHIEVE A SENSE OF COMFORT AND SELF-ESTEEM, OR CLIENT WILL PARTICIPATE IN HAIR-CARE PRACTICES 1. 2. 3. 4. BRUSHING AND COMBING SHAMPOOING SHAVING MOUSTACHE AND BEARD CARE D. VII. EYE CARE A. ASSESSMENT 1. eyebrow 2. eyelids 3. eyelashes 4. lacrimal sac 5. sclera or conjunctiva 6. pupil size, shape, light response 7. eye movement 8. contacts or eyeglasses B. IMPLEMENTATION 1. BASIC CARE 2. UNCONSCIOUS CLIENT 3. EYEGLASSES 4. CONTACT LENS 5. ARTICICIAL EYE VIII. EAR CARE A. ASSESSMENT Dryness, crusting, debris, drainage B. IMPLEMENTATION IX. NOSE CARE A. ASSESSMENT Inflammation, moistness of nasal mucosa, color, drainage B. IMPLEMENTATION CLIENT S ROOM ENVIRONMENT The nurse also promotes the client s well-being by controlling the room environment. A. B. C. D. E. MAINTAINING THE CLIENT S ROOM ROOM EQUIPMENT COMMON BED POSITIONS ROOM ACCESSORIES BEDMAKING 1. basic principles of asepsis 2. good body mechanics 3. unoccupied bed either open or closed X. XI. EVALUATION OF HYGIENE CARE IS BASED ON THE CLIENT S EXPRESSION OF A SENSE OF COMFORT, RELAXATION, WELL-BEING, AND AN UNDERSTANDING OF PERSONAL HYGIENE TECHNIQUES. HYGIENE CASE STUDIES 1. Mrs. Truman is a 62-year-old woman being seen in the internal medicine clinic during her follow-up appointment for management of her diabetes mellitus. During the nurse s conversation with Mrs. Truman, the client says, You know, last week I found a sore on my lift foot. I didn t even know it was there. What type of assessment should the nurse conduct for Mrs. Truman? And what recommendations are needed for Mrs. Truman s foot care regimen? 2. Mr. Green had abdominal trauma in a motorcycle accident. Abdominal surgery resulted in an ileostomy, which is leaking liquid fecal material onto his skin. In addition, he has a postoperative infection, is diaphoretic and has a high fever. He has a Nasogastric tube in place. What factors must you consider when providing hygiene care? Include rationales for assessments and interventions. 3. Peter North is an 18-year-old admitted to the neurosurgical intensive care unit after a head injury. Peter is currently unconscious, responsive only to painful stimulus. What assessment is critical for the nurse to perform before providing oral hygiene?

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