Class 3-Hygiene Flashcards
Personal Hygiene
-cleanliness and grooming that promotes physical and psychological well being and enhances the healing process
-the nurse is responsible for the patient’s hygiene
4 principles of skin function
- intact skin is the body’s first line of defense; resistance to skin injury varies among people
- adequate nutrition and hydration (2-3 L) of cells helps to prevent skin injury
- adequate circulation is needed to maintain skin cell life
1. intact skin
2. nutrition
3. hydration
4. circulation
**3 things that decrease patient outcome: failure to recognize, rescue, plan
What is the Braden scale used for?
-risk assessment for pressure injury
-lower the score the higher the risk for injury
Skin in the elderly (gerontology)
-thinning of subcutaneous and dermal layer (more injury prone)
-decrease activity of glands (dryer skin; sebaceous glands)
-longer time window for cell renewal (if breaks down longer to heal)
-nail changes (nails grow up & thicker)
-decrease in collagen fiber (need collagen to heal)
Morning care (a.m. care)
-after breakfast, nurse completes morning care
-toileting (normal 1st thing)
-oral care
-bathing & ROM
-back massage
-hair care
-denture care
-anti embolism stockings (come off when washing)
-shaving (face: down; legs: up)
-nail and foot care
-eye, ear, & nose
-perineal care (genital care)
-linens
-position for comfort
-organize & clean up bedside
Oral care
Assessment:
-lips
-color and surface of gums
-teeth
-tongue
-hard & soft palates
-dentures
Care:
-the gold standard is brushing the patient’s teeth (oral care with mouth breathing/O2 breathing is drying)
-poor oral care can lead to cardiac, renal, dementia? problems
Cleaning dentures
-wear gloves
-use toothbrush
-use washcloth in bottom of sink
Tooth brushing
-brush teeth, gums, tongue
Swabbing
-use with no teeth or in-between tooth brushes
Do we brush an unconscious patient’s teeth?
yes! tilt face to side
Medical treatments and/or diseases that create a dry oral cavity
-oxygen therapy
-nasogastric tubes
-side effects of medications
-mouth breathing that occurs with infection
-mechanical ventilation
Observing oral care in the mechanically ventilated patient
-oral hygiene is standard nursing care; often neglected in critically ill patients on ventilators or performed by swabbing patients’ mouths
-lack of oral care leads to VAP
oral care on mechanically ventilated patients
-observed during random 4 hour time blocks over 2 months at 5 hospitals in chicago
-conclusion:
-effective oral care is lacking for majority of mechanically ventilated patients
-gap exists between evidence-based research and actual nursing practice
-despite importance of brushing teeth to remove dental plaque, swabbing remains primary oral cleansing tool
Poor oral hygiene in long term care
-evidence links poor oral care to serious disease processes
-typically assigned to CNA’s
-only 16% of ECF residents received oral care
-average tooth brushing time for ECF residents was 16.2 seconds..DO LONGER!
Purposes of bathing
-cleansing and conditioning of skin
-relaxation
-promotes circulation (movement on skin)
-improvement of self-image and emotional well being
-movement and exercise
-assessment opportunities
-strengthens nurse/patient relationship
Types of baths
-showers
-bathing:
-complete
-partial assist
-CHG baths (vascular catheter, central line, surgery, have AV fistulas, things that invasively break skin)
-bag baths (no rinse; good for elderly)
The bath
-gather all equipment
-wash using no rinse cleansers
-dry
-lotion
-privacy & warmth (close door; close curtain)
**soap is drying & needs to be rinsed; don’t use powders
Why CHG baths
-studies show daily baths with CHG cloths reduce the risk of MDRO (multi drug resistant organisms) and HAI’s
-Chlorhexidine baths on medical/surgical units
-central IV lines
-PICC lines & mid lines
-hemodialysis catheters
-bath patient first then chlorhexidine wipe all body areas, then use a lotion compatible with CHG
CHG wipes
-rinse free; need 3 packs
-don’t bring into room until ready to use
-CHG bath wipes come prepackaged in a single packet that contains 3 individual packets
-each individual packet contains 2 CHG impregnated wipes
-CHG wipes will be warmed using the CHG warming cabinet
-warming helps activate
Indicator lights
Yellow light:
-cloth is warming, not ready yet
Solid green light:
-cloth is ready to. use
Blinking green light:
-cloth is aging out, use this one first
Red light:
-cloth is expired, do not use, dispose of it
CHG bath instructions
**see slide 29 for picture
-Use one wipe each (6 total)
1. to clean neck, chest, abdomen, & groin
2. to clean back & buttocks
3. to clean left arm
4. to clean right arm
5. to clean left leg
6. to clean right leg
-do not wash face or perineal area with CHG wipes
-do not use CHG on mucous membranes or severely abraded skin (mouth)
Remember to chart it
all CHG baths should be documented in EPIC
Purewick external female catheter
Criteria:
-strict I&O ordered, incontinent & unable to use a bedpan or commode
-post surgery and requires immobilization
-approved by wound care and/or surgery
-palliative care CMO
-patient is critically ill with life threatening hemodynamic/respiratory instability
Purewick external female catheter
Best practice:
-attach to low suction
-replace at least every 8-12 hours
-empty the urine container Q8 hours or more frequently
-do not use barrier cream-cream may impede suction
-change suction tubing at least every 30 days
-not recommended for agitated patient’s or having frequent BM’s
