Hygiene
Scientific Knowledge
The Skin
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Active organ that functions to protect, secrete/excrete, regulate temperatures and senses
Has 3 layers: Epidermis, Dermis and Subcutaneous
Epidermis (outer most layer):
o Composed of several layers undergoing different stages of maturation
o Protects dermis and subcutaneous layers from water loss and injury
o Prevents the entry disease-producing microorganisms
o Bacteria commonly reside on the outer epidermis, but they do not cause disease,
instead they inhibit the multiplication of disease-causing microorganisms
Dermis (middle layer):
o Contains the collagen and elastic fibers that support the epidermis, nerve fibers, blood
vessels, sweat glands (sudoriferous glands), oil glands (sebaceous glands), and hair
follicles
Subcutaneous (tissue layer):
o Contains blood vessels, nerves, lymph and loose connective tissue filled with fat cells
 Fatty tissue acts as heat insulator
Skin reflects change in the body’s physical condition by alterations in color, thickness, texture,
turgor (rigidity), temperature and hydration
BOX 38-1 Cultural Aspects of Care
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For dark-skinned patients, assess baseline skin tone by asking patient or family
Frequently asses skin for changes in changes in baseline skin tone
Try to always use natural light sources
Examine area of body with the least amount of melanin for underlying skin color identification
The Feet, Hands and Nails
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Requires special attention to prevent infection
Any injury or deformity to the foot can interfere with a patient’s normal ability to walk and bear
weight
Any condition that interferes with the movement of the hand (superficial or deep pain or joint
inflammation) can impair a patient’s self-help abilities
Diseases can cause changes in the shape, thickness and curvature of the nail
o Healthy nails are transparent, smooth and convex with a pink nail bed and translucent
white tip
The Oral Cavity
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Consists of the lips, the cheeks, the tongue and its muscles, and the hard and soft palates
The floor of the mouth is richly supplied with blood vessels
o Any ulceration or trauma can result in significant bleeding
Buccal glands (found in the lining of the cheeks and mouth) maintain the hygiene and comfort of
oral tissues
o Salivary secretions may be impaired by the effects of medications, exposure to radiation
and mouth breathing
Teeth are organs of mastication (chewing)
o Normal tooth consists of
 Crown – the white part you see
 Neck – the white part just atop the gum
 Root – has blood vessels
o Healthy Teeth appear white, smooth, shiny and properly aligned
Difficulty in chewing may be due to the gum being infected or inflamed, or when teeth are lost
or become lost
o Regular oral hygiene is necessary to maintain the integrity of tooth surfaces and to
prevent gingivitis or gum inflammation
The Hair
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Hair growth, distribution and pattern can indicate a person’s general health status
o Hormonal changes, emotional and physical stresses, aging, infection and certain
illnesses can affect hair characteristics
The Eyes, Ears and Nose
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Requires careful attention during the provision of hygiene
Nursing Knowledge Base
As nurses, we must individualize care from knowledge about the patient’s unique hygiene practices and
preferences. Hygiene isn’t a routine; the care requires intimate contact with patients and good
communication skills in order to build and promote a therapeutic relationship.
Social Practices
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Social groups influences hygiene preferences (the type of product used and the nature and
frequency of personal care)
During childhood, hygiene is influenced by family customs
During adolescent years, hygiene is influenced by peer group behaviors
During adulthood, hygiene is influenced by the involvement with friends and work groups who
shape the expectations of personal care
For older adults, hygiene is influenced by their living conditions, health status and available
resources
Personal Preferences
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Each patient has a personal preference for what product to use, how often they use them to
perform personal care
As nurses, we need to deliver individualized care for patients and also to help patients develop
new hygiene practices when necessitated by an illness or condition
Body Image
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The physical appearance may reflect the importance of hygiene for a patient
o Effort should be taken to promote patient’s hygienic comfort and appearance
Body image also affects the way in which hygiene is maintained
o For neatly groomed patients, we should pay more attention to details and consult the
patient before making decisions about how hygiene care is to be provided
o For unkempt or those uninterested in hygiene, we should educate on the importance of
hygiene
Socioeconomic Status
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A patient’s economic status may influence the type and extent of hygiene practices used
When patients have the added problem of a lack of socioeconomic resources, it becomes
difficult to participate and take a responsible role in health-promotion activities
We must assess whether the use of basic care items are acceptable among a patient’s social or
cultural group
Health Beliefs and Motivation
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Patients are more receptive to counseling and teaching efforts when they recognize that a risk is
present and that reasonable action can be taken to reduce the risk
Cultural Variables
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Individuals from diverse cultural backgrounds follow different self-care practices
Feelings of disapproval must not be conveyed when caring for clients whose hygienic practices
are different from your own
BOX 38-2 Cultural Influences on Hygiene
Hygiene is a personal matter and bathing, perineal hygiene and hair care practices can be sensitive
issues
Implications for practice
 Maintain privacy
 Beware of physical contact as in some cultures, it is taboo
 Do not cut or shave patient’s hair without prior consent
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Be aware that in some cultures (Chinese and Filipino) discourage bathing 7-10 days after
birth
Some cultures consider the upper body cleaner than the lower body
Be aware that Hindus and Muslins, the left hand is used for cleaning and the right hand
is used for eating and praying
Physical Condition
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Patient’s with a cast, or has an IV line or other devices connected to the body needs assistance
with hygiene
Patients under sedation lack the mental clarity or coordination to perform self-care
Chronic illnesses may exhaust or incapacitate a patient
Nursing Process
Assessment
Assessment is an ongoing process. Not all regions of body need to be assessed before administering
hygiene; however, routine assessment of a patient’s condition is undertaken whenever patient care is
given.
Physical Examination
Our assessment reveals the type and extent of hygiene care required. Special attention should be given
to the structures most influenced by hygiene measures (IE: is the skin intact, especially over bony
prominences? Is the skin dry from too much bathing?)
The Skin:
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Thoroughly examine the color, texture, thickness, turgor, temperature and hydration
o Careful attention should be paid in areas such as under the female patient’s breast and
around the perineal tissues, and under the male patient’s scrotum
Skin should be smooth, warm, supple and have good turgor
Observed skin problems should be explained to the patient and instruction for proper skin care
and specific hygiene techniques should also be discussed
TABLE 38-2 Common Skin Problems
Dry Skin – flaky, rough texture
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Implications:
o Skin may become infected if epidermal layer is cracked
Interventions:
o Ask client to bathe less frequently
o Add moisture to air through humidifier
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Use non allergenic moisturizers to aid healing
 Cream can form a protective barrier and assist with keeping fluid within the skin
Use creams to clean the skin that is dry
Acne – inflammatory, usually involving bacterial breakdown of sebum
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Implications:
o Infected material within pustule can spread if area is squeezed or picked
o Permanent scarring can result
Interventions:
o Wash hair and skin thoroughly each day with soap to remove oil
o Use cosmetics sparingly
o Use prescribed topical or oral anti-biotics
Skin Rashes – skin eruption that may result from over-exposure to sun or moisture or from an allergic
reaction
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Implications:
o If skin is continually scratched, inflammation and infection may occur
Interventions:
o Wash the area thoroughly and apply antiseptic spray or lotion to prevent further itching
and aid in the healing process
o Apply cold or warm soaks to relieve inflammation
Contact Dermatitis – inflammation of skin characterized by abrupt onset with erythema, pruritus, pain
and appearance of scaly oozing lesions
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Implications:
o Often difficult to eliminate because the person is usually in continual contact with the
substance causing the skin reaction and it may be hard to identify the substance
Interventions:
o Avoid causative agents (cleansers and soaps)
Psoriasis – noncontagious, chronic skin condition characterized by an abnormal growth or keratinocytes
and an inflammatory reaction that result in the formation of thick, silvery, scaly, inflamed patches of skin
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Implications:
o Causes are unknown and no cure exists
o Symptoms are similar to eczema and atopic dermatitis
Interventions:
o Treatment options are aimed at reducing the extent and severity of the condition
o Avoid trigger agents such as smoking, stress, excessive alcohol and skin injury
Abrasion – scraping or rubbing away of epidermis that may result in localized bleeding
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Implications:
o Infection occurs easily because of the loss of this protective skin layer
Interventions:
o Take care not to scratch patient
o Wash abrasions with mild soap and water; dry thoroughly and gently
o Observe for retained moisture in dressing or bandages
 Excess moisture can increase the risk of infection
BOX 38-3 Risk factors for Skin Impairment
Immobilization – when movement is restricted, patient’s dependent body parts undergo pressure,
reducing blood circulation to the affected body part. Must take note which patients require assistance
to change positions
Reduced Sensation – must check, while bathing a patient, the status of sensory nerve function by
checking for pain, tactile sensation and temperature sensation
Nutrition and Hydration Alterations – patient’s with limited caloric and protein intake can develop
thinner, less elastic skin which can delay the healing process
Secretions and Excretion on the Skin – moisture on the skin serves as a medium for bacterial growth and
can cause irritation and can lead to skin breakdown
Vascular Insufficiency – inadequate blood flow can cause ischemia and tissue breakdown and the risk of
infection also exists due to the decrease in the delivery of nutrients, oxygen and white blood cells
External Devices – external devices applied to or around the skin exerts pressure and friction on the skin
and those areas must be assessed
The Feet and Nails:
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Perform a thorough examination of all skin surfaces including areas between the toes and over
the soles of the feet
The alignment of the foot should be straight with the ankle and tibia
Assess patient’s gait
Inspection and daily foot care can help prevent the development of a foot ulcer, which has been
found to be the most common single precursor to lower extremity amputations with patients
with diabetes mellitus
Patients with diabetes mellitus should also be checked for neuropathy, the degeneration of the
peripheral nerves, characterized by the loss of sensation
Inspect the condition of the fingernails and toenails, looking for lesions, dryness, inflammation
and cracking
The Oral Cavity:
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Assess the color, hydration, texture and lesions of the oral cavity
Patients who don’t follow regular oral hygiene may have receding gum tissues, inflamed gums, a
coated tongue, discolored teeth, dental caries, missing teeth and halitosis (bad breath)
Patients who have undergone radiation or chemotherapy have reduced saliva, resulting in
drying and inflammation of the oral mucosal tissues
The Hair:
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Healthy hair is clean, shiny and untangled; the scalp is clean of lesions
In community and home care settings, it is important to inspect the hair for pediculosis capitis
(head lice)
The Eyes, Ears and Nose:
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Examine the condition and function
Sclerae are visible and should be white, eye-lids should be pink without inflammation and
eyebrows should be symmetrical
Determine if a patient is wearing contact lenses
o Observe cornea for the presence of a soft or rigid lens; if you don’t see one, observe the
sclera to detect whether a contact lens has shifted
Inspect external ear
Use otoscope for auditory canal and tympanic membrane
o When performing hygiene, take note of accumulated cerumen, drainage local
inflammation, tenderness or patient’s report of pain
Developmental Changes
The Skin:
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Neonate’s skin
o Very fragile as epidermal and dermal layers are loosely bound together
o Friction on skin can lead to bruising and any break can easily lead to infection
Toddler’s skin
o Skin layers are more tightly bound and thus have greater resistance to infection and
skin irritation
o But due to lack of hygiene, greater attention is needed from parents and caregivers to
provide thorough hygiene and being teaching good hygiene habits
Adolescent’s skin
o Girl’s skin become more soft, smooth and thicker with increased vascularity
o Boy’s skin become more think and some darkening in color
o The sweat glands in both genders are more active and thus both genders are more
prone to acne
Adult’s skin
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Condition of skin depends on the adult’s hygiene practices and exposure to
environmental irritants
 Skin should be elastic, hydrated smooth and firm
Aging skin
o The skin will lose its resiliency and moisture and both sweat and oil glands become less
active
o Epithelium thins and the elastic collagen fibers shrink, losing its elasticity
o Since the skin will become more dry, frequent bathing should be decreased
The Feet and Nails:
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Aging will cause the cushioning layer of fat on the soles of the feet to become thin
Sweat glands also become less active and thus make the feet more dry and more susceptible to
cracks in the skin
o Diseases such as diabetes, rheumatoid arthritis or osteoarthritis will contribute to foot
pain and thus cause abnormal gait
Fungal infections can occur under nails and if unresolved, patients can become disabled
The Oral Cavity:
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As individuals grow older, poor oral care may result from chronic diseases, physical disabilities
involving hand grasp and lack of attention to oral care
Teeth can become uneven, jagged and fractured
Gums may also lose vascularity and tissue elasticity
The Eyes, Ears and Nose:
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Aging patients may be at risk for changes in visual acuity due to cataracts or glaucoma
Aging patients may also be at risk for changes in hearing acuity due to foreign objects left in the
ear, or result from repeated infections or exposure to loud noise
o Older may also have changes in the structure and the small bones in the inner ear also
affect hearing acuity
Changes in the sense of smell are more common in older adults and may affect taste and
patient’s appetite
Self-Care Ability
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Assessment of patient’s self-care ability must include
o Muscle strength, flexibility and dexterity
o Balance
o Coordination
o Activity tolerance
o Patient’s vision
o Hand grasp
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o Range of motion of extremities
When patient has self-care limitations, we must also assess whether or not family or friends are
available to assist
o Must also assess home environment and its influence on the patient’s hygiene practices
Hygiene Practices
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Every patient has their own routine of hygiene car, and thus we must individualize hygiene care
for each patient
BOX 38-6 NURSING DIASNOSTIC PROCESS
1. Assessment Activities
o Observe patient’s ability of self-care
o Assess patient’s upper extremity strength
o Ask patient about level of fatigue after bathing
o Obtain vital sign before and after bathing
2. Defining characteristics
o Unable to perform self-care
o Limited range of motion and strength with coordination inadequacies
o Gets tired after bathing and requires rest
o BPM increased, BP increased, respirations increased
3. Nursing diagnosis
o Self-care deficit in bathing or hygiene related to upper extremity weakness and general
fatigue
Planning
Goals and Outcomes
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Goals are established with the patient’s self-care abilities and resources in mind and focuses on
maintaining optimal functioning of organs and extremities
Setting Priorities
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Timing is important, allow ample time for patient to rest after extensive diagnostic tests before
bathing them
Continuity of Care
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Vital to plan for care throughout the hospital stay, in discharge to a rehabilitation facility and at
home
Family will be a valuable resource and helping and maintaining proper and good hygiene
Implementation
A vital part of implementation is assisting patients to administer their own hygiene practices. This
includes educating them about proper hygiene techniques and connecting them with community
resources.
Health Promotion
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Educate and counsel patients as well as family members on proper hygiene techniques
Acute and Restorative Care
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Knowledge and skills required for performing hygiene care are consistent across all health care
settings
Bathing and Skin Care
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The extent of patient’s bath and methods used for bathing depend on their physical abilities,
health problems, and the degree of hygiene required
o Complete bed bath – used for patients who are totally dependent and require total
hygiene care
o Partial bed bath – involves bathing only the body parts that would cause discomfort or
odor if not bathed and those areas not easily reached by the patient
 When administering either complete or partial bathing techniques, it is
important to take note of the condition of the skin to determine what type of
product(s) should be used
Regardless of the type of bath the patient needs the following guidelines must be met
o Provide privacy – expose only the areas to be bathed
o Maintain safety – place call light within patient’s reach when leaving temporarily
o Maintain warmth – keep patient covered, exposing only areas to be cleaned
o Promote independence – encourage patient to participate in some if not all of the
bathing process
o Anticipate needs – have a new set of clothing ready
SKILL 38-1 Bathing a Patient
Procedure
1. Review specific safety measure concerning patient
2. Explain procedure and encourage and promote independence by assessing how much of the
bath he or she wishes to complete
3. Assess patient’s ability to self-care, activity tolerance, and bathing preferences
4. Ask about abnormal skin patterns and observe the skin throughout the bathing process
5. Begin complete or partial bed bath
a. Perform hand hygiene, and use gloves if skin is soiled (ensure gloves used will not
provoke allergic reactions from patient)
b. Aide patient into assuming most comfortable position, usually supine
c. Use bath blanket to help keep patient warm, remove their gown
a. Exercise caution when there are IVs. Do not remove IV unless required for
removal of gown
d. Fill wash basin 2/3 full of warm water and have patient test temperature
e. Remove pillow and replace with bath towel
f. Immerse washcloth in water and wring thoroughly
g. Inquire if patient is wearing contact lenses, wash patient’s eyes with plain warm water
a. Use a different section of the mitt for each eye
b. Soak an y crusts on eyes for 2-3 minutes before attempting removal
c. Dry thoroughly and gently
h. Inquire if patient would want soap used on face. Wash, rinse and thoroughly dry
i. Wash arm that is furthest away from you length wise from distal end to proximal end.
Rinse and dry
j. Soak patient’s hands for 3-5 minutes before washing hands and fingernails
k. Cover arm with bath blanket and repeat for other arm
l. Expose chest by folding down bath towel. Wash using long firm strokes
a. Cover chest back with bath towel between rinsing and drying process
m. Fold bath towel length wise and cover abdomen and chest. Wash abdomen with care.
Cover it between rinsing and drying
n. Wash far leg by folding bath blanket toward midline. Be sure to support the leg if
patient cannot
o. Wash foot and be sure to clean between toes. Clip nails as requested by physician.
Repeat with other leg
p. Assist patient in assuming prone or side-lying position to wash back from neck to butt
using long firm strokes
a. Pay special attention to folds of the butt and the anus for redness or skin
breakdown
Female perineal care
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Cover all areas of body, exposing only the genitalia
Clean perineal area and pay special attention to skinfolds
a. Infections, fecal matter, etc.
Wash labia majora. Wipe from perineum to rectum. Repeat on other side using a
different washcloth
Separate labia with non-dominant hand, exposing the urethral meatus and vaginal
orifice. Wash downwards from pubic area toward rectum in smooth strokes. Be sure to
use a different section of the cloth for each section
a. Thoroughly clean around the labia minora, clitoris and vaginal orifice
Remove disposable gloves and perform hand hygiene
Male perineal care
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Gently raise the penis and place a bath towel underneath. Gently grasp the shaft, and if
patient is uncircumcised, gently retract the foreskin
a. If patient has an erection, defer perineal care until later
Wash tip of penis at the urethral meatus first using a circular motion
Wash the shaft gen gentle but firm downward strokes
Gently cleanse scrotum, making sure to wash underlying skinfolds
Rinse and dry thoroughly
Inspect after cleansing. If client has bowel of urinary incontinence, apply some cream
Return patient to comfortable position and cover with bath blanket
q. Assist patient in dressing and comb hair. Men may want to shave while women may
want to apply makeup
r. Make the patient’s bed
s. Remove gloves and perform hand hygiene
6. Perform tub or whirlpool bath or shower
a. Check tub or shower for cleanliness
b. Prepare all hygienic aids and place within easy reach for patient
c. Assist patient to the bathroom and ensure they are wearing a bathrobe and slippers
inside the bathroom
d. Provide shower seat or tub chair if needed. Also show how to use the call signal for
assistance. Make sure when filling bath tub with water to obtain approval of
temperature of water
a. Be sure to explain which faucet controls what temperature
e. Instruct patient to use safety bars when getting in and out of tub or shower
f. Be sure the patient is not to remain in the tub for more than 20 minutes
a. Observe ROMs
g. For unsteady clients, drain water in tub first before exiting the tub. Place towel on
patient’s shoulders to keep warmth
h. Observe skin condition
i. Assist patient as needed in dressing and returning to a bed or chair
j. Clean the tub or shower
k. Perform hand hygiene
Unexpected Outcomes and Related Interventions
Inflammation of skin and genitalia, with localized tenderness, swelling and presence of foulsmelling discharge
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Bathe area frequently to keep it clean and dry
Obtain an order for a sitz bath
Apply a protective barrier
Notify doctor and apply prescribed cream
Client expresses perineal discomfort
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Increase the frequency of perineal care
Assess the perineum for signs of irritation or discharge
Client unable to perform perineal care correctly
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Position the client and have client observe the cleansing procedure
Client becomes excessively fatigued and unable to cooperate or participate in bathing
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Reschedule bathing to a time when the client is more rested
Notify doctor about changes in patient’s fatigue level
Schedule rest periods
Client seems unusually restless or complains of discomfort
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Schedule rest periods before bathing
Recording and reporting
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Record condition of skin and any significant findings (reddened areas, bruises, nevi or joint or
muscle pains)
Report any evidence of change in skin integrity or wound secretions
Record presence of abnormal findings and record any related procedure performed
Record the appearance of a suture line
Record all procedures performed, the amount of assistance provided and the extent of the
patient’s participation
Home Care considerations
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Assess the patient’s tub and shower area for safety needs
Assess patient for assistive bathing devices (shower chair or hand-held shower)
Instruct care givers to check perineal areas daily for signs of infection and skin breakdown
Older adult considerations
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Check the temperature of water used for bathing
Bathing everyday may not be required for patients with dry skin
Bag Baths:
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Helps in prevention of harboring Gram-negative organisms
Usually microwaved before use
Bathing times have been reported to be shorter
Perineal Care:
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Patients in need are usually those at greater risk for acquiring an infection
o Females undergoing menstruation also require good perineal care
If patients perform self-care be sure to check bed linen for signs of discharge and if patient
notices any burning feeling when urinating
Back Rub:
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Promotes relaxation
Usually performed after bath