Chapter 7 Assisting Clients With Hygiene
Good physical hygiene is necessary for comfort, safety, and well-being. Whereas well people
are usually capable of meeting their own hygiene needs, ill people may require assistance. The
nurse determines a client’s ability to perform self-care and provides hygiene care according to the
client’s needs and preferred practices.
The nurse carries out many hygiene measures each day. These are commonly performed at
specified times (see section 5 of this chapter.) Hygiene practices involve care of the teeth, oral
cavities, hair, skin, perineal areas. Because hygiene care often requires intimate contact with the
client, the nurse uses communication skills to promote the therapeutic relationship and to learn
about a client’s emotional needs. During hygiene care the nurse can also assesses readiness to
learn and teach health promotion practices. The nurse must also consider clients’ specific physical
limitations, beliefs, values, and habits. The nurse preserves as much of the clients’ independence
as possible, ensure privacy, and fosters physical well-being.
Section 1 Oral Care
The major part of a tooth is the dentin, an ivory substance harder than bone. Dentin surrounds
a tooth’s pulp cavity. A layer of enamel covers the upper portion of each tooth at the crown. The
periodontal membrane, just below the gum margins, surrounds the tooth root and holds it firmly in
place. Healthy teeth are white, smooth, shiny, and properly aligned.
Oral hygiene helps to maintain the healthy state of the mouth, teeth, gums, and lips. Brushing
cleans the teeth of food particles, plaque, and bacteria. It also massages the gums and relieves
discomfort resulting from unpleasant odors and tastes. Complete oral hygiene enhances well-being
and stimulates the appetite. The nurse’s responsibilities in oral hygiene are maintenance and
prevention. The nurse can help clients to maintain good oral hygiene by teaching correct
techniques or by performing hygiene for weakened or disabled clients.
Assessment
Condition of oral Hygiene
A thorough assessment for problems related to oral hygiene should be included in every
client’s care. During the assessment the nurse can inform the client about good oral hygiene habits.
The nurse may also refer the client to a specialist if common oral problems are found. Early
identification of poor oral hygiene practices and common oral problems can reduce the risk of
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gum disease and dental caries or cavities.
Examine the lips for color, moisture, lumps, ulcers, lesions, and edema. Examine the buccal
mucosa for color, moisture, lesions, nodules, and bleeding. Examine the color of the gums and
surface of the gums for lesions, bleeding, edema, and exudates. Examine for loose, missing, or
carious teeth. Note the presence of dentures or other orthodontic devices. Examine the tongue for
color, symmetry, movement, texture, and lesions. Examine the hard and soft palates for intactness,
color, patches, lesions, and petechiae. Examine the oropharynx for movement of the uvula and
condition of tonsils, if present. Note unusual mouth odors. Assess adequacy of mastication and
swallowing. Clients who do not follow regular oral hygiene practices may have receding gum
tissue, inflamed gums, a coated tongue, discolored teeth, dental caries, missing teeth, and halitosis.
Localized pain is a common symptom of a gum disease and certain tooth disorders.
It is especially important to examine the oral cavity of clients receiving radiation or
chemotherapy. Both treatments can cause serious changes in salivary gland function and mucosal
integrity. The nurse’s assessment serves as a basis for preventive care for clients as they undergo
treatment.
Self-Care Ability
The nurse assesses a client’s physical and cognitive ability to perform basic hygiene
measures. Client’s self-care abilities determine if assistance is needed in managing activities of
daily living, including routine hygiene. The nurse’s assessment must include measurement of a
client’s muscle strength, flexibility and dexterity, balance, coordination, and activity tolerance
necessary in performing activities such as brushing teeth. The degree of assistance needed by a
client during hygienic care may also depend on vision, the ability to sit without support, attached
equipment, hand grasp, and the range of motion in the client’s extremities. The nurse can assess
self-care ability by asking clients to perform activities such as tooth brushing. Observe the client
carefully and note not only if the activity is performed correctly, but also if the client is able to
thoroughly complete the task.
Knowledge About oral care
Ask clients about habit and preferences (e.g., frequency of brushing and flossing, dental
products used, denture care, and visits to dentist). Have client demonstrate practices.
Examination of Denture
Before the denture is picked off, observe whether the denture wears suitable. After it is
picked off, examine whether its inner sheath is covered with tartar, plaque, food particles, and
whether it is broken and cracked.
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Implementation
Complete oral hygiene enhances well-being and comfort. Oral problems can cause appetite
reduction, localized pain and systemic disease. Broken, absent, unclean, or crooked teeth can
affect self-image. Halitosis can negatively influence social interaction. The condition of the oral
cavity hygiene affects nutritional intake. The nurse assists clients in maintaining good oral hygiene
by teaching the importance of correct techniques and a routine daily schedule. Education about
common gum and tooth disorders and methods of prevention can motivate clients to follow good
oral hygiene practices. The nurse also assists in performing hygiene for weakened or disabled
clients. When clients have variations in oral mucosal integrity, the nurse provides hygiene
techniques to ensure thorough and effective care.
Teaching Oral Hygiene
Thorough brushing of the teeth is important in preventing tooth decay. The mechanical action
of brushing removes food particles that can harbor and incubate bacteria. It also stimulates
circulation in the gums, thus maintaining their healthy firmness.
Dental products used
A toothbrush should be small enough to reach all teeth. It should be cleaned and dried
between uses. Rounded, soft bristles provide gum stimulation without causing abrasion. Replace
toothbrushes every 3 months. Fluoride toothpaste is often recommended because of its
antibacterial protection.
Brushing
Brushing is usually done upon arising and at bedtime, but brushing should also be done after
each meal. Daily tongue brushing and teeth flossing are also recommended in aspects of oral
hygiene.
Brushing removes dental plaque from the teeth and beneath the gum margin. For cleaning the
outside surfaces of all teeth and inside surfaces of back teeth, place the bristles of the brush at a
45°angle to the teeth. Place the brush with the tips directed slightly onto the furrow surrounding
a tooth. Without disengaging the brush tips, vibrate the brush back and forth with short strokes.
The toothbrush will reach only two or three teeth at a time. After brushing one area, overlap
placement with an adjacent position. For inside surfaces of front teeth, use the bristles on the end
of the brush in a vibratory motion. To clean the chewing surfaces, brush back and forth. The nurse
observes the client to be sure proper techniques are used.
After brushing the teeth, brush the tongue. Tongue brushing decreases the number of
microorganisms and removes debris. When helping someone, ask the person to protrude the
tongue. Holding the brush at a right angle to the length of the tongue, direct the bristle tips toward
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the throat. With light pressure, bring the brush forward and over the tip of the tongue. Then brush
the tongue’s sides. Now have the person thorough rinse the mouth. Repeat brushing and rinsing as
needed until the mouth is clean. Thorough rinsing after brushing is important to remove dislodged
food particles and excess toothpaste. Cleanse the toothbrush under running water to remove debris.
Shake out excess water and allow to dry.
Flossing
Brushing alone cannot completely remove dental plaque and debris round the teeth. Flossing
removes dental plaque between teeth, helps prevent periodontal disease, and helps remove oral
debris. Flossing once a day is sufficient. Unwaxed dental floss is recommended because it is
thinner, slides easily between teeth, and is more absorbent than waxed floss.
Loosely wrap floss around index or middle finger of each hand. To floss the lower teeth, hold
the floss so that the foreigners of both hands are on top of the strand. Loop the floss around a tooth
and pull the ends forward to curve it into a C shape against the sides of the tooth. Then slide the
floss to the gum line. Move the floss back and forth to clean both sides of the tooth. Carefully
work the floss under the gum until it meets resistance. Then bring the floss toward the biting
surface.
To floss the upper teeth, hold the floss so that it is over the thumb of one hand and the
foreigner of the other hand. The thumb is to the outside of the teeth to hold back the cheek work
the floss between the teeth as done with the lower teeth.
When floss becomes soiled or frayed, move to a new section by slipping a turn of floss from
the middle finger of one hand and adding a turn to the finger on the other. After flossing, rinse
vigorously to remove loose debris. Although firm pressure is needed against the sides of the teeth,
do not traumatize the gums. Placing a mirror in front of the client will help the nurse to
demonstrate the proper method for holding the floss and cleaning between the teeth.
Denture Care
Dentures collect debris, dental plaque, and tarter just as natural teeth do. They need to be
cleaned regularly, at least once a day. The same type of toothbrush used for natural teeth can be
used for dentures. Clients should be encouraged to clean their dentures on a regular basis to avoid
gingival infection and irritation. When clients become disabled, the nurse or family caregiver can
assume responsibility for denture care. Wearing gloves, remove dentures to clean them and
provide oral care. The dentures are rinsed well after cleaning. The client should be given the
opportunity to rinse the mouth before the dentures are replaced. Dentures must be removed at
night to give the gums a rest and prevent bacterial buildup. When dentures are removed from the
mouth, store them in a labeled denture cup to prevent loss or breakage. Denture should not be
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wrapped in toilet tissue or disposable wipes because these are likely to be thrown away. Encourage
people to wear dentures continuously during the day. This improves eating technique, speech,
appearance, and contour of the mouth.
Special Oral Care
For the client who is debilitated or unconscious or who has excessive dryness, sore, or
irritations of the mouth, it may be necessary to clean the oral mucous and tongue in addition to the
teeth. Mouth care for unconscious or debilitated people is important because their mouths tend to
become dry and consequently predisposed to infection. Dryness occurs because the client cannot
take fluids by mouths, is often breathing through the mouth, or may be receiving oxygen, which
tends to dry the mucous membranes. Normal saline solution is recommended for oral hygiene for
the dependent client. While cleaning the oral cavity, the nurse should never use fingers to hold the
client’s mouth open. A human bite is highly contaminated. Special oral hygiene focuses on oral
care for unconscious person but may be adapted for conscious persons who are seriously ill or
have mouth problems.
Skill 5-1 Performing Mouth Care for an Unconscious or Debilitated Client
Purposes
1.To clean and moisten the membranes of the mouth and lips, to prevent oral infections
2.To prevent or eliminate odor, improve appetite
3.To promote comfort
Equipment
●
bowl(one contained with tampon, one with collutory)
●
pipette
●
tweezers
●
cotton-tipped applicator
curved forceps
●
●
kidney basin
●
●
spatula
●
paraffine
flashlight
●
gauze
●
Common Solutions for Mouth Care
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towel
Table 5-1
Solution name
Concentration
Normal saline solution
Hydrogen peroxide solution
Common Solutions for Mouth Care
Function
Cleaning mouth cavity, preventing infection
1%-3%
Preventing oral cavity odor, using for the client whose
oral cavity has ulceration, necrosis tissue
Sodium bicarbonate solution
1%-4%
Alkaline solution, using for fungus infection
Chlorhexidine solution
0.02%
Cleaning oral cavity, eliminating bacterium
Furacilin solution
0. 02%
Cleaning oral cavity, eliminating bacterium
Acetic acid solution
0.1%
Using for aeruginosin pyocyanolysin bacilli infection
Boric acid solution
2%-3%
Acid solution, restraining bacterium
Metronidazole solution
0.08%
Using for anaerobic bacilli infection
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Section 2 Hair Care
A person’s appearance and feeling of well-being often depend on the way the hair looks and
feels. Illness or disability may prevent a client from maintaining daily hair care. An immobilized
client’s hair soon becomes tangled. Dressings may leave sticky blood or antiseptic solutions on the
hair. Proper hair care is important to the client’s body image. Brushing, combing, and shampooing
are basic hygiene measures for all clients. Clients should be permitted to shave when their
condition allows.
Assessment
Condition of Hair and Scalp Hygiene
Before performing hair care, the nurse assesses the condition of the hair and scalp. Normally
the hair is clean, shiny, and untangled, and the scalp is clear of lesions. Illness affects the hair,
especially when endocrine abnormalities, increased body temperature, poor nutrition, or anxiety
and worry are present. Changes in the color or condition of the hair are related to changes in
hormonal activity or to changes in the blood supply to hair follicles. Assess condition of hair and
scalp. Consider age-appropriate changes. Consider racial or ethnic differences. Determine reasons
for change in distribution or loss of hair. Check oiliness and texture of hair. Inspect scalp for
lesions, inflammation, infection, or parasites. Findings will reveal the frequency and extent of care
needed. Table 1 summarizes hair and scalp problems the nurse may identify.
Knowledge About Hair care and Self-Care Ability
Assess client’s ability to grasp comb or brush. Determine client’s ability to physically care for
hair. Does client become easily fatigued? A client’s self-care ability can be altered by conditions
such as arthritis, fatigue, and the presence of physical encumbrances (e.g., cast or IV). The nurse
assesses the client’s physical ability to perform hair care. It is also essential to consider a client’s
personal hair care practices so every effort can be made to maintain the client’s preferred
appearance. Assess client’s preferences in hair styling. Identify client’s preference for hair care
and shaving products. Assess adequacy of client’s hygiene practices. Determine client’s
perceptions of own appearance. Assess client’s socioeconomic background.
Illness of patients and its therapy
Illness affects the hair, especially when endocrine abnormalities, increased body temperature,
poor nutrition, or anxiety and worry are present. Changes in the color or condition of the hair are
related to changes in hormonal activity or to changes in the blood supply to hair follicles.
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Implementation
Basic daily hair care consists of brushing, combing, and shampooing. Nurses provide or
facilitate hair care at least once a day. Hair care may be done with morning care so the person feels
refreshed and well-groomed for the day.
Combing Hair in Bed
Daily brushing of the hair helps to keep it clean and distributes oil along the shaft of each hair.
Brushing also stimulates the circulation of blood in the scalp. When possible, have the person sit
up in the chair or in high Flower’s position in the bed. Place a towel over the client’s shoulders to
catch loose hair and dirt.
Long hair may present a problem for clients confined to bed as it may become matted. It
should be combed and brushed at least once a day to prevent this. The best way to protect long
hair from matting and tangling is to ask the client for permission to braid it. Parting the hair in the
middle on the back of the head and making two braids, one on either side, prevents the discomfort
of lying on one heavy braid on the back of the head. Use fingertips for scalp massage.
Occasionally, a client’s hair is almost hopelessly matted, and cutting the hair may be necessary.
Before recommending cutting, try applying water with alcohol to hair to help remove matting and
tangles. Section the hair and firmly hold one section at a time between your index finger and
thumb as you work with it. Brush or comb in similar manner as with curly hair. Start at the ends,
with your hand just above the snarled area, and gently remove snarls. Repeat with all other
sections.
Shampooing Hair in Bed
Frequency of shampooing the hair depends on a person’s daily routines and the conditions of
the hair. The nurse should remind clients in hospitals that staying in bed, excess perspiration, or
treatments that leave blood or solutions in the hair might require more frequent shampooing.
There are several ways to shampoo client’s hair, depending on their health, strength, and age.
The client who is well enough to take a shower can shampoo while in the shower. The client who
is unable to shower may be given a shampoo while sitting on a chair in front of a sink. The client
who must remain in bed can be given a shampoo with water brought to the bedsides.
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Section 3 Care Of Skin
Skin, the largest body organ, has three continuous layers: Epidermis, dermis, and
subcutaneous tissue. The skin is an active organ with the function of protection, temperature
regulation, sensation, excretion and secretion. The skin is one of the body’s vital organs and is
essential for maintaining life.
Assessment
The condition of the skin provides clues about a person’s general health and need for hygiene.
While assisting a client with personal hygiene, the nurse assesses all external body surfaces. Using
inspection and palpation, the nurse looks for alterations, determines the need for hygiene, and
notes skin changes in response to therapies. The nurse observes the skin’s color, texture, thickness,
turgor, temperature, and hydration. The box below describes normal skin characteristics. The
nurse pays special attention to the characteristics most influenced by hygiene measures. Is the skin
dry from too much bathing?
Normal Skin Characteristics
Skin is intact and has no abrasions.
Skin feels warm when palpated.
Localized changes in texture can be palpated across skin’s surface.
There is good turgor (elastic and firm), with skin generally smooth and soft.
Skin color varies from body part to body part.
Certain conditions place clients at risk for impaired skin integrity. Nurses must be
particularly alert when assessing clients with reduced sensation, vascular insufficiency, and
immobility. The development of pressure sores is a common complication that extends hospital
stays.
Color
The amount of melanin varies between and within racial groups. Descriptive terms for skin
color are somewhat vague: pallor, cyanotic, rubefaction, jaundice, and melanin deposited.
Temperature
The temperature of the skin gives clues to possible inflammatory and circulation problems.
Assess skin temperature by touching the person’s skin with the back of your fingers. Skin
temperature is influenced by room temperature and is correlated with skin color. Cyanosis may
signal a cold environment or circulatory problems. Erythema may indicate a hot environment or
inflammation.
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Suppleness and thickness
The suppleness refers to the pliability or ease of movement. Suppleness is affected by amount
of moisture and oil, texture, turgor, fiber elasticity in the dermis, and edema. Thickness of skin is
influenced by body part, age, and sex.
Elasticity
Skin elasticity of people old or with dehydration is poor.
Integrity and Lesions
The nurse pays special attention to the presence and condition of any lesion. Inspect and
palpate for lesions and rashes. Notice whether lesions are localized or generalized over the body.
Sensation
Assess sensation while palpating the skin for lesions. Palpate with a light but firm pressure
and ask the person what is felt. Also ask the person to describe the temperature of your hands.
Limited sensation of temperature, pressure, and touch may indicate generalized or localized
problems. Itching may indicate dry skin or allergies.
Cleanliness
Assess skin cleanliness by noting body odor and amount of moisture, dirt, and oil on the skin.
While inspecting the skin, the nurse notes the presence and condition of lesions. Certain
common skin problems affect Hygiene. Special care is also given to assess less obvious surfaces,
such as under the female client’s breasts or around perineal tissues. The nurse who observes skin
problems should explain proper skin care to the client. The nurse may also educate the client about
avoiding irritants, which can worsen the skin condition.
Implementation
Teaching Skin Hygiene
Bathing removes accumulated oil, perspiration, dead skin cells, and some bacteria. In
addition to cleaning the skin, bathing also stimulates circulation. A warm or hot bath dilates
superficial arterioles, bringing more blood and nourishment to the skin. Bathing also produces a
sense of well-being. It is refreshing and relaxing and frequently improves self-esteem, appearance.
Bathing offers an excellent opportunity for the nurse to assess ill clients. The nurse can observe
the condition of the client’s skin and physical conditions. While assisting a client with bath, the
nurse can assess the client’s psychosocial needs.
The bathing method and the amount of assistance needed are nursing judgments based upon
assessment of benefit to the person, safety factors, individual preferences, and contraindications.
The extent of a client’s bath and the methods used for bathing depend on the client’s physical
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abilities, health problems, and the degree of hygiene required. People were encouraged to bathe
themselves to prevent the complications of immobility. If a client is physically dependent or
cognitively impaired, more attention must be paid by the nurse to providing thorough, preventive
skin care. Excessive bathing, however, can interfere with the intended lubricating effect of the
sebum, causing dryness of the skin.
Regardless of the type of bath the client receives, the nurse should use the following
guidelines.
★Provide privacy. Close the door, or pull room curtains around the bathing area. While
bathing the client, expose only the area being bathed.
★Ensure safety. Keep side rails up while away from the client’s bedside. (This is critical for
dependent and unconscious clients.)Place the call light in the client’s reach if leaving the room
temporarily.
★Maintain warmth. The room should be kept warm because the client is partially uncovered
and may easily be chilled. Wet skin causes an excess loss of heat through convection. Control
drafts, and keep windows closed. Keep client covered, only exposing the body part being washed
during the bath.
★Promote independence. Encourage the client to participate in as much of the bathing
activities as possible. Offer assistance when needed.
★Anticipate needs. Bring a new set of clothing and hygiene products to the bedside or
bathroom.
Shower and Tub Bath
The tub bath or shower can be used to give a more thorough bath than a bed bath. Many
ambulatory clients are able to use shower facilities and require only minimal assistance from the
nurse. Tub baths are preferred to bed baths because it is easier to wash and rinse in the tub. The
bathing should be given 1h after a meal to avoid affecting digest. Safety is most important when
assisting someone with a shower or tub bath. Both tubs and showers should be equipped with grab
bars for clients to hold on to during entry and exit and maneuvering. The amount of assistance the
nurses offers depends on the abilities of the client.
Bath in Bed
Bed bathing is indicated primarily for people with restricted mobility; limited exertion; and
often for first-day postoperative people who may experience hypotension or are very weak.
Back rub
A back rub generally follows the client’s bath. Giving a back rub provides an opportunity for
the nurse to observe the skin for signs of breakdown. It improves circulation and provides a means
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of communication with the client through the use of touch. When providing a back rub, the nurse
can enhance relaxation by reducing any noise and ensuring the client is comfortable. The nurse
should be aware of the client’s diagnosis when a back rub is being contraindicated, for example,
when the client has had back surgery or has fractured ribs.
Prevention and Care of Pressure Ulcers
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Section 4 Perineal Care
Perineal hygiene refers to cleaning of the external genitalia and surrounding area. Perineal
hygiene is usually part of the complete bed bath. Clients most in need of perineal care are at
greatest risk for acquiring an infection (e.g., clients who have indwelling urinary catheters or who
are recovering from rectal or genital surgery or childbirth). A client able to perform self-care
should be allowed to do so. Many nurses are embarrassed about providing perineal care,
particularly to clients of the opposite sex. This should not cause the nurse to overlook the client’s
hygiene needs. A professional, dignified attitude can reduce embarrassment and put the client and
the nurse at ease. Wear clean disposable gloves while assisting with perineal care. Explain to the
person that your purpose for wearing gloves is to prevent the possibility of carrying organisms
from one person to another.
Because the perineum has several orifices, it is common portal of entry for pathogens. The
perineal area is conductive to growth of pathogenic organisms because it is warm and moist and
not well ventilated. Through hygiene is essential to maintain skin condition and protect body
integrity. The urethral orifice is the “cleanest” area, and the anal orifice is the “dirtiest” area.
Always stroke from front to back to wash from “clean” to “dirty” parts.
Assessment
Condition of Perineal Hygiene
Observe whether the perineum has infection, skin keeps integrity, secretion of perineum is
normal.
Self-Care Ability
Assess the degree of assistance needed by a client during perineal hygienic care. The nurse can
assess self-care ability by asking clients to perform daily perineal hygiene. Observe the client
carefully and note not only if the activity is performed correctly, but if the client is able to
thoroughly complete the task.. If a client performs self-care, various problems such as vaginal or
urethral inflammation, skin irritation, and unpleasant odors may go unnoticed. The nurse must be
alert for complaints of burning during urination, localized soreness or excoriation, or perineal pain.
The nurse also inspects bed linen for signs of discharge.
Knowledge and Skills about Perineal Care
Assess whether the client recognizes the perineal hygiene is important to health. Observe the
client carefully and note if the activity is performed correctly.
Implementation
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Bedpan
Perineal care
Section 5 Morning Care and Evening Care
(Hygiene care schedule)
When clients require nursing assistance with personal hygiene, it is important to schedule this
care at regular intervals.
Morning care (AM Care)
Morning care is provided to clients as they awaken in the morning. The nurse offers
assistance with toileting; oral care; bathing; back massage; special skin care measures (e.g.,
pressure ulcer); hair care; dressing; and positioning for comfort. The nurse changes bed linen,
makes the client’s bed, and keeps neat. When morning care is completed, the client should feel
refreshed and be in a comfortable and safe environment. For some clients, this may mean
positioning the call light within reach and using protective devices such as bed rails or restraints.
Morning care is often characterized as self-care, partial care, or complete care. Self-care
clients are capable of managing their personal hygiene independently once oriented to the bottom.
These clients should still be offered a back rub. Partial care clients most often receive morning
hygiene care at the bedside or in the bathroom. Because of weakness, these clients may be able to
wash only the parts of their bodies that are within easy reach. The nurse washes the back and legs
and sometimes the axillae and perineum because these body parts have the most secretions and are
difficult to reach. Complete care clients require nursing assistance with all aspects of personal
hygiene.
Hour of Sleep Care (HS Care)
Hour of sleep care is provided to clients before they retire for the night. It usually involves
providing for elimination needs, washing face and hands, giving oral care, and giving a back
massage. The client should be positioned comfortably. Protective devices are indicated for night
hours. The call light and any other objects the client desire should be within easy reach.
As needed care (prn Care)
Nursing care is provided as required by the client. For example, a client who is diaphoretic
(sweating profusely) may need bathing and changes of clothes and bed linen frequently. Some
clients require oral care every 2 hours.
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Section 6 Prevention and Care of Pressure
Ulcers
The integument is the body’s largest organ. It is a protective barrier against disease-causing
organism; is a sensory organ for pain, temperature, and touch; and synthesize vitamin D, and so on.
Injury to the integument poses risks to safety and triggers a complex healing response. This
session presents pressure ulcers, one of the common skin impaired integrity. When pressure ulcers
occur, interventions and treatments can spare the client unnecessary pain and discomfort and
waste medical resources. In addition, the ulcerative areas can become so massive that it may take
many months or years of treatment and costs thousands of dollars to repair them during which
time the patient’s mobility will be further limited.
Pressure ulcer, pressure sore, decubitus ulcer, and bedsore are terms used to describe
impaired skin integrity. Pressure ulcer is the most current term. A pressure ulcer is defined as a
localized area of tissue necrosis that tends to develop when soft tissue is compressed between a
bony prominence and an external surface for a prolonged period. Any client experiencing
decreased mobility, impaired neurological functioning, irritation of skin, decrease sensory
perception, or decreased circulation is at risk for pressure ulcer development.
Contributing Factors to Pressure Ulcers Formation
Factor of pressure
The normal capillaries pressure ranges from 16 to 32 mmHg. Tissue damage occurs when the
pressure exerted on the capillaries is high enough to close the capillaries. Necrosis eventually
occurs, leading to the characteristic ulcer. Two mechanisms contribute to pressure ulcer
development: external pressure that compresses blood vessels, and friction and shearing forces
that tear and injure blood vessels.
Pressure
Prolonged vertical pressure on an area is the major cause for pressure ulcer, which causes
disturbances in the nerve impulses to and from this area, and also decreases the blood supply that
in turn diminishes the nutrition of that part. A pressure ulcer occurs as a result of a time-pressure
relationship. The greater the pressure and the duration of the pressure, the greater the incidence of
the ulcer formation is. The skin and subcutaneous tissue can tolerate some pressure without cell
death for a short period. If the pressure is greater than 32 mmHg and remains unrelieved to the
point of hypoxia, the vessels will collapse and thrombose. Pressure ulcer may occur when this
lasts for a long period.
Friction
Friction occurs when two surfaces move across each other. The injury resembles an abrasion
and can also damage superficial layers of skin. Friction damage often occurs as a result of poor
lifting technique. The client who lies on wrinkled sheers is likely to sustain tissue damage due to
friction.
Shearing force
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Pressure ulcer also forms as results of shearing force and friction. Shearing occurs when the
skeleton and deep fascia slide downwards with gravity, whilst the skin and upper fascia remain in
the original position. Deep necrosis can occur when the shearing between two layers of tissue
leads to stretching, kinking and tearing of vessels in the subcutaneous tissues. Shearing forces
should not be considered separately from pressure. Shearing most often occurs when individuals
slide down or are dragged up a bed or chair.
Moisture to the Skin
Prolonged moisture on the skin reduces the skin’s resistance to trauma. Moisture from urinary
and fecal incontinence, wound drainage and sweat are irritants to the skin, harbors microorganism,
and makes an individual prone to skin breakdown and infection.
Nutritional Status
Nutritional factors are crucial in the development of pressure ulcers. Prolonged inadequate
nutrition causes muscle atrophy and the loss of subcutaneous tissue. These reduce the amount of
padding between the skin and the bones, thus increasing the risk of pressure ulcer development.
The obesity individuals may also be vulnerable to pressure damage because the body weigh
exerted more pressure on skin when lying. Dehydration may reduce the elasticity of tissues and
thus increase tissue deformability under pressure or friction. Edema (the presence of excess fluid
in the tissues) makes skin more prone to injury by decreasing its elasticity, resilience. Enema
increases the distance between the capillaries and the cells, thereby, slowing the diffusion of
oxygen to the tissue cells and of metabolites away from the cells.
Age
Advanced age is associated with an increase in cardiovascular and neurological disease, and
changes to the resilience and elasticity of the skin. Individuals over 65 years of age are at greater
risk than the general population in developing pressure ulcers.
Fever (infection)
Fever is also a factor in the development of pressure ulcer. Fever usually indicates infection
occurring among the client. Infection and fever increase the body’s metabolic rate, thus increasing
the needs of the cells for oxygen. This particularly makes an already hypoxemic tissue more
susceptible to ischemic injury. In addition, fever results in diaphoresis and increased skin moisture,
which further predispose the client to skin breakdown. Therefore, severe infections with fever may
affect the body’s ability to deal with the effects of tissue compression.
Orthopedic Devices
Orthopedic Devices such as plaster, bandage, splint, retractor reduce mobility of the client or
of an extremity. A client with a cast has an increased risk of pressure ulcer development because of
mechanical external force of friction from the surface of the cast rubbing against the skin. A
second mechanical force is the pressure exerted the cast on the skin if the cast clamps too tightly
or if the extremity swells.
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Prediction and Prevention of Pressure Ulcers
Prevention of pressure ulcers is apriority in caring for clients and is not limited to clients with
restrictions in mobility. Impaired skin integrity is not a problem in healthy, immobilized
individuals but is a serious and potentially devastating problem in the ill or debilitated client.
Assessment
Patients With High Risk of Pressure Ulcers
Clients with the neural diseases: such as coma, paralysis, impaired mobility,
confined to bed long term, prolonged local body pressed
Old people: The skin of an older adult client is more fragile and has an increased risk
for skin breakdown (see gerontologic nursing practice guidelines box)
Gerontologic nursing practices for the client with
impaired skin integrity
★Older adult’s skin is less tolerant to pressure, friction, and shear because of decreased
elasticity due to normal aging.
★The older adult has decreased number of sweat glands, leaving the skin dry and less tolerant
to shear and friction.
★Impaired skin integrity is a high risk to older adult; it is among the five most common
nursing diagnoses for older adult clients in long-term care facilities.
★Dermis of the older adult’s skin is thinner due to the normal absence of subcutaneous fat,
therefore making the older adult more susceptible to skin breakdown.
★After the age of 50 epidermal cell renewal reduces by one third, and as a result wound
healing is approximately 50% slower than a 35-year-old adult.
★In the presence of chronic coronary or peripheral vascular diseases circulation to the
extremities is reduced.
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Obesity: Obesity can speed pressure ulcer development. Adipose tissue in small
quantities protects the skin by cushioning bony prominences against pressure. However, adipose
tissue is poorly vascularized, and the adipose and underlying tissues are more susceptible to
ischemic damage. When excessive adipose is present, the client is more susceptible to pressure
ulcers.
Debilitated and malnutrition: Poor nutrition increases the risk of pressure ulcer
formation. Clients with poor nutrition experience muscle atrophy and decreases in subcutaneous
tissue. Because of these changes, less tissue is present to serve as padding between the skin and
underlying bone. Therefore the effects of pressure are increased on remaining tissue. The client
can have protein deficiency and negative nitrogen balance and have an inadequate intake of
vitamine C. Cachexia is generalized ill health and malnutrition, marked by weakness and
emaciation. It is usually associated with severe diseases such as cancer and end stage
cardiopulmonary or renal diseases. This condition increases the client’s risk for pressure ulcers.
Basically the cachexic client has lost the adipose tissue necessary to protect bony prominences
from pressure.
Edema: Edema increases the affected tissue’s risk for pressure ulcers. Poor nutrition
alters fluid and electrolyte balance. In clients with severe protein loss, hypoalbuminemia (serum
albumin below 3.0g/100ml) leads to a shift of fluid from the extracellular fluid volume to the
tissues, resulting in edema. The blood supply to the edematous tissue is decreased, and waste
products remain because of the changing pressures in the capillary circulation and capillary bed.
Pain: The client with pain will take a compelled lying position and reduce mobility,
avoiding pain.
orthopedic devices: Patients with orthopedic devices limit mobility.
urinary and fecal incontinence: Excretion and moisture stimulate skin.
fever: Fever will increase perspiration and moisture to stimulate skin.
quietive therapy: Quietive therapy will reduce mobility.
Predicting Pressure Ulcers Risk
Baseline and continual assessment data provide critical information about the client’s skin
integrity and the increased risk for pressure ulcer development. A benefit of the predictive
instruments is to increase the nurse’s early detection of clients at greatest risk for ulcer
development. Once these clients are identified, appropriate interventions are instituted to maintain
skin integrity.
It is best to use predictive instruments to assess risks for impaired skin integrity in those
clients who are immobilized, malnourished, incontinent, or paralyzed. Prompt identification of
such clients enables nurses to individualize costly resource to appropriate clients, and reduce their
risk.
At present time the Braden Scale and the Norton Scale are the common risk assessment tools.
In addition, the Gosnell and Knoll instruments are also effective in pressure ulcer prediction. The
overall objective of predictive instruments is to effectively and efficiently identify those clients
with the greatest risk for pressure ulcer development.
Braden Scale The Braden Scale is composed of six subscales: activity, mobility,
friction and shear, sensory perception, moisture, and nutrition (Table 5-2) . A hospitalized adult
with a score of 16 or below is considered at risk. In older clients, a score of 17 or 18 may be a
more efficient prediction of risk. The instrument is highly reliable in the identification of clients at
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greatest risk for pressure ulcers.
Table 5-2
Items/points
the Braden Scale
4
3
2
1
Walks
frequently
Walks
occasionally
Chairfast
(chair
or
wheelchair)
Bedfast
Mobility: Ability to change and
control body position
No limitations
Slightly
limited
Very limited
Completely
immobile
Friction and shear:
Not at all
No apparent
problem
Potential
problem
Problem
Sensory perception: Ability to
respond
meaningfully
to
pressure-related discomfort
No
impairment
Slightly
limited
Very limited
Completely
limited
Moisture: Degree to which skin is
exposed to moisture
Rarely moist
Occasionally
moist
Very moist
Constantly
moist
Excellent
Adequate
Probably
inadequate
Activity:
activity
Degree
of
Nutrition:
Usual food intake pattern
physical
Very poor
Norton Risk Assessment Scale The Norton Scale is designed to score eight risk
factors----mental condition, nutritional condition, activity, mobility, incontinence, circulation,
temperature, medications. This tool is especially used to assess pressure ulcer risk factors of the
old clients. A lower score indicates a higher risk for pressure ulcer development. If a client with a
score of 14 or below is considered at risk of pressure ulcer.
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Table 5-3 the Norton Scale
Items/points
4
3
2
1
Mental condition
Nutrition condition
Mobility
Activity
Incontinence
Alert
Good
Full
Ambulatory
Absent
capillary vessel
affused
promptly
Confused
Poor
Very limited
Chair-bound
Fecal
incontinence
Edema slightly
Stupor
Very poor
immobile
Bedfast
Double
Circulation
Apathetic
Fair
Slightly limited
Walks with help
Urine
incontinence
capillary vessel
affused slowly
Edema
moderately
seriously
Temperature
36.6-37.2℃
37.2-37.7℃
37.7-38.3℃
＞38.3℃
Medications
Not
Administering
sedatives
and
steroidal drugs
Administering
sedatives
Administering
steroidal drugs
Double use
or
Common Pressure Ulcer Sites
The nurse includes visual and tactile inspection over the body areas most frequently at risk
for pressure ulcer development. When a client lies in bed or sits in a chair, body weight is heavily
placed on certain bony prominences. Body surfaces subjected to the greatest weight or pressure
are at greatest risk for decubitus ulcer formation. The common sites of pressure ulcer are different
with different position.
Supine position: Occipital bone, scapula, spine carina, elbow, iliac crest, sacrum,
heel
Lateral position: ear, shoulder, elbow, anterior iliac crest, trochanter, medial knee,
lateral knee, medial malleolus, lateral malleolus
Prone position: cheek (chin), ear, shoulder, breast(female), genitals(male), iliac crest,
knee, toes
Sitting position: ischium tuber, shoulder, elbow, sacrum, sole
Figure 5-1 common pressure
ulcer sites
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Preventative interventions
When the client is immobile, the major risk to the skin is the formation of pressure ulcers.
Nursing interventions focus on prevention of pressure ulcer.
Avoid pressure on local tissues permanently
Turn the patients periodically (every 2 hours or 30 minutes necessarily)
The immobilized client should be repositioned at least every 2 hours. But the exact
time interval is individualized. If redness on bony prominence is noted, the client should be
repositioned more frequently, every 30 minutes necessarily. In the sitting position, the pressure on
the ischial tuber is greater than when in the supine. In addition, a high risk client sitting in a chair
should be taught or assisted to shift weight every 15 minutes. Shifting weight provides short-term
relief on the ischial tuber. A client should also sit on gel or an air cushion to redistribute weight so
that it is not all on the ischium. Rigid and donut-shaped cushions are contraindicated because they
reduce blood supply to the area, resulting in wider areas of ischemia. A written turning and
positioning schedule is recommended to use to ensure correct position turning. After the client is
repositioned, the nurse reassesses the skin and observes for normal reactive hyperemia and
blanching. The reddened areas should never be massaged. Massaging the reddened areas increases
breaks in the capillaries in the underlying tissues and increases the risk of pressure ulcer
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formation.
Protect bony prominence and support interspace
A variety of special beds and mattresses have been designed to reduce the hazards of
immobility to the skin and musculoskeletal system. However, none eliminates the needs for
meticulous nursing care. No single device eliminates the effects of pressure on the skin. Clients
and families need to be taught the reason for and proper use of beds or mattresses. When used
correctly, these mattresses and specialty beds assist in reducing pressure ulcers in high-risk clients.
Special mattresses such as air-filled or water filled alternating pressure mattresses, and sheepskin
sheets are validated to prevent the formation of pressure ulcer. Positioning devices such as pillows
can be used to keep body weight off bony prominences. For example, a standard pillow under the
calves effectively raises the heels off the bed and alleviates pressure.
Devices used to prevent or treat pressure ulcers
Devices to support pressure areas
Flotation pads are pliable pads with a consistency like body fat, which disperse pressure
over a larger area. Pillows and bridging techniques lift the pressure site off the mattress
and separate two points of pressure.
Devices to aid in turning a client
A Guttman bed rotates the client from prone to supine positions and from side to side.
Kinetic therapy continuously rotates the client 270 degrees every 3 minutes.
Devices to minimize or equalize pressure
Alternating air mattresses made of polyvinyl air cells are attached to a pump that
inflates and deflates them every 3-7 seconds, alternating pressure points.
Water mattresses disperse and evenly distribute the client’s body weight.
High and
low
loss bedright,
allowsuch
deformation
of bed
surface splint,
to the body
contours,
Use
theairdevices
as plaster,
bandage,
retractor
thereby The
reducing
tissue pressure
capillary
closure.
also eliminate
nurse should
watch outbelow
for dressing
condition
andThese
color,beds
temperature
of toes and
shear
and
friction
and
reduce
moisture.
fingers for clients with plaster, bandage, splint, retractor. What’s more, the nurse should adjust
degree of tightness appropriately according clients’ complaint and circulation condition of local
tissue.
Reduce shear and friction
To prevent injury due to friction and shearing forces, clients must be positioned, transferred,
and turned correctly. When moving a client to change position, nurses should lifting rather than
dragging the client across or up in bed. The friction that results from dragging the skin against a
sheet can cause blisters and abrasions, contributing to more extensive tissue damage. For
bedridden clients, shearing force can be reduced by elevated the head of the bed to no more than
30 degrees.
Protect skin of patients (Hygiene and skin care)
The nurse must keep the client’s skin clean and dry. When the skin is cleaned, soaps are
avoided. Soaps and alcohol-based lotions cause drying and leave an alkaline residue. The alkaline
residue discourages the growth of normal skin bacteria, thus promoting an overgrowth of
137
opportunistic bacteria, which can then enter an open wound.
After the skin is cleansed and completely dried, protective moisturizer should be applied to
keep the epidermis well lubricated but not oversaturated. Cornstarch is a dry lubricant and helps to
reduce friction. A & D, Unicare, and Pericare are bland, water-repellent ointments that protect the
skin from moisture. In addition, these ointments are easily cleansed from the skin. When the nurse
uses any water-repellent ointment, the nurse must completely clean the area on a routine basis.
Ointment, when left in place too long, can be a medium for bacteria and can cause further skin
problems such as maceration and infection. When the client’s skin is exposed to body fluids such
as urine, stool, or wound drainage, the area should be cleansed, and a skin barrier containing
petrolatum (e.g., Vaseline) or zinc oxide is applied. These barriers protect the skin from excessive
moisture and toxins from urine or stool.
When clients are incontinent, absorptive underpads such as adult diapers or incontinence
briefs can be used. Those products drain moisture away from the client’s skin. The proper
absorptive garments have a quilted lining and contain a polymer filling. The newer products also
lubricate the skin as well as protect from moisture. These absorptive underpads are placed in direct
contact with the skin. As the client moves, the skin is lubricated and friction is reduced and excess
moisture is absorbed into the pad. When providing skin care to the incontinent client, the heath
care team must also assess and treat the causes of the incontinence.
Stimulating blood circulation of skin
For immobilized clients, active or passive ROM exercise on bed is necessary to promote
blood circulation. Warm water bathing on bed not only cleanses clients’ skin but also stimulates
skin circulation. However, the water cannot be too hot which can burn the skin.
Provide adequate nutrition
Because an inadequate intake of calories, protein, and zinc is believed to be a risk factor for
pressure ulcer development, nutritional supplements should be considered for nutritional
compromised clients. The nurse should ensure that clients receive sufficient protein, vitamins (A,
C, B1, B 5), and zinc.
Health education: Educate clients and care givers regarding pressure ulcer
prevention
Clients and families need an understanding about basic information about pressure ulcers in
order to effectively participate in or to independently carry out measures to prevent pressure ulcers.
The nurse must present following information: risk factors, common sites, manifestations, and
preventive and treating interventions of pressure ulcers.
Treating and nursing pressure ulcer
Stages of Pressure Ulcer
There are four recognized stages in pressure ulcer formation related to observable tissue damage.
Stage I Stage I pressure ulcer is called nonblanchable erythema of intact skin, the heralding lesion
of skin ulceration, occurs. The ulcer appears as a defined area of persistent redness lightly
pigmented skin, whereas in darker skin tones the ulcer may appear with persistent red blue or
purple hues. Redness, swollenness, heat, and pain may appear on the affected area.
Stage Ⅱ Partial thickness skin loss involves damage or necrosis of epidermis, dermis, or both.
The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
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Stage Ⅲ Full thickness skin loss involves damage or necrosis of subcutaneous tissue that may
extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater
with or without undermining of adjacent tissue. The client complains of more severe pain.
Stage Ⅳ Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle,
bone, or supporting structure such as tendon or joint capsule. Undermining and sinus tracts may
also be associated with stage Ⅳ pressure ulcers. The severe case may complicate with
septicopyemia, which can lead to death.
Stage I
Stage Ⅱ
Stage Ⅲ
Stage Ⅳ
Treating pressure ulcer
Despite preventive tactics, pressure ulcers may develop in certain high-risk individuals.
Effective treatment measures by the nurse are the key to healing pressure ulcers. Clients, families,
and health care providers collaborate and communicate to decide on appropriate treatment goals.
Aspects of pressure ulcer treatment include local care of wound and supportive or systemic
measures.
Supportive or systemic measures:
Supportive measures involve providing adequate nutrition, controlling infection and so on.
Nutritional status
Maintaining adequate protein intake and hemoglobin levels is important in treatment of
pressure ulcers.
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Protein status. Clients with a potential for or decreased serum albumin levels or
poor protein intake need a nutritional evaluation to ensure proper caloric intake. Increased protein
intake, 2 to 4 times above the daily recommended requirement, helps rebuild epidermal tissue.
Increased caloric and protein intakes help promote healing of pressure ulcers. Increased intake of
vitamin C promotes protein synthesis and tissue repair.
Hemoglobin. A low hemoglobin level decreases delivery of oxygen to the tissues
and leads to further ischemia. When possible, hemoglobin should be maintained at 12 g/100 ml.
Controlling infection
When a patient has a pressure ulcer the prevention of infection is prime nursing
concern. Infection not only tetrads healing of ulcer, but also may lead to systemic infection. This
in turn may cause septicopyemia, or even death. Body substance isolation and good handwashing
technique must be followed to prevent infection. Sterile dressing and instrument are used for
dressing following infection control procedures.
Local care of the wound
Stage I
In stage I, care emphasizes on eliminating risk factors or contributing factors to
pressure ulcers, preventing pressure ulcers from progressive development.
As followed, preventive interventions can be effectively used now, such as increasing
turning frequency, avoiding local tissue pressed long term, improving circulation, keeping bed
linen clean, smooth, dry without oddment, reducing friction and shearing force, avoiding excretion
and moisture stimulating to skin, increasing nutrition and enhancing immunity and so on.
Stage Ⅱ
In stage Ⅱ, care focuses on protecting skin and preventing infection.
Besides preventive measure followed, the nurse should intensify care of blister. Small
untorn blister should be minimized being touched and chafed, preventing infection. It will be
absorbed by itself. While for big blister the nurse should draw out liquid in blister with sterile
injector, unnecessarily scissoring pellicle, and then sterilize the surface and cover it with sterile
dressings. The nurse may choose ultraviolet or infrared treatment.
Stage Ⅲ
In stage Ⅲ, care focuses on keeping cleanliness of the ulcer area.
Moisture-retentive dressings are recommended for pressure ulcers because they create a
healing environment. It allows epithelial cells or bridge the open surface of the wound more easily
and close it. Some dressing can keep the wound moist but still allow gas exchange to occur
between the wound and the environment. These dressing also decrease the risk of infection. Types
of moisture-retentive dressing include transparent films, hydrocolloid dressing, and hydrogels.
Stage Ⅳ
In stage Ⅳ, care focuses on cleaning the ulcer area, debriding necrotic tissue (such as
eschar and slough), keeping drainage smoothly, promoting acestoma growing. Chinese traditional
medicine is one of the most effective in treating pressure ulcer.
When the ulcer area develops infection, the ulcer should be rinsed with sterilized
normal saline or 1:5000 Furacilin solution, and then covered with sterilized Vaseline gauze or
dressings which need be changed once a or two days. The ulcer may also be covered with
Metronidazole dressing or be daubed with Sulfapyridine Argentums or Furacilin after rinsing the
ulcer area with normal saline. If the ulcer is very deep and drainage is obstructed, the ulcer can be
140
cleansed with 3% Hydrogen Peroxide solution that can restrain anaerobic bacteria.
In addition, oxygen therapy can be used. Purified oxygen may not only restrain
anaerobic bacteria growing and promote metabolism of the affected tissue but also keep the ulcer
area dry and promote scabbing and cicatrizing.
For large size of ulcer deep to bone, the nurse should cooperate with the doctor to
debride necrotic tissue or eschar or slough, and repairing impaired tissue by skin grafting and skin
flap. Eschar is a thick, leathery devitalized necrotic tissue. Slough is the shedding of loose,
stringy necrotic tissue as the result of skin ulceration.
Providing care in other treatment options
Several treatments modalities are being considered and investigated at present. They
include electrical stimulation, laser irradiation, ultrasound, and miscellaneous topical agents and
systemic drugs.
141