Nursing Management of Clients
with Stressors that Affect
HYGIENE
NUR101
Lecture # 5
Fall 2008
K. Burger, MSED, MSN, RN, CNE
PPP by: Sharon Niggemeier, RN MSN
Revkburger906,707
Hygiene
Principles of skin care
Healthy intact skin and mucous
membranes are the body’s first
line of defense against pathogens
Adequate circulation, nutrition,
hydration and resistance to injury
are necessary to maintain intact
skin
Assessing Personal Hygiene
Skin
Hair
Nails
Oral
Shaving
Skin Assessment
Color
Temperature
Turgor
Texture
Dryness
Lesions
Rashes
Factors Affecting Hygiene Needs
Developmental
Cultural
Spiritual
Knowledge
Physical health
Socioeconomic
Personal preference
Bathing
Cleanses skin
Relaxes client
Promotes circulation
Promotes comfort
Sensory input
Increases self image
Promotes nurse-pt.
relationship
Shower/tub safety
Gather all supplies
Assist into tub/shower
Use shower chair
Check water temperature
Provide privacy
Don’t lock door
Assist with bathing
Bedbaths
Bath given in bed for those on
CBR (complete bed rest)
Provide privacy/Use a bath blanket
Allow pt. to complete as much as
possible, assist as needed
Nursing Interventions Bathing
Monitor skin integrity
Water temp.110-115 F
Use lotions and omit soap if skin
is dry
Use powder/deodorant as per
personal preference
Provide massage
Shampooing-Interventions
Wet hair, lather, rinse, dry
Shampoo in bed-utilize trough
and basin
Dry/spray shampoos
Style as best to pt. likes
Shaving-Interventions
Anticoagulant therapy?
Wear gloves
Pull skin taunt
Let soap/shave cream
soften hair
Shave in direction hair
grows
Use electric razors if
possible
Oral Hygiene-Interventions
Wear gloves
Assess oral hygiene
Assist brushing teeth
Assist flossing
Denture care
Teaching oral care
Oral care dependent
client
Perineal Care
Female-always wash from front (pubic
area) to back (to anus), separate labia,
cleanse down center of perineum
Male-wash from tip of urinary meatus in
circular motion then down shaft. If
uncircumcised remember to retract
foreskin, cleanse, then return foreskin
over tip
Assessing Skin Integrity
Risk
assessment
scale Braden
Note if skin is
intact
If not intact note
location, size,
color, exudate,
granulation
tissue of lesion
Reactive
hyperemiareddened area
that fades 1-2
hrs. after
pressure has
been removed.
Not a stage I
pressure ulcer
Impaired Skin Integrity
Pressure ulcers-lesions caused
by unrelieved pressure
Pressure causes blood vessels to
collapse-necrosis death of cells
results
Cells die and ulcer develops
Factors Affecting Pressure Ulcer
Development
Mobility
Nutrition &
hydration
Moist skin
Physical
health
Age
Friction
Shearing
force
Mental status
THINK-PAIR-SHARE
60,000 Americans die from complications
related to pressure ulcers.
The National Pressure Ulcer Advisory Panel
estimates that more than 1 million patients in
hospitals and nursing homes have pressure
ulcers.
Approximately $1.3 billion is spent annually
in the U.S. on pressure ulcers 2,663 LTC
providers received pressure ulcer
deficiencies in 2001.
Average monetary recovery in pressure
ulcer cases is $13.5 million; the median
recovery is $1.06 million. Juries find in
clients’ favor 74% of the time.
Stages of Pressure Ulcers
Stage I- reddened area
Non-blanchable erythema
Stage II – partial-thickness skin
loss,abrasion,blister or shallow crater
Stage III- full thickness skin loss, open
lesion crater exposing subcutaneuos
tissue
Stage IV- full thickness skin loss,
extensive tissue necrosis, damage to
muscles and bone possible.
Skin Integrity- Nursing
Interventions
PREVENTION of pressure ulcers
Assess skin especially bony
prominences daily
Increase mobility and activity
T & P q2h
Linens dry & wrinkle free
Skin and clothing dry
Skin Integrity-Nursing
Interventions
Avoid friction/shearing
Protective positioning:
Thirty degree lateral position
Maintain proper nutrition/hydration
Redistribute pressure by applying
specialty mattress ie: air mattress,
Clinitron bed; PUP mattress
(Specialty mattress requires physician order)
Therapeutic Mattress / Bed
Alternating
Pressure Mattress
Example: PUP
Air-fluidized
Mattress
Example: Clinitron
Evaluation Hygiene
Has all clients hygiene needs
been met?
Is client more comfortable?
Have potential problems been
resolved?
Critical Thinking
Ms Jenkins is a 58y.o. female with
metastatic cancer of the bladder. She is
alert & oriented X3 but extremely fatigued
from her chemotherapy treatments. She
has been bedfast for 5 days and is very
uncomfortable changing positions in bed.
She is often incontinent of urine. Her
current ht =5’5” wt =105 lbs and she is
anorexic as a side effect of her therapy.
USE THE BRADEN SCALE TO ASSESS
MS JENKINS RISK FOR PRESSURE
ULCER