Nursing Management of Clients with Stressors that Affect HYGIENE

NUR101Lecture # 5Fall 2009

K. Burger, MSED, MSN, RN, CNEPPP 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 pathogensAdequate circulation, nutrition, hydration and resistance to injury are necessary to maintain intact skin

Assessing Personal Hygiene

Skin HairNailsOral Shaving

Skin AssessmentColorTemperatureTurgorTextureDrynessLesionsRashes

Factors Affecting Hygiene NeedsDevelopmentalCulturalSpiritualKnowledgePhysical healthSocioeconomicPersonal preference

BathingCleanses skinRelaxes clientPromotes circulationPromotes comfortSensory inputIncreases self imagePromotes nurse-pt. relationship

Shower/tub safetyGather all suppliesAssist into tub/shower Use shower chair Check water temperatureProvide privacyDon’t lock doorAssist with bathing

BedbathsBath given in bed for those onCBR (complete bed rest)

Provide privacy/Use a bath blanketAllow pt. to complete as much aspossible, assist as needed

Nursing Interventions Bathing

Monitor skin integrityWater temp.110-115 FUse lotions and omit soap if skin is dryUse powder/deodorant as per personal preferenceProvide massage

Shampooing-Interventions

Wet hair, lather, rinse, dryShampoo in bed-utilize trough and basin Dry/spray shampoos Style as best to pt. likes

Shaving-InterventionsAnticoagulant therapy?Wear glovesPull skin tauntLet soap/shave cream soften hairShave in direction hair growsUse electric razors if possible

Oral Hygiene-Interventions

Wear glovesAssess oral hygieneAssist brushing teethAssist flossingDenture careTeaching oral careOral care dependent client

Perineal CareFemale-always wash from front (pubic area) to back (to anus), separate labia, cleanse down center of perineumMale-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 BradenNote if skin is intact If not intact note location, size, color, exudate, granulation tissue of lesion

Reactive hyperemia- reddened 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 pressurePressure causes blood vessels to collapse-necrosis death of cells resultsCells die and ulcer develops

Factors Affecting Pressure Ulcer Development

MobilityNutrition & hydrationMoist skinPhysical health

AgeFrictionShearing forceMental status

THINK-PAIR-SHARE60,000 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 UlcersStage I- reddened area

Non-blanchable erythemaStage II – partial-thickness skin loss,abrasion,blister or shallow craterStage III- full thickness skin loss, open lesion crater exposing subcutaneuos tissueStage IV- full thickness skin loss, extensive tissue necrosis, damage to muscles and bone possible.

Skin Integrity- Nursing Interventions

PREVENTION of pressure ulcersAssess skin especially bony prominences dailyIncrease mobility and activityT & P q2hLinens dry & wrinkle freeSkin and clothing dry

Skin Integrity-Nursing Interventions

Avoid friction/shearingProtective positioning:Thirty degree lateral position Maintain proper nutrition/hydrationRedistribute 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 MattressExample: 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