Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K....
-
date post
22-Dec-2015 -
Category
Documents
-
view
215 -
download
0
Transcript of Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K....
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
Hair
Nails
Oral
Shaving
Skin Assessment
ColorTemperatureTurgorTextureDrynessLesionsRashes
Factors Affecting Hygiene Needs
DevelopmentalCulturalSpiritualKnowledgePhysical healthSocioeconomicPersonal preference
BathingCleanses skinRelaxes clientPromotes circulationPromotes comfortSensory inputIncreases self imagePromotes 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 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, dry
Shampoo in bed-utilize trough and basin
Dry/spray shampoos
Style as best to pt. likes
Shaving-Interventions
Anticoagulant therapy?Wear glovesPull skin tauntLet soap/shave cream soften hairShave in direction hair growsUse 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 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 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-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 erythema
Stage 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/shearing
Protective 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 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