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Nursing
Hygiene and Self-Care
| Question | Answer |
|---|---|
| Nurse Professional Appearance | Clean and neat hair style, excellent oral and skin care, minimal make up, minimal jewelry, short and natural nails, no perfumes, clean shoes, clean, wrinkle free uniform |
| Early morning care-Usually before breakfast | Assist to bathroom, BSC, bedpan, or urinal. Provide supplies for hand/face washing, mouth care, comb hair. Assist with glasses, denture, and hearing aide insertion |
| AM Care- Usually After breakfast | Assist with partial or complete bath, shower, or baths in bag. Provide privacy. Maintain safety. Keep H2O warm and change PRN. Wash top to bottom front to back. Use gentle, firm strokes. Dry thoroughly. Promote independence. |
| Leg, foot and nail care | Wash feet with lukewarm water. Dry thoroughly especially in-between toes. Apply lotion to dry areas. Always remove TEDs and SCDs before bath and replace after completion. Avoid massage of reddened areas. |
| Hair Care | Comb or brush hair. Wash as appropriate: shampoo and water, waterless shampoo, hair bags. Shaving: groom beard and mustache, shave in direction of hair growth, note if pt on blood thinners-use electric razor |
| Mouth and Oral Care | Assist with brushing and flossing-pt on blood thinner, soft brush. Use swabs for pts with stomatitis (inflammation in mouth). Pt with dentures: Clean mouth, clean dentures (line sink with wash cloth or towel) |
| Mouth and Oral Care for pt on Oxygen | Mucous membranes dry out. Keep moist and provide good mouth care. |
| Mouth and Oral Care for unconscious pt | Lower the head of bed. Place pt in sims position. Head well Towards side. Use kidney basin and suctioning to prevent aspiration |
| Eye care | Use new area of wash cloth on each eye. Wash Inner to outer canthus. Assist removal/insertion of contacts/artificial eye. Clean glasses and assist with placement |
| Ear Care | Wash behind ears and in ear with moistened end of wash cloth. Never use sharp objects to clean ear canal. Clean hearing aides with soft cloth. Assist with placement of hearing aides. Turn on After you put around ear |
| Nose Care | Particular attention is required when a pt has a nasogastric, feeding, or endotracheal tube inserted through the nose: clean accumulated secretions from around tube, replace tape once a day to prevent nasal mucosal irritation |
| Feeding | Assess pt's ability to feed themselves. Desire to make food choices/eat. Energy and muscular movement to eat. Ability to chew and swallow. |
| Toileting | Use of toilet, bedside commode, or bedpan. Frequently associated with falls. Assess pt's condition to assist. Check ambulation orders. Urinal use. Keep off of bed table. If urinal is full, assess amount of urine, color, and clarity, empty & record output |
| Dressing and Grooming | Personal preferences. Clothing if any. Hair- wash and comb. Shaving- use electric razor for pt taking anticoagulants. |
| Bed Time Care | Assist with elimination. Assist pt in washing hands and face. Oral Care. Skin care. Straighten or change bed linens PRN |
| Back Massage | Used as a relaxant after the bath or at bed time. Use warm lotion. Use long, slow, gliding strokes-effleurage. Increased comfort and relaxation in as little as 3 mins. |
| Lifespan considerations | Younger people may be independent with self-care. Older adult- skin less elastic, thinner, hair is thinner, dentures, may be HOH |
| Factors affecting self-care | Environment, lack of access to facilities, poverty may limit resources-water. Pts in wheelchairs- wheelchair access. Motivation. Belief that self-care is important. Pt to be as independent as possible |
| Cognitive Ability and Self Care | May not recognize the need for care. May not be able to safely perform care. |
| Pain and Self care | Pt may be unwilling to move or care for themselves |
| Nursing Diagnosis | Self care deficit. Impaired skin integrity. Risk for injury. Impaired mobility. Ineffective health maintenance. |
| Bathing rationales | Provides opportunity for thorough skin assessment. Eliminate perspiration, skin oils, dead skin cells, and bacteria. Prevents body odor. Enhances circulation and conditions skin. Stimulates resp rate and depth. Provides sensory input |
| Pts most in need for perineal care | Those at greatest risk for infection: uncircumcised males, pts with indwelling catheters, rectal/genital surgery/birth |
| Male perineal care | Clean crevices. Retract and replace forskin |
| Female perineal care | Clean front to back. Maintain a professional attitude to avoid embarrassment. Engage pt in conversation for diversion |
| Room Clean-up and safety | Functioning call light within reach at all times. Bed in low position. Wheels locked. Uncluttered wall space. Note temperature, ventilation, noise, and lighting in relation to pt's preference. |
| Bed making | Wear clean gloves. Encourage pt to get out of bed. Place soiled linens in linen bag avoiding contact with your uniform. Avoid shaking sheets, fold out on the surface of bed. Do not place pillow under your chin. |
Created by:
senmark
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