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    19 views54 pages

    NCM 122 Nursing Interventions

    Uploaded by

    Rody Seraspe

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    Nursing Interventions stn pei Fundamentals of Nursing Practice Nathalie C. Fat, RN, MAN The science of health and its maintenance. GE Personal hygiene is the self-care by which people 7 = attend to such functions as bathing, toileting, general body hygiene, and grooming HYGIENIC CARE SCHEDULE EARLY MORNING CARE ‘As they awaken “Provide urinal or bedpan “Wash face and hands, ora are MORNING CARE eee ery Parente les HOUR OF SLEEP/ PM CARE | nine rir tented enter ut AS NEEDED (PRN) ‘As required by the cent FACTORS INFLUENCING HYGIENE PRACTICES [_currure || RELIGION ENVIRONMENT FACTORS INFLUENCING HYGIENE PRACTICES DEVELOPMENTAL ONAL LEVEL HEALTH PERS EFERENCES AND i ENERGY Definitions and Descriptors for Functional Level Oy) (1) | (+2)Semi-dependent | (+3) Moderately (+4) Totally Completely | -Requires use | -Requires help from dependent dependent independent | of equipment | another person for | -help from another | _-Does not ordevice | assistance, supervision | person, and participate in orteaching __| equipment or device activity ‘Bathing Theanepronieteqdpmant, | Rune nopiealleesomens |The clent needs 2 Footantbecartintbed) | poston ent washertock Cincom Client completes | nts serneon oietner | Complete bath: heath, ecartortetaa | Pore seeeded The client | Annet assist atl. eet canassist =] Thenusepovises equpmen | The nase he bask wes | The murze completes theclient does the task. | mouth on posions the as Hygiene Sent asec process Tierunepahentewstathe | Thenaneconindewshon | Teclrtvendrtobe Dressing/ onimaybaten ip orve | aut wandresing bwtons, | dressed, andar st Grooming ‘oting The lent dresses | tescoting sedis shoes | theme; neon ‘le/herslt ‘Seetsate Tolleting The lent canwalktothe | Thenurse providers | The cents ‘bathroom/ commode with | bedpan,peutoretmecent_| incontinent’; the nurse ssitance; the nur hele | enoretibeteasan ana | aces the client on 2 oes recmuectententte | bedpan or commode. TYPES OF SKIN LESIONS * Macule A flat, circumscribed area of color with no elevation of its surface 1mm to 1cm freckles, flat moles TYPES OF SKIN LESIONS * Patch Same as macule but waa larger than 1.cm r Ae port wine birth mark ’ TYPES OF SKIN LESIONS * Papule * Acircumscribed, solid elevation of skin * Less than 1cm * Warts, Acne TYPES OF SKIN LESIONS ¢ Plaque * Same as papule but larger than cm * Eczema TYPES OF SKIN LESIONS * Nodule + Asolid mass that extends deeper into the dermis than does a papule * Pigmented mole TYPES OF SKIN LESIONS °Tumor * A solid mass larger than a nodule * Epithelioma TYPES OF SKIN LESIONS + Cyst * Elevated, thick-walled lesion containing fluid or semi-solid matter TYPES OF SKIN LESIONS * Vesicle * A circumscribed elevation containing serous fluid * Less than Icm * Blister, Chickenpox Te Cun To TYPES OF SKIN LESIONS + Bulla * A larger-fluid filled sac TYPES OF SKIN LESIONS * Pustule A vesicle or bulla filled with pus Acne vulgaris Impetigo TYPES OF SKIN LESIONS + Wheal * A relatively reddened, elevated, localized collection of edema fluid, irregular in shape + Mosquito bite * Hives * Urticaria TYPES OF SKIN LESIONS + Telangiectasia * Dilated capillary, fine red lines * Seen in patients with certain conditions like Liver cirrhosis TYPES OF SKIN LESIONS *Petechiae + Pinpoint red spots Secondary skin lesions * Scale *Thickened epidermal cells * Dandruff, psoriasis Secondary skin lesions * Crust + Fissure * Dried serum or pus on A deep linear crack the skin Athlete’s foot * Impetigo Secondary Skin Lesions * Erosion + Excoriation * Loss of all parts of the * A superficial linear or epidermis hollowed-out crushed area + Appears moist demarcated exposing the dermis depressed areas * Ex. Scratch * Ex. Ruptured chicken pox vesicles Secondary skin lesions * Atrophy * Scar A decrease in the volume of the epidermis A formation of a connective tissue Striae healed wound Aged skin Secondary Skin lesions * Lichenification * Ulcer = Epidermal thickening resulting in * An excavation extending into elevated plaque with an the dermis or below accentuated skin marking * Due to repeated scratching or * Decubitus ulcer rubbing * Chronic atopic dermatitis General guidelines for skin care ¥ Intact, healthy skin is the body’s first line of defense v The degree to which the skin protects the underlying tissues from injury depends on the general health of the cells, the amount of subcutaneous tissue, and the dryness of the skin. ¥ Moisture in contact with the skin for more than a short time can result in increased bacterial growth and irritation. General guidelines for skin care ¥ Body odors are caused by resident skin bacteria acting on body secretions. Skin sensitivity to irritation and injury varies among individuals and in accordance with their health v Agents used for skin care have selective actions and purposes. Common Skin Problems Problem and Appearance Nursing Interventions + ABRASION * Keep the wound clean and dry + Superficial layers of the skin are to prevent infection eee sar eee i * Lift instead of sliding, pulling, or : pear red, and may have 5 Seer localized bleeding or serous pushing the client into bed weeping * Use two or more people for assistance Do not wear jewelry when performing procedures Common Skin Problems Problem and Appearance Nursing Interventions * EXCESSIVE DRYNESS + Apply cream, or alcohol-free + Flaky/scaly and rough lotion or moisturize the skin to prevent it from cracking, or having an infection. * Encourage fluid intake * Bathe less frequently, use nonirritating soap or limit use of soap, and rinse skin thoroughly Common Skin Problems Problem and Appearance Nursing Interventions * AMMONIA DERMATITIS * Keep skin dry and clean by (DIAPER RASH) applying protective ointments containing zinc oxide to areas at * Cause by skin bacteria reacting with urea in the urine * Boil or wash cloth diapers with antibacterial detergents, and rinse thoroughly. risk. * red and sore Common Skin Problems Problem and Appearance Nursing Interventions * ACNE * Keep skin clean to prevent * Inflammatory condition with infection papule and pustules * Avoid cosmetics and oily creams * Treatment varies widely + Avoid foods with high carbohydrate and fat content Common Skin Problems Problem and Appearance * ERYTHEMA * Redness associated with different conditions such as: * Rashes * Exposure to sun * Elevated body temperature We Nursing Interventions * Wash the area carefully to remove excess microorganisms. * Apply antiseptic spray or lotion to prevent itching, promote healing, and prevent skin breakdown. Common Skin Problems Problem and Appearance + HIRSUTISM + Excessive hair on a person's body and face * Usually women Nursing Interventions * Remove unwanted hair using depilatories, shaving, electrolysis, or tweezing * Enhance client’s self-concept Common Skin Problems Problem and Appearance Nursing Interventions * Hyperhidrosis — excessive * Management: Anticholinergic perspiration drugs, Botox (block), surgery (stop), iontophoresis/ electrolysis (temporarily close) * Address underlying condition * Bromhidrosis — foul-smelling perspiration + Vitiligo — patches of Pypopienoie skin due to * Topical and laser treatments jlestruction of melanocytes in ji * Avoid sun exposure (aggravate the area (no cure) the Condition) (age TYPES OF BATHS * 1. Cleansing baths — hygiene purposes + 2. Therapeutic baths — given for physical effects - to soothe irritated skin or to treat a specific area Cleansing baths [Complete bed bath ‘The nurse washes the entire body of a dependent client in bed. Selt-help bed bath ‘The client is able to bathe with help from the nurse like the back. | Partial bath (abbreviated bath) Only parts of the body that might cause discomfort Bag bath Use commercially prepared 10-12 presoaked disposable washcloths that contain no-rinse cleanser solution. ‘Towel bath Uses regular towels; useful for bedridden, and with dementia Tub bath Use for therapeutic baths, the degree of assistance depends on the clients ability Dependent clients ‘Sponge bath — Newborn ‘Ambulatory clients; minimal assistance eas | Water temperature should be warm or feel comfortable to client 43-46 °C/ 110-115 °F Lifespan consideration ™, Infants Children Adolescents -sponge bath -do not leave -active sweat glands -daily tub bath are phasis Deodorants/ not necessary -Encourage antiperspirants participation Lifespan consideration Older Adults -minimize dryness -flexible bath schedule -give choices -use calm approach -stop when distressed -shorten bath -moisturize -avoid excessive powder ensure safety PURPOSE OF BED BATH * Bathing is an important part of personal hygiene * Bathing cleanses the skin makes the patient more comfortable + It stimulates the circulation and relaxes the patient. * It’s a good opportunity to serve the observe the client body and as well as communicate with the patient. Fig |. The procedure: bed bathing a patient 1d. Wash the genital area of fernsle patients from front to Back Te. Wash the patients back and sacrum, moving from top to Perineal-Genital Care * Perineal-genital care + Perineal care or pericare + Part of the bed bath + The client will clean his/ her genitalia with minimal assistance. + “I'll give the washcloth to finish your bath or clean your private parts in privacy.” * Wear gloves. Perineal Care Those patients who may need the nurses’ assistance’ — Vaginal ar urethral discharge - Sanimiation - Catheter ~ Surgical dressings ~ /ncontinent of urine ar feces Perineal-Genital Care Draping the patient for Position: perineal-genital care lesitions * Female: dorsal recumbent position * Male: supine position * When cleaning the anus, side- lying [FIGURE 16-24 Separate the labia with 1 hand, Use amited washcloth FIGURE 16-25 The etal area fs deamed by wiping from the vagina to 1 dean betwen the Labia with dowrmnard stole the ans The sie yng positon lows the ana area tobe deaned more oreuy Perineal-Genital Care For female clients: * Use separate quarters of washcloths (cotton balls) each stroke * Use anterior to posterior stroke (up-downward/ front to back) * Rinse and dry thoroughly (use a bedpan). * For menstruating women and with indwelling catheters, use wipes. + For post-delivery and menstruating women, apply perineal pad. Perineal —Genital Care For male clients: Wash and dry the penis with firm strokes. + Use circular motion from the tip of the glans penis towards the penile shaft. + If uncircumcised, retract the prepuce (foreskin)- to remove smegma * Wash and dry scrotum and buttocks/ anus. Common NURSING DIAGNOSIS Foot Care + Part of the bath * Eliminate sources of infection and decrease odors * Assess feet and nails * Wash feet daily, and dry them, especially the interdigital spaces. * Use warm water or foot soak — soften nails loosen debris Foot Care * Change socks or hosiery daily. * Trim nails only if permitted or allowed in your institution — but mostly not allowed * Teach the client to cut nails straight across + Show close attention to diabetic patients — peripheral neuropathy; risk for infection; and gangrene + Wear comfortable, well-fitted shoes. + Exercise feet — promote circulation. * Avoid constricting clothing- impede good circulation * Avoid crossing your legs. Common Foot Problems Callus Corn * Painless, flat, a thickened * Keratosis caused by friction and epidermis-a mass of keratotic pressure from a shoe materlalk * Circular and raised * Bony prominences + Fourth and fifth toe bib from shoes * Can be removed surgically * Soak with Epsom salts + Wear comfortable shoes and * Apply lanolin creams massaging toes * Use oval corn pads Common Foot Problems Unpleasant odors Plantar warts * Perspiration and interaction with * Papovavirus Hominis Virus microorganisms * Contagious * Frequent washing, and wearing + Cause pain and difficulty hosiery walking * Use foot powders/ deodorants —« Apply salicylic acid * Curettage/ Freezing with CO2 Common Foot Problems * Dryness Fissures * Cracks in the skin * Foot hygiene and application of antiseptic Common Foot Problems * Inward growth of the nail causing Ingrown toenails trauma to soft tissues * Due to trimming the lateral edges * Surgical removal of the portion of t * Frequent hot antiseptic soaks iene the nail embedded in the skin * Proper nail-trimming technique Common Foot Problems Tinea Pedis * Cracking and scaling of the skin particularly between toes, caused by fungus * There may be blisters * Athletes’ foot, ringworm of the foot Nail Care Common Nursing Diagnosis acs Tay eet) lesen Common Problems of the Mouth Halitosis Glossitis Gingivitis Periodontal disease Reddened or excoriated mucosa Excessive dryness of the buccal Cheilosis Dental carries Bad breath ‘Teach or provide oral hygiene Inflammation of the tongue As above Inflammation of the gums As above Gums appear spongy and bleeding As above Check for ilhfitting dentures Increase fluid intake as health permits Cracking of lips Lubricate lips; use antimicrobial ointment Teeth have darkened areas; may be Advise to see a dentist painful Common Problems of the Mouth * SORDES * Accumulation of foul matter in the mouth * Teach or provide regular cleaning Common Problems of the Mouth * STOMATITIS + Inflammation of the oral mucosa * Teach or provide regular cleaning Common Problems of the Mouth ocd seanpestied °PAROTITIS * Inflammation of parotid salivary glands * Often associated with mumps * Teach or provide oral hygiene. Common Problems of the Mouth + PLAQUE * TARTAR * An invisible soft film of * Avisible hard deposit of bacteria, saliva, epithelial plaque and bacteria cells and leukocytes that forms in the gum line adhere in the enamel surface of the teeth * When unchecked — tartar Oral Problems + A coated tongue may indicate poor oral hygiene and low fluid intake. * Pyorrhea * Pus * Loose teeth + Advanced periodontal disease * Xerostomia * Dry mouth * Medications such as antihistamines, antidepressants, antihypertensive ORAL Care (Interventions) * Brushing teeth thoroughly after meals and at bedtime. + Floss teeth daily. * Ensure adequate intake of food rich in calcium, phosphorous, Vitamins A, C, D, and fluoride. * Avoid sweet foods and drinks between meals, in moderation. * Eat coarse, fibrous foods such as fresh fruits and vegetables. * Dental check-up every 6 months * Apply topical fluoride as prescribed by the dentist. Oral Care * Oral hygiene starts at the first eruption of teeth. * Brushing begins at about 18 months with a soft toothbrush * Dental visit as soon as 20 primary teeth have erupted Oral Care + Side-lying or sitting * Moisten bristles and apply dentifrice (paste or powder, e. g. Colgate) dentifrice * Hold the kidney basin under the chin * Up and down, back and forth stroke * Brush and scrub artificial dentures * Use a foam swab or soft toothbrush for dependent client NURSING DIAGNOSIS Impaired oral a nalied Deficient | tire Knowledge membrane 8 Hair Shampoo + The appearance of the hair may reflect a person’s sense of well-being and health status. * Brushing and combing stimulate blood circulation in the scalp * Oil helps arrange the hair Common Hair and Scalp Problems * Dandruff * Alopecia . Appeals diffuse scaling * Hair loss or baldness of the scalp * Thinning or baldness * Hair shampoo * Aging * Hereditary * Medications Hair transplant Medications Wear hairpiece Common Hair and Scalp Problems *Ticks * Use blunt tweezers Eye Care ‘Ceaning the ee from inner

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