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HYGIENE

PRESENTOR:

Pajaron,Edwin D. Valdez, May ann

Batancilia, Jellian

Gozum, Juvy

HYGIENE

Is the science of health and its maintenance. highly personal matter determined b individuals values and practices.

ex: care of the skin, feet, nails, oral and nasal cavities, teeth, hair, eyes, ears and perineal-genital areas.

PERSONAL HYGIENE

is the “self-care” by which people attend to such functions as BATHING, TOILETING, GENERAL BODY HYGIENE AND GROOMING.

TYPES OF HYGIENIC CARE

  • 1. Early morning care is provided to clients as they “awaken in the morning”.

Consist of:

Providing A urinal or bedpan to the client confined to bed Washing the face and hands Oral care

2. Morning care is often provided “after clients have breakfast”, although it may be provided “before breakfast”.

Providing elimination needs

Bath or shower Perineal care Back massages

oral, nail and hair care bed making

CONT.’ TYPES OF HYGIENE

3. Hour of sleep – “pm care”, is provided t clients before they retire for night. Providing elimination needs Washing face and hands Oral care Back massage

4. As needed (prn) care as required by the client Diaphoretic (sweating profusely) may need more frequent bathing and change of clothes and linen.

FACTORS INFLUENCING INDIVIDUAL HYGIENIC

PRACTICES

  • A. CULTURE

    • B. RELIGION

  • C. ENVIRONMENT

  • D. DEVELOPMENTAL LEVEL

  • E. HEALTH AND ENERGY

  • F. PERSONAL PREFERENCES

SKIN

Is the largest organ of the body

5 major functions

  • 1. It protects underlying tissues from injury by preventing the passage of microorganisms

  • 2. Regulates the body temperature

  • 3. It secretes sebum, an oily substance that softens and lubricates hair and skin

  • 4. It transmits sensations through nerve receptors.

  • 5. It produces and absorbs vitamin d in conjunction with uv rays from the sun.

ASSESSMENT

Nursing health history to determine:

  • A. The client’s skin care practices

    • B. Self-care abilities

    • C. Past or current skin’s problem

Physical assessment of the skin (inspection and palpitation)

  • A. Collect data about skin color, uniformity of color, texture, turgor temperature, intactness and lesions.

Identification of clients at risk for developing skin impairments.

DIAGNOSING

Self-care deficit- used for clients who have problems performing hygiene care. Nanda’s 4 self-care deficit:

  • 1. Self-care deficit: bathing/hygiene inability to wash the body or body parts, to obtain or get water source and to regulate water temperature or flow.

  • 2. Self-care deficit: dressing/grooming inability to obtain, put on, take off, fasten, or replace articles of clothing and to maintain appearance at satisfactory level

  • 3. Self-care deficit: toileting involves in difficulties getting to the toilet or sitting or rising from it

  • 4. Self-care deficit: feeding

EXAMPLES OF ASSOCIATED DIAGNOSES INCLUDE

THE FOLLOWING:

  • 1. Deficient knowledge related to:

  • a. Lack of experience with skin condition (acne) and need to prevent secondary infection.

  • b. New therapeutic regimen to manage skin problems.

  • c. Lack of experience in providing hygiene care to dependent person.

  • d. Unfamiliarity with devices available to facilitate sitting on or rising from toilet

2. Standard low self-esteem related to:

  • a. Visible skin problem ( eg. Acne or alopecia)

  • b. Body odor

DIAGNOSING (client with skin problem)

SCENARIO:

Mark Drake, 15 years old has facial pustules and papules. facial skin is inflamed. he states, “I hate going to school

anywhere looking like this. I don’t think any girl wants to go out

with me. can you do something to get rid of this?”.

DIAGNOSING (client with skin problem)

Nursing Diagnosis

Sample Desired

 

Indicators

Selected

 

Sample NIC

Outcome

 

Interventions

Activities

Situational Low Self

Self Esteem /

Verbalizations of

Self-Esteem

Encourage client

Esteem related to

Personal

self-accept acne

Enhancement /

 

to identify

acne/ Development

judgement of self-

 

Maintenance of

Assisting a client to

strengths

of negative

worth

 

grooming/hygiene

increase his/her

 

Convey

perception of self-

 

Description of

personal judgement

confidence in

worth in response to

 

success in social

of self-worth.

 

client’s ability to

a current situation

groups

handle situation.

negative

 

Assist client to reexamine

 

perceptions of self-worth

PLANNING

Planning to assist client personal hygiene includes consideration of the client’s personal preferences, health and limitations; the best time to give the care; and the equipment, facilities and personnel available.

Another consideration for the nurse is to assess the client’s comfort level with the gender caregiver.

To provide continuity of care, it is important that the nurse assess the client’s family’s abilities for care and the need for referrals and home health services

FEET

Are essential for ambulation and merit attention even when people are confined to bed.

Each foot contains 26 bones, 107 ligaments, and 19 muscles. These structures function to gather for both standing and walking.

ASSESSING

Assessment of the client’s feet includes a nursing health history, physical assessment of the feet, and identifying clients at risk for foot problems.

1. Nursing health history should determine:

Normal nail and foot care practices Type of footwear worn Self-care abilities Presence of risk factors for foot problems Any foot discomforts Any perceived problems with foot mobility.

2. Physical assessment each foot and toe is inspected for shape, size an presence of lesions and is palpated to assess areas of tenderness, edema and circulatory status

DIAGNOSING

Self-care deficit: Hygiene related to:

Visual impairment Impaired hand coordination. Risk for impaired skin integrity related to:

Altered tissue perfusion: peripheral (associated with edema, inadequate arterial circulation). Poorly fitting shoes. Risk for infection related to:

Impaired skin integrity (ingrown toenail, corn, trauma) Deficient nail or foot care. Deficient knowledge (diabetic foot care) related to *Lack of teaching/learning activities about diabetic foot care.

SCENARIO

Kyle Stevens, 14 years old, lives with his mother and eight

sisters and brothers in a three-room walk-up. Bathroom down

the hall is shared with other tenants in the building, shoes are ragged and fit poorly. States “I can’t get new ones”.

Nursing Diagnosis

Sample Desired

Indicators

Selected

 

Sample NIC

Outcome

Interventions

Activities

Risk for

Tissue

Not

Skin

Monitor skin for

Impaired Skin

Integrity: Skin

Compromised

Surveillance/

areas of redness

Integrity related

& Mucous

intactness and

*Skin

Collection and

and breakdown

to poorly fitting

Membranes/

intactness

analysis of client

Monitor skin for

shoes and limited access

Structural

data to maintain skin and

excessive dryness and

to bathing

normal

mucous.

moisture.

facilities / At

physiologic

membrane

Institute

the skin.

risk for skin

function of skin

integrity

measures o

being adversely altered.

and mucous membranes.

prevent deterioration of

Instruct client and family about signs of skin breakdown.

PLANNING

Identifying nursing interventions that will help the client maintain or restore healthy foot care practices

Establishing desired outcomes for each client. Interventions may include teaching the client about correct nail and foot care, proper footwear, wearing the correct size and ways to prevent potential foot

problems.

NAILS

NAILS ARE NORMALLY PRESENT AT BIRTH.

THEY CONTINUE TO GO THROUGH-OUT LIFE AND CHANGE VERY LITTLE UNTIL PEOPLE ARE

ELDERLY.

THE NAILS OF AN OLDER PERSON NORMALLY GROW LESS QUICKLY THAN THOSE YOUNGER PERSON AND MAY BE RIDGED AND GROOVED.

ASSESSING

DURING THE NURSING HEALTH HISTORY, THE NURSE EXPLORES THE CLIENT’S USUAL NAIL CARE PRACTICES, SELF-CARE ABILITIES, AND PROBLEMS ASSOCIATED WITH THEM.

PHYSICAL ASSESSMENT INVOLVES INSPECTION OF THE NAILS. (E.G., NAIL SHAPE AND TEXTURE, NAIL BED COLOR, AND TISSUES SURROUNDING NAILS).

DIAGNOSING

NURSING DIAGNOSES RELATED TO NAIL CARE AND NAIL PROBLEMS INCLUDE SELF-CARE DEFICIT AND RISK FOR INFECTION.

SELF-CARE DEFICIT: GROOMING RELATED TO

A. IMPAIRED VISION RISK FOR INFECTION AROUND THE NAIL BED RELATED TO A. IMPAIRED SKIN INTEGRITY OF CUTICLES B. ALTERED PERIPHERAL CIRCULATION

DIAGNOSING (CLIENT WITH FOOT PROBLEM)

SCENARIO:

SALLY BROWN, AN 83-YEAR OLD WIDOW, LIVES ALONE. HAS HOME-MAKER SERVICES TWICE A

WEEK AND MEALS ON WHEALS SERVICE DAILY. MANAGES TO SHOWER ONCE A WEEK WITH

DAUGHTERS HELP. HAS PRONOUNCED HAND TERRORS AND OBVIOUS CATARACTS. STATE, “I CAN’T SEE WELL ENOUGH TO CUT MY NAILS AND EVEN IF I COULD SEE, MY HAND SHAKES SO BADLY.”

DIAGNOSING (CLIENT WITH FOOT PROBLEMS)

Nursing Diagnosis

Sample Desired Outcome

Indicators

Selected Interventions

Sample NIC Activities

Self-Care Deficit:

Self-care: Hygiene

Severely compromised:

Foot care

Inspect skin for

Hygiene (Foot Care) related to impaired hand coordination and visual

(0305)/Ability to maintain own personal cleanliness and kempt

Cares for nails

(1660)/Cleansing and inspecting the feet for the purposes of relaxation, cleanliness,

irritation, cracking, lesions, corns, calluses, or edema Instruct family on

using the curve of

impairment/impaired ability to perform or complete

appearance independently with or without assistive device

 

and healthy skin

the importance of foot care Cut normal-thickness

bathing/hygiene activities for oneself

toenail clipper and

the toe as a guide

Refer to podiatrist

for trimming of thickened nails, as appropriate

PLANNING

THE NURSE IDENTIFIES MEASURES THAT WILL ASSIST THE CLIENT TO DEVELOP OR MAINTAIN HEALTHY NAIL CARE PRACTICES.

A SCHEDULE OF NAIL CARE NEEDS TO BE ESTABLISHED.

MOUTH

EACH TOOTH HAS THREE PARTS:

THE CROWN IS THE EXPOSED PART OF THE TOOTH, WHICH IS OUTSIDE THE GUM. THE ROOT IS EMBEDDED IN THE JAW AND COVERED BY A BONY TISSUE CALLED CEMENTUM THE PULP CAVITY THE CENTER OF THE TOOTH CONTAINS THE BLOOD VESSELS AND NERVES. TEETH USUALLY APPEAR 5-8 MONTHS AFTER BIRTH.

ASSESSING

ASSESSMENT OF THE CLIENT’S MOUTH AND HYGIENE PRACTICES INCLUDES A NURSING HISTORY, PHYSICAL ASSESSMENT, AND IDENTIFICATION OF CLIENTS AT RISK FOR DEVELOPING PROBLEMS.

1. NURSING HEALTH HISTORY, THE NURSE OBTAINS DATA ABOUT:

CLIENT’S ORAL HYGIENE PRACTICES CLIENT’S SELF-CARE ABILITIES PAST OR CURRENT MOUTH PROBLEMS 2. PHYSICAL ASSESSMENT

DIAGNOSING (CLIENT WITH ORAL CAVITY PROBLEMS)

SCENARIO:

JOE KWAN, 46 YEARS OLD, WAS ADMITTED WITH A FRACTURED FEMUR. TEETH STAINED FROM HEAVY SMOKING. ONE LARGE CAVITY EVIDENT IN 2 ND LOWER LEFT MOLAR, TARTAR BUILD UP ALONG GUM MARGINS, AND PRONOUNCED HALITOSIS. GUMS ARE REDDENED IN SOME AREAS AND BLEED WHEN FLOSSED. STATES , “I CAN’T REMEMBER WHEN I LAST SAW A DENTIST.”

DIAGNOSING

Nursing Diagnosis

Sample Desired

Indicators

Selected

Sample NIC Activities

Outcome

Interventions

Impaired Oral Mucous

Oral Hygiene

Not Compromised:

Oral Health

Use a soft toothbrush for

Membrane related to

(1100)/Condition of

Cleanliness of

Restoration

removal of dental debris

ineffective oral

the mouth, teeth,

teeth

(1730)/Promotion

Use toothettes or disposable

hygiene/Disruption of the lips and soft tissue

gums, and tongue

Cleanliness of gums

of healing for a client who has an

foams swabs to stimulate gums and clean oral cavity

platelet levels are above

of the oral cavity

oral mucosa or

Encourage flossing between

dental lesion

teeth twice daily with

 

No: Halitosis Bleeding

unwaxed dental floss, if

 

50,000/mm3

Discourage smoking

Reinforce oral hygiene regimen as part of discharge

teaching.

PLANNING

IN PLANNING CARE, THE NURSE AND IF APPROPRIATE, THE CLIENT AND/OR FAMILY SET OUTCOMES FOR EACH NURSING DIAGNOSIS.

THE NURSE THEN PERFORMS NURSING INTERVENTIONS AND ACTIVITIES TO ACHIEVE THE CLIENT OUTCOMES.

DURING THE PLANNING PHASE, THE NURSE ALSO IDENTIFIES INTERVENTIONS THAT WILL HELP THE CLIENT

ACHIEVE THESE GOALS. SPECIFIC , DETAILED NURSING ACTIVITIES TAKEN BY THE NURSE MAY INCLUDE THE FOLLOWING:

MONITOR EVERY SHIFT FOR DRYNESS OF THE ORAL MUCOSA.

MONITOR FOR SIGNS AND SYMPTOMS OF GLOSSITIS (INFLAMMATION OF THE TONGUE) AND STOMATITIS

(INFLAMMATION OF THE MOUTH).

ASSIST DEPENDENT CLIENTS WITH ORAL CARE.

PROVIDE SPECIAL ORAL HYGIENE FOR CLIENTS WHO ARE DEBILITATED, ARE UNCONSCIOUS, OR HAVE LESIONS OF THE MUCOUS MEMBRANES OR OTHER ORAL TISSUES.

TEACH CLIENTS ABOUT GOOD ORAL HYGIENE PRACTICES AND OTHER MEASURES TO PREVENT TOOTH DECAY.

REINFORCE THE ORAL HYGIENE REGIMEN AS PART OF DISCHARGE TEACHING.

HAIR

THE APPEARANCE OF THE HAIR OFTEN REFLECTS A PERSON’S FEELINGS OF SELF-CONCEPT AND SOCIOCULTURAL WELL-BEING.

THE HAIR MAY ALSO REFLECT STATE OF HEALTH (E.G., ENDOCRINE CHANGES CAN AFFECT THE PATTERN OF HAIR GROWTH, AND COLOR CHANGES MAY REFLECT AGING.

NEWBORNS MAY HAVE LANUGO THE FINE HAIR ON THE BODY OF THE FETUS, ALSO REFERRED TO AS DOWN OR WOOLLY HAIR) OVER THEIR SHOULDERS, BACK, AND SACRUM.

IN OLDER ADULTS, THE HAIR IS GENERALLY THINNER, GROWS MORE SLOWLY, AND LOSES ITS COLOR AS A RESULT OF AGING TISSUES AND DIMINISHING CIRCULATION.

ASSESSING

ASSESSMENT OF THE CLIENT’S HAIR, HAIR CARE PRACTICES, AND POTENTIAL PROBLEMS INCLUDES A NURSING HEALTH HISTORY AND PHYSICAL ASSESSMENT.

NURSING HISTORY THE NURSE ELICITS DATA ABOUT USUAL HAIR CARE, SELF-CARE ABILITIES, HISTORY OF HAIR SCALP PROBLEMS, AND CONDITIONS KNOWN TO AFFECT HAIR.

PHYSICAL ASSESSMENT PROBLEMS INCLUDE DANDRUFF, HAIR LOSS, TICKS, PEDICULOSIS, SCABIES, AND HIRSUTISM.

DIAGNOSING

NURSING DIAGNOSES RELATED TO HAIR HYGIENE AND HAIR AND SCALP PROBLEMS INCLUDE SELF-CARE DEFICIT: GROOMING, IMPAIRED SKIN,

RISK FOR INFECTION, AND DISTRIBUTION BODY IMAGE. SELF-CARE DEFICIT: GROOMING RELATED TO

A. ACTIVITY INTOLERANCE

B. IMPOSED IMMOBILITY(BED REST)

C. PAIN UPPER EXTREMITIES

D. ALTERED LEVEL OF CONSCIOUSNESS

LACK OF MOTIVATION ASSOCIATED WITH DEPRESSION

IMPAIRED SKIN INTEGRITY RELATED TO

A. SCALP LACERATION

B. INSECT BITE

RISK FOR INFECTION RELATED TO

A. SCALP LACERATION

INSECT BITE

DISTURBED BODY IMAGE RELATED TO

ALOPECIA

DIAGNOSIS

Nursing Diagnosis

Sample Desired

 

Selected

Sample NIC Activities

Outcome[NOC#]Defin

INDICATORS

Interventions[NIC#]Definiti

ition

on

Self-Care Deficit:

Self-Care:

Shampoos hair

Hair Care

Wash hair, as needed

Dressing/Grooming/Im

Grooming

Combs or brushes

[1670]/promotion of neat,

and desired

paired ability to

[0304]ability to

hair

clean, attractive hair

Dry hair with hair

perform or complete

maintain kempt

Maintains net

dryer

dressing and grooming activities for self

appearance

appearance

Brush/comb hair daily or more frequently, as needed Monitor scalp daily

Braid or otherwise

arrange hair as client

wishes Use hair care products

of client’s preference,

as available

ASSESSING

EYES

> ASSESSMENT OF THE CLIENT’S EYES INCLUDES A NURSING HEALTH HISTORY AND PHYSICAL ASSESSMENT.

NURSING HEALTH HISTORY DURING THE NURSING HISTORY, THE NURSE OBTAINS DATA ABOUT THE CLIENT’S EYEGLASSES OR CONTACT LENSES, RECENT EXAMINATION BY AN OPHTHALMOLOGIST, AND ANY HISTORY OF EYE PROBLEMS AND RELATED TREATMENTS.

PHYSICAL ASSESSMENT ALL EXTERNAL EYE STRUCTURES ARE INSPECTED FOR SIGNS OF INFLAMMATION, EXCESSIVE DRAINAGE, ENCRUSTATIONS OR OTHER OBVIOUS ABNORMALITIES

DIAGNOSING

EYES

NURSING DIAGNOSES RELATED TO EYE PROBLEMS MAY INCLUDE SELF CARE DEFICIT, RISK FOR INFECTION AND RISK FOR INJURY. EXAMPLES OF THESE DIAGNOSES AND POSSIBLE CONTRIBUTING FACTORS FOLLOW:

* SELF-CARE DEFICIT (CONTACT LENS INSERTION, REMOVAL AND CLEANING) RELATED TO:

A. DEFICIENT KNOWLEDGE B. IMPAIRED VISION ASSOCIATED WITH CATARACTS

DIAGNOSING RISK FOR INFECTION RELATED TO:

EYES

A. IMPROPER CONTACT LENS HYGIENE B. ACCUMULATION OF SECRETIONS ON EYELIDS

RISK FOR INJURY RELATED TO:

A. PROLONGED WEARING OF CONTACT LENSES

B. ABSENCE OF BLINK REFLEX ASSOCIATED WITH UNCONSCIOUSNESS.

PLANNING

IN PLANNING CARE, THE NURSE IDENTIFIES NURSING ACTIVITIES THAT WILL ASSIST THE CLIENT

TO MAINTAIN THE INTEGRITY OF THE EYE STRUCTURES OR A PROSTHESIS AND TO PREVENT EYE

INJURY AND INFECTION.

-NORMAL EARS REQUIRE MINIMAL HYGIENE.

EARS

-CLIENTS WHO HAVE EXCESSIVE CERUMEN (EARWAX) AND DEPENDENT CLIENTS WHO HAVE HEARING AIDS MAY REQUIRE ASSISTANCE

FROM THE NURSE. -HEARING AIDS USUALLY REMOVE BEFORE THE SURGERY.

CLEANING THE EARS

-THE AURICLES OF THE EAR ARE CLEANED DURING THE BED BATH.

-CLIENTS NEED TO BE ADVISED NEVER TO USE BOBBY PINS , TOOTHPICKS, OR COTTON TIPPED APPLICATORS TO REMOVE CERUMEN.

TYPE OF HYGIENE CARE

1. BEHIND THE EAR BTE, OR POSTAURAL AID .

-THE HEARING AID CASE IS WHICH HOLDS THE MICROPHONE -AMPLIFIER AND RECEIVER , IS ATTACHED TO THE EARMOLD BY A PLASTIC TUBE

2. IN THE EAR AID (ITE , OR INTRA-AURAL)

HOME CARE CONSIDERATIONS

SUPPORTING A HYGENIENIC

THREE TYPE OF EQUIPMENT

ROOM TEMPERATURE

NOISE