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Nursing Management of Clients with Stressors that Affect HYGIENE

Nursing Management of Clients with Stressors that Affect HYGIENE. NUR101 Lecture # 5 Fall 2008 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier, RN MSN Revkburger906,707. Hygiene Principles of skin care.

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Nursing Management of Clients with Stressors that Affect HYGIENE

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  1. Nursing Management of Clients with Stressors that Affect HYGIENE NUR101Lecture # 5Fall 2008 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier, RN MSN Revkburger906,707

  2. Hygiene Principles of skin care • Healthy intact skin and mucous membranes are the body’s first line of defense against pathogens • Adequate circulation, nutrition, hydration and resistance to injury are necessary to maintain intact skin

  3. Skin Hair Nails Oral Shaving Assessing Personal Hygiene

  4. Skin Assessment • Color • Temperature • Turgor • Texture • Dryness • Lesions • Rashes

  5. Factors Affecting Hygiene Needs • Developmental • Cultural • Spiritual • Knowledge • Physical health • Socioeconomic • Personal preference

  6. Bathing • Cleanses skin • Relaxes client • Promotes circulation • Promotes comfort • Sensory input • Increases self image • Promotes nurse-pt. relationship

  7. 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

  8. Bedbaths Bath given in bed for those on CBR (complete bed rest) Provide privacy/Use a bath blanket Allow pt. to complete as much as possible, assist as needed

  9. Nursing Interventions Bathing • Monitor skin integrity • Water temp.110-115 F • Use lotions and omit soap if skin is dry • Use powder/deodorant as per personal preference • Provide massage

  10. Shampooing-Interventions • Wet hair, lather, rinse, dry • Shampoo in bed-utilize trough and basin • Dry/spray shampoos • Style as best to pt. likes

  11. Shaving-Interventions • Anticoagulant therapy? • Wear gloves • Pull skin taunt • Let soap/shave cream soften hair • Shave in direction hair grows • Use electric razors if possible

  12. Oral Hygiene-Interventions • Wear gloves • Assess oral hygiene • Assist brushing teeth • Assist flossing • Denture care • Teaching oral care • Oral care dependent client

  13. 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

  14. Risk assessment scale Braden Note 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 Assessing Skin Integrity

  15. 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

  16. Mobility Nutrition & hydration Moist skin Physical health Age Friction Shearing force Mental status Factors Affecting Pressure Ulcer Development

  17. THINK-PAIR-SHARE 60,000 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.

  18. Stages of Pressure Ulcers • Stage I- reddened areaNon-blanchable erythema • Stage II – partial-thickness skin loss,abrasion,blister or shallow crater • Stage III- full thickness skin loss, open lesion crater exposing subcutaneuos tissue • Stage IV- full thickness skin loss, extensive tissue necrosis, damage to muscles and bone possible.

  19. Skin Integrity- Nursing Interventions • PREVENTION of pressure ulcers • Assess skin especially bony prominences daily • Increase mobility and activity • T & P q2h • Linens dry & wrinkle free • Skin and clothing dry

  20. Skin Integrity-Nursing Interventions • Avoid friction/shearing • Protective positioning:Thirty degree lateral position • Maintain proper nutrition/hydration • Redistribute pressure by applying specialty mattress ie: air mattress, Clinitron bed; PUP mattress(Specialty mattress requires physician order)

  21. Alternating Pressure Mattress Example: PUP Air-fluidized Mattress Example: Clinitron Therapeutic Mattress / Bed

  22. Evaluation Hygiene • Has all clients hygiene needs been met? • Is client more comfortable? • Have potential problems been resolved?

  23. 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

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