Bathing on Adult or Pediatric Client

8/13/2019 Bathing on Adult or Pediatric Client

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Bathing on Adult or Pediatric Client

Purposes

To remove transient microorganism body secretions and excretions, and dead skin cells.To stimulate circulation of the skin

To produce sense of well beingTo promote relaxation and comfortTo prevent or eliminate unpleasant body odor

Assessment

Condition of the skin, texture, turgor, presence of pigmented sports, temperature, lesions, excoriationsand abrasionsFatiguePresence of pain and need for adjunctive measures (e.g. an analgesic) before the bathRange of motion of the joints

Any other aspect of health that may affect the clients bathing process (e.g. mobility, strength, cognition) Need for use of clean gloves during the bath

Planning

Delegation

The nurse often delegates the skills of bathing to UAP. However, the nurse remain responsible for the assessmentand client care. The nurse needs to do the following:

Inform the UAP of the type of bath appropriate for the client and precautions, if any specific to the needsof the clientRemind UAP to notify the nurse of any concerns or changes (e.g. redness, skin breakdown, rash) so thenurse can assess, intervene if needed , and document.Instruct the UAP to encourage the client to perform as much self care as appropriate in order to promoteindependence and self-esteemObtain a complete report about the bathing experience form the UAP

Equipment

Basin or sink with warm water (between 43 to 46C or 110 and 135f)Soap and soap dishLinens: bath blanket, two bath towels, washcloth, clean gown or pajamas or clothes as needed, additionalbed linen and towels, if required

Gloves, if appropriate (e.g. presence of body fluids or open lesions)Personal hygiene articles (e.g. deodorant, powder, lotions)Shaving equipment for male clientsTable for bathing equipmentLaundry hamper

Implementation


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Preparation

Before a client bathing determine:

a. the purpose and type of bath the client needs

b. Self care ability of the client

c. any movement or positioning precautions specific to the client

d. Other care of the client may be receiving such as physical therapy or x-rays, in order to coordinate all aspects ofhealth care and prevent unnecessary fatigue

e. Clients comfort level with being bathed by someone else, and

f. necessary bath equipment and linens

Performance Yes No Remarks1 Explain the what you are going to do, why is it necessary, and how she or he can

cooperate. Discuss with client the plan of bathing and explain any unfamiliarprocedures to the client.

2 Wash hands and observe other appropriate infection control procedures.3 Provide for client privacy by drawing the curtains around the bed or closing the

door to the room. Some agencies provide signs indicating the need for privacy.Hygiene is personal matter

4 Prepare the client and the environmentInvite a family member or significant other to participate if desiredClose the windows and doors to ensure the room is a comfortabletemperature. Air currents increase loss of heat from the body byconvectionOffer a client bedpan or urinal or ask the client wishes to use the toilet or

commode. Warm water and activity can stimulate the need for void. Theclient will be more comfortable after voiding, and voiding before cleaningthe perineum is advisableEncourage the client to perform as much personal self -care as possible .This promotes independence, exercise, and self esteemDuring the bath, assess each area of the skin carefully

For a BED BATH5 Prepare the bed and position the client appropriately

Position the bed at a comfortable working height. Lower the side rail onthe side close to you. Keep the other side rail up. Assist the client to movenear you. This avoids undue reaching and straining and promotes goodbody mechanics

Place the bath blanket over the top sheet from under the bath blanket bystarting a clients shoulders and moving linen down towards the clientsfeet. Ask the client to grasp and hold the top of the bath blanket whilepulling linen to the foot of the of the bed. The bath linen provides comfort,warmth, and privacy. Note, if the bed linen is to be reused, place over thebedside chair. If it is to be changed, place it in the linen hamperRemove clients gown while keeping the client covered with the b athblanket. Place gown in linen hamper

6 Make a bath mitt with the washcloth. A bath mitt retains water and heat better


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than a cloth loosely held and prevents ends of washcloth from dragging across theskin. Used triangular or rectangle methods)

7 Wash the face. Begins the bath at the cleanest area and downward toward the feetPlace the towel under clients head Wash the clients eye with water only and dry them well. Use a separatecorner of the washcloth for each eye. Using separate corners prevents

transmitting microorganisms from one eye to the other. Wipe from theinner to the outer canthus. Theses prevent secretions from enteringnasolacrimal ductsAsk whether the clients wants soap used on the face. Soap has a dryingeffect, and the face, which is exposed to the air more than, body partstend to be drierWash, rinse, and dry the clients face, ear and neckRemove the towel from under the clients head

8 Wash the arm and hands. (Omit the arms for a partial bath)Place a towel lengthwise under the arm away from you. It protects the bedbecoming wetWash, rinse, and dry the arm elevating the clients arm support ing the

clients wrists and elbow. Use long, firm strokes from wrists to shoulder,including the axillary area. Form, strokes from distal to proximal areaspromote circulation by increasing venous blood returnApply the deodorant or powder if desired(Optional) Place a towel on the bed and put a wash basin on it. Place theclients hands in the basin. Many clients enjoy immersing their hands inthe basin and washing themselves. Soaking loosens dirt under the nails.Assist the client as needed to wash, rinse, and dry the hands, payingparticular attention to the spaces between the fingersRepeat for hand and arm nearest you. Exercise caution if an intravenousinfusion is present, and check its flow after moving the arm

9 Wash the chest and abdomen. (Omit) the chest and abdomen for partial bath.However, the areas under a womens breast may require bathing if this area isirritated or if the client has significant perspiration under the breast)

Place bath towel lengthwise over chest. Fold bath blanket down to theclients pubic area. Keeps the clients warm while preventing unnecessaryexposure of the chest.Lift the bath towel off the chest and abdomen with your mitted hand usinglong, firm stokes. Gives special attention to the skin folds particularly if theclient is over weight. Rinse and dry wellReplace the bath blanket when the area have been dried.

10 Wash the legs and feet. (omit legs and feet for a partial bathing)Exposed the leg farthest from you by folding the bath blanket toward youthe other leg being careful to keep the perineum covered. Covering theperineum promotes privacy and maintains the clients dignity

Lift leg and place the bath towel lengthwise under the leg. Wash, rinse,and dry the leg using long, smooth, strokes from the ankle to the knee tothe thigh. Washing from the distal to proximal areas promotes circulationby stimulating venous blood flowReverse the covering and repeat for the other legWash the feet by placing them in them in the basin of waterDry each foot, Pay particular attention to the spaces between the toes. Ifyou prefer that leg before washing the legObtain fresh, warm bathwater now or when necessary. Water may


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become dirty or cold. Because surface skin cells are removed with washingthe bathwater from dark skinned clients may be dark. However this doesnot mean the client is dirty. Raise side rails when refilling basin. Thisensures the safety of the client.

11 Wash the back and then the perineumAssist the client into a prone or side lying position facing away from you.

Place the bath towel lengthwise alongside the back and buttocks whilekeeping the client covered withy the bath blanket as much as possible.This provides warmth and undue exposureWash and dry the clients back, moving from the shoulders to thebuttocks and upper tights paying attention to the gluteal foldPerform back massage now or after completion of bathAssist the client to the supine position and determine whether the clientcan wash the perineal area independently. If the client cannot do so, drapethe client and wash the area

12 Assist the client with grooming aids such as powder, lotion, or deodorantUse powder sparingly. Release as little as possible into the atmosphere.This will avoid irritation of nthe respiratory tract by powder inhalation.

Excessive powder can cause caking, which leads to skin irritationHelp the client put on a clean gowns or pajamasAssists the client to care fro hair , mouth and nails. Some people prefer orneed mouth care prior to their bath

For a TUB BATH OR SHOWER13 Prepare the client and the tub

Fill the tub about 1/3 rd to one half full of water at 43 to 46C. Sufficientwater is needed to cover the perineal areCover all intravenous catheters or wound dressings with plastic coverings,and instruct the client to prevent wetting these areas as possiblePut a rubber bath mat or towel on the floor of the tub if safety stips arenot on the tub floor. These prevent slippage of the client during the bathor shower

14 Assist the client into the shower or tubAssist the patient taking standing shower with the initial adjustment of thewater temperature and water flow pressure as needed . Some clients needa chair to sit on the shower because of weakness. Hot water can causeelderly people to feel faintIf the client requires considerable assistance with a tub bath, a hydraulicbathtub chair may be requiredExplain how the patient can signal for help, leave the client for 2 to 5minutes, and place an occupied sign on the door. For safety reasons, d onot leave a client with decreased cognition or clients s who may be at risk(e.g. history of seizures, syncope)

15 Assist the client washing and getting out of the tubWash the clients back, lower legs ,and feet if necessary Assist the client out of the tub. If the client is unsteady, place bath towelover the clients shoulders and drain the tub of water before the clientattempts to get out of it. Draining the water first lessens the likelihood of afall. The towel prevents chilling

16 Dry the client, and assist with follow up careFollow step 12Assist the client back to his or her room


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Clean the tub or shower in accordance with agency practice, discard theused linen in the laundry hamper and place the unoccupied: sign on thedoor

17 DocumentType of bath given (i.e. complete, partial, or self help) This is usuallyrecorded on a flowsheet

Skin assessment, such as excoriation, erythema, exudates, rashes,drainage or skin breakdownNursing interventions related to skin integrityAbility of the client to assists or cooperate with bathingClient response for bathingEducational needs regarding hygieneInformation or teaching shared with the client and their family

VARIATION: BATHING USING A HYDRAULIC BATHTUB CHAIRA hydraulic lift, often used in long-term care or rehabilitation setting can facilitatethe transfer of the client who is unable to ambulate to a tub. The lift also helpeliminate strain on the nurse s back

Bring the client to the tub room in a wheelchair or a shower chair

Fill the tub and check the water temperature with a bath thermometer toavoid thermal injury in the clientLower the hydraulic chair lift to its lowest point, outside the tubTransfer the client to the chair lift and secure the seat beltRaise the chair lift above the tubSupport the clients legs down into the water and slowly lower the chairlift into the tubAssist in bathing the client, if appropriateReverse the procedure when taking the client out of the tubDry the client and transport him or her to the room

Providing Perineal-Genital Care

Purposes

To remove perineal secretions and odorsTo promote client comfort

Assessment

Assess the presence of


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Irritation, excoriation, inflammation, swellingExcessive dischargeOdor, pain or discomfortUrinary or fecal incontinenceRecent rectal or perineal surgery

Indwelling catheter

Determine

Perineal-genital hygiene practicesSelf-care abilities

Planning

Delegation

Perineal-genital care can be delegated to UAP, if the client has recently had perineal, rectal, or genital surgery, thenurse needs to assess if it appropriate for the UAP to perform perineal-genital care.

Equipment

Perineal-genital care in conjunction with the bedbath

Bath towelBath blanketClean glovesBath basin with water at 43 to 46CSoapWash cloth

Special Perineal-genital care

Bath towelBath blanketClean glovesCotton balls or swabsSolution bottle, pitcher, ot container filled with warm water or a prescribed solutionBedpan to receive rinse waterMoisture-resistant bag or receptacle for used cotton swabs

Perineal pad

Implementation

Preparation

Determine whether the client is experiencing any discomfort in the perineal-genital areaObtain and prepare the necessary equipment and supplies


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Performance Yes No Remarks1 Explain to-the client what you are going to so, why is it necessary , and how he/she

can cooperate, being particularly sensitive to any embarrassment felt by the client2 Wash hands and observe other appropriate infection control procedures (e.g. clean

gloves)3 Provide for client privacy by drawing the curtains around the bed or closing the

door to the room. Some agencies provide signs indicating the need for privacy.Hygiene is personal matter.

4 Prepare the clientFold the top bed linen to the foot of the bed and fold the gown up toexpose the genital areaPlace a bath towel under the clients hips. The bath towel prevents the bedfrom becoming soiled

5 Position and drape the client and clean the upper inner thighsFOR FEMALES

Position the female in aback lying position with the knees flexed andspread well apartCover her body and legs with the blanket. Drape the legs by tucking the

bottom corners of the bath blanket under the inner sides of the legs.Minimum exposure lessens embarrassment and helps to provide warmth.Bring the middle portion of the base of the blanket up over the pubic areaPut gloves, wash hands and dry the upper inner thighs

FOR MALESPosition the male client in a supine position with knees slightly flexed anships slightly externally rotatedPut on gloves, wash and dry the upper inner thighs

6 Inspect the perineal areaNote particular areas of inflammation, excoriation, or swelling especiallybetween the labia in females and the scrotal folds in malesAlso note excessive discharge or secretions from the orifices and the

presence of odorsFOR FEMALESClean the labia majora. Then spread the labia to wash the folds betweenthe labia majora and the labia minora. Secretions that tend to collectaround the labia minora facilitate bacterial growthUse separate quarters of the wash cloth for each stroke, and wipe fromthe pubis to the rectum. For menstruating women and clients withindwelling catheters, use clean wipes, cotton balls, or gauze. Take a cleanball for each stroke,. Using separate quarters of the wash cloth or newcotton balls or gauzes prevents the transmission of microorganism fromone area to the other. Wipe from the area of least contamination (thepubis) to that greatest (the rectum)Rinse the area well. You may place the client on bedpan and use a periwash or solution bottle to pour warm water over the area. Dry theperineum thoroughly, paying particular attention to the folds between thelabia. Moisture supports the growth of any microorganism

FOR MALESWash and dry the penis, using firm strokes, using firm strokes. Handlingthe penis firmly may prevent an erectionIf the client is uncircumcised , retract the prepuce (Foreskin) to expose theglans penis (the tip of the penis) for cleaning. Replace the foreskin after


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cleaning the glans penis. Retracting the foreskin is necessary to removethe smegma that collects under the foreskin and facilitates bacterialgrowth. Replacing the foreskin prevents constriction of the penis, whichmay cause edemaWash and dry the scrotum. The posterior folds of the scrotum may need tobe cleaned when the buttocks are cleaned. The scrotum tends to be more

soiled that the penis because of its proximity to the rectum; thus it isusually cleaned after the penis

8 Inspect perineal orifices for intactnessInspect particularly around the urethra in clients with indwelling catheter.A catheter may cause excoriation around the urethra.

9 Clean between the buttocksAssist the client to turn onto the side facing away from youPay particular attention to the anal area posterior folds of the scrotum inmales. Clean the anus with toilet tissue before washing it, if necessaryDry the area wellFor post delivery or menstruating females, apply a perineal pad as neededfrom front to back. This prevents contamination of the vagina and urethra

from the anal area10 Document any unusual findings such as redness, excoriation, skin breaks down,discharge and any localized areas of tendernessEVALUATION

Relate current assessments to previous assessmentsConduct appropriate follow up such as prescribed ointment for excoriationReport any deviation from normal to the physician

Providing Foot Care

Purposes

To maintain the skin integrity of the feetTo prevent foot infectionTo prevent foot odorsTo assess or monitor foot problems

ASSESSMENT


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History of any problem s with foot odor, foot discomfort, foot mobility, circulatory problems (e.g.swelling, changes in skin color and/or temperature, and pain) structural problems (e.g. bunion, hammertoe, or overlapping digits)Usual foot care practices (e.g. frequency of washing feet and cutting nails, foot hygiene products used,how often socks are changed, whether the client ever goes barefoot, whether the client see a podiatrist)

ASSESS

Skin surfaces for cleanliness, odor, dryness, and intactnessEach foot and toe for shape, size, presence of lesions (e.g. corn, callus, wart, or rash), and areas oftenderness, ankle edemaSkin temperatures of the feet to assess circulatory status and the dorsalis pedis pulsesSelf-care abilities (e.g. any problems managing foot care

PLANNING

Delegation

Foot care for no diabetic client can be delegated to UAP. Remind the UAP to notify the nurse of anything that looksout of the ordinary. Review UAP agency policy about cutting or trimming nails.

EQUIPMENT

Washbasin containing warm waterPillowMoisture-resistant disposable padTowelsSoapWashcloth

Toenail cleaning and trimming g equipmentLotion or foot powder

Performance Yes No Remarks1 Explain to the client what you are going to do, why it is necessary, and how he or

she can cooperate.2 Wash hands and observe other appropriate infection control procedures3 Provide client privacy by drawing the curtains around the bed or closing the door

to the room. Some agencies provide signs indicating the need for privacy. Hygieneis personal matter

4 Prepare the equipment and the client

Fill the washbasin with warm water at about 40 to 43C. Warm waterpromotes circulation, comforts and refreshesAssist the ambulatory client to a sitting position in a chair, or the bed clientto a supine or semi fowlers positionPlace a pillow under the bed clients knees. This provides support andprevent muscle fatiguePlace the washbasin on the moisture-resistant pad at the foot of the bedfor a bed client or on the floor infront of the chair for an ambulatory clientFor a bed client, pad the rim of the washbasin with a towel. The towel


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prevents undue pressure on the skin5 Wash the foot and soak it

Place one of the clients feet in the basin and wash it with soap, payingparticular attention to the interdigital area. Prolonged soaking is generallynot recommended for diabetic clients or individuals with peripheralvascular disease. Prolonged soaking may remove natural skin oils, thus

drying the skin and making it more susceptible to cracking and injuryRinse the foot well to remove soap. Soap irritates the skin if not properlyremovedRub callused areas of the foot with the washcloth. This helps remove deadskin layersIf the nails are not brittle or thick and require trimming, replace the waterand allow the foot to soak for 10 to 20 minutes. Soaking softens the nailsand loosens debris under themClean the nails as required with an orange stick. This removes excessdebris that harbours microorganismsRemove the foot from the basin and place it on powders

6 Dry the foot thoroughly and apply lotion or foot powder

Blot the foot gently with the towel to dry it thoroughly, particularlybetween the toes. Harsh rubbing can damage the skin. Thorough dryingreduces the risk of infectionApply lotion or lanolin cream. This lubricates dry skinorApply a foot powder containing a nonirritating deodorant if the feet tendto perspire excessively. Foot powder have greater absorbent propertiesthan regular bath powders; some also contain menthol which makes thefeet feel coolIf agency policy permits, trim the nails of the first foot while the secondfoot is soaking

8 Document any foot problems observedFoot care is not generally recorded unless problems are notedRecord any signs of inflammation , infection, breaks in the skin, corns,troublesome calluses , bunions and pressure areas. This is of particularimportance for clients with peripheral vascular disease, and diabetes

EVALUATIONInspect nails and skin after the soakCompare to prior assessment dataReport any abnormalities to the physician

Brushing and Flossing the Teeth

Purposes

To remove food particles from around and between the teethTO remove dental plaqueTo enhance the clients feelings of well being To prevent sores and infection of the oral tissues

ASSESSMENT


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Determine the extent of the clients self -care abilitiesAssess the clients usual mouth care practices Inspect lips, gums, oral mucosa, and tongue for deviations from normalIndentify presence of oral problems such as tooth caries, halitosis, gingivitis and loose or broken teethCheck if the client has bridgework or wear dentures, if the client has dentures, ask if any tenderness or

soreness is present and, if so, the location of the areas for on going assessment

PLANNING

Delegation

Oral care brushing and flossing of teeth, and denture care can be delegated to the UAP. After performing theabove assessment, the nurse should instruct the UAP as to the type of oral care and amount of assistance neededby the client. Remind the UAP to report changes in the clients oral mucosa.

EQUIPMENT

BRUSHING AND FLOSSING

TowelDisposable glovesCurve basin (emesis basin)ToothbrushCup of tepid waterDetrifrice (toothpaste)MouthwashDental floss, at least two pieces 20 cm ( 8 inches) in lengthFloss holder (optional)

FOR CLEANING ARTIFICIAL DENTURES

Disposable glovesTissue or piece of gauzeDenture containerClean washclothToothbrush or stiff bristle brushDentrifice or denture cleanerTepid waterContainer of mouthwashCurved basin (emesis basin)

Towel

PREPARATION

Assemble all the necessary equipment


she can cooperate.


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2 Wash hands and observe other appropriate infection control procedures (e.g.disposable gloves). Wearing gloves while providing mouth care prevents the nursefrom acquiring infections. Gloves also prevent transmission of microorganism to theclient

3 Provide client privacy by drawing the curtain around the bed or closing the door tothe room. Some agencies provide signs indicating the need for privacy. Hygiene is a

personal matter4 Prepare the client

Assist the client to a sitting position in bed if health permits. If not, assistthe client to a side-lying position with the head turned so liquid may beprevented from draining down the clients throat

5 Prepare the equipmentPlace the towel under the clients Put on disposable glovesMoisten the bristles of the toothbrush with tepid water and apply thedentrifice to the toothbrushUse a soft toothbrush (a small one for a child ) and the clients choice ofdentrifice

For the client who must remain in bed, place or hold the curved basinunder the clients chin, fitting the small curve around the chin or neck Inspect the mouth and teeth

6 Brush the teethHand the toothbrush to the client or brush the clients teeth as follows: A. Hold the brush against the teeth with bristle at a 45 degree angle. Thetip of the outer bristle should rest against and penetrate under the gingivalsulcus . The brush will clean under the sulcus of two or three teeth at onetime . this sulcular technique removes plaque and cleans under thegingival marginsB. Move the bristles up and down using a vibrating or jigging motion fromthe sulcus to the crowns of the teethC. Repeat until outer and inner surfaces of the teeth and sulci of the gumsare cleanedD. Clean the biting surfaces by moving the back and forth over them inshort strokesE. If the tongue is coated, brush it gently with the toothbrush. Brushingremoves accumulated materials and coatings. A coated tongue may becaused by poor oral hygiene and how fluid intake. Brushing gently andcarefully helps prevent gagling or vomitingHand the client the water cup or mouthwash to rinse the mouthvigorously. Then ask the client to spit the water and excess dentrifice intothe basin. Some agencies supply a standard mouthwash. Alternatively, amouth rinse of normal saline can be an effective cleaner and moisturizer.Vigorously rinsing loosens food particles and washes out already loosened

particlesRepeat the preceding steps until the mouth is free or dentrifice and foodparticlesRemove the curved basin and help then client wipe the mouth

7 Floss the teethAssist the client to floss independently, or floss the teeth as follows.Waxed floss is less likely to fray than unwaxed floss; particles between theteeth attach more readily to unwaxed floss than to waxed floss. Somebelieve that waxed floss leaves a residue on the teeth and that plaque


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then adheres to the waxA. Wrap the end of the floss around the third finger of each handB. To floss the upper teeth, use your thumb and index finger to stretch thefloss. Move the floss up and down between the teeth form the tops of thecrowns to the gum along the gum lines as far as possible. Make C withthe floss around the tooth edge being flossed. Start at the back on the

right side and work around to the back of the left side or work form thecenter teeth to the back of the jaw on the either sideC. To floss the lower teeth, use your index fingers to stretch the flossGive client tepid water or mouthwash to rinse the mouth and a curvedbasin in which to spit the waterAssist the client in wiping the mouth

8 Remove the disposable equipment appropriatelyRemove and cleaned the curved basinRemove and discard the gloves

9 Document assessment of the teeth, tongue, and oral mucosa include any problemssuch as sores or inflammation, bleeding and swelling. Brushing and flossing teethare not usually recorded

VARIATION: ARTIFICIAL DENTURES1 Remove the dentures

Put on the gloves. Wearing gloves protects the nurse and the client frominfectionIf the client cannot remove the dentures take the tissue or gauze, graspthe upper plate at the front teeth with your thumb and second finger, andmove the denture up and down slightly. The slight movement breaks thesuction that holds the place on the roof of the mouthLower the upper plate, move it out of the mouth, and place it in thedenture containerLift the lower plate, turning it so that the left side. For example, is slightlylower that the right, to remove the plate from the mouth withoutstretching the lips. Place the lower plate in the denture containerRemove a partial denture by exerting equal pressure on the boarder ofeach side of the denture, not on the claps, which can be bend or break

2 Clean the denturesTake the denture container to a sink. Take care not to drop the dentures asthey may break. Place a washcloth in the bowel of the sink to preventdamage if the dentures are droppedUsing a toothbrush or special stiff bristled brush, scrub the dentures withthe cleaning agent and tepid water. Hot water is not used because heatwill change the shape of some denturesRinse the dentures with tepid running water. Rinsing removes the cleaningagent and food particlesA. If the dentures are stained, soak them in a commercial cleaner. Be sureto follow the manufacturer s directions. To prevent corrosion, dentureswith metal parts should not be soaked overnight

3 Inspect the dentures and the mouthObserve the dentures afor any rough, sharp, or worn areas that couldirritate the tongue or mucous membranes of the mouth, lips and gumsInspect the mouth for any redness, irritated areas, or indications ofinfectionsAssess the fit of the dentures. People who have them should see a dentist


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at least once a year to check the fit and the presence of any irritation tothe soft tissues of the mouth. Clients who need repairs to their denturesmay need a referral for financial assistance

4 Return the dentures to the mouthOffer some mouthwash and a curved basin to rinse the mouth. If the clientcannot insert the dentures independently, insert the plates one at a time.

Hold each plate at a slight angle while inserting it, to avoid injuring the lips5 Assist the client as needed

Wipe the clients hand and mouth with the towel If the client does not want to or cannot wear the dentures, store them in adenture container with water. Label the container with the clients nameand identification number

6 Remove and discard gloves7 Document all assessments and include any problems such as an irritated area on

the mucous membrane

Providing Special Oral Care

Purposes

To maintain the intactness and health of the lips, tongue, and mucous membranes of the mouthTo prevent oral infectionTo clean and moisten the membranes of the mouth and lips

ASSESSMENT

Inspect lips, gums, oral mucosa, and tongue for deviations from normalIdentify presence of oral problems such as tooth carries, halitosis, gingivitis, and loose or broken teethAssess for gag reflex, when appropriate


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PLANNING

Delegation

Special oral care may delegated to UAP, however, the nurse needs to assess for the gag reflex. Dependent on thisassessment, the nurse needs to inform the UAP of the correct positioning of the client and how to use the oral

suction catheter, if needed. Remind the UAP to report changes in the clients oral mucosa.

EQUIPMENT

TowelCurved basin (emesis basin)Disposable clean glovesBite-block to hold the mouth open and teeth apart (optional)ToothbrushCup of tepid waterDentrifice or denture cleaner

Tissue or piece of gauze to remove dentures (optional)Denture container as neededMouthwashRubber-tipped bulb syringedSuction catheter with suction apparatus (optional)Foam swabs and cleaning solution for cleaning mucus membranesPetroleum jelly (Vaseline)

Performance Yes No Remarks1 Explain to the client what you are going to do, why it is necessary.

2 Wash hands and observe other appropriate infection control procedures (e.g.disposable gloves).

3 Provide client privacy by drawing the curtain around the bed or closing the door tothe room. Some agencies provide signs indicating the need for privacy. Hygiene is apersonal matter

4 Prepare the clientPosition the unconscious client in side-lying position, with the head of thebed lowered. In this position, the saliva automatically run out by gravityrather than being aspirated into the lungs. This position is the one of thechoice for unconscious client receiving mouth care. If the clients headcannot be lowered, turn it to one side. The fluid will readily run out of themouth or pool in the side of the mouth, where it can be suctioned

Place the towel under the clients chin Place the curved basin against the clients chin and lower cheek to receivethe fluid from the mouthPut on gloves

5 Clean the teeth and rinse the mouthIf the person has natural teeth, brush gently and carefully to avoid injuringgums, if the client has artificial teeth, clean them.Rinse the clients mouth by drawing about 10 ml of water or alcohol freemouthwash into the syringe and injecting it gently into each side of the


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mouth. If the solution is injected with forced, some of it may flow downthe clients throat and be aspirated into the lungs.Watch carefully to make sure that all the rinsing solution has run out ofthe mouth into the basin. If not suction the fluid from the mouth. Fluidmaintaining in the mouth may be aspirated into the lungsRepeat rinsing until the mouth is free of dentrifice, if used

6 Inspect and clean the oral tissuesIf the tissues appear dry or unclean, clean them with the foam swabs orgauze and cleaning solution following agency policy:Picking up a moistened foam swab, wipe the mucous membrane of onecheek. If no foam swabs are available, wrap a small gauze square around atongue blade in a waste container; use a fresh one to clean the next area.Using separate applicators for each area of the mouth prevents thetransfer of microorganisms from one area to anotherClean all mouth tissues in an orderly progression, using separateapplicators: the cheeks, roof of the mouth, base of the mouth and tongueObserve the tissues closely for inflammation and drynessRinse the clients mouth as described in step 5

Remove and discard gloves7 Ensure client comfort

Remove the basin, and dry around the clients mouth with the towel.Replace artificial dentures, if indicatedLubricate the clients lips with petroleum jelly. Lubrication preventscracking and subsequent infections. If the client is on oxygen therapy, donot used petroleum jelly, because it can cause burns to the skin andmouth. Use another mouth care products that does not have petroleum init.

8 Document assessment of the teeth, tongue, gums, and oral mucosa. Include anyproblems such as sores or inflammation and swelling of the gumsEVALUATION

Consider the client medical diagnosis and treatment (e.g. chemotherapy,oxygen) and the necessary nursing interventions related to oral hygieneConduct an ongoing assessment, if appropriate of the oral mucosa, gums,tongue, and lipsReport deviations from normal to the physicianConduct appropriate follow-up such as a referral to a dentist for dentalcaries


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Providing Hair Care for Clients

Purposes

To stimulate the blood circulation to the scalpTo distribute hair oils and provide a healthy sheenTo increase the clients sense of well -beingTo assess or monitor hair or scalp problems (e.g. matted hair or dandruff)

ASSESSMENT

History of the following conditions or therapies; recent chemotherapy, hypothyroidism, radiation of thehead, unexplained hair loss, and growth of excessive body hairUsual hair care practices and routinely used hair care products (e.g. hair spray, shampoo, conditioners,hair oil preparation, hair dye, curling or straightening preparations)


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Whether wetting the hair will make it difficult to comb. Kinky hair is easier to comb when wet, however, itis very difficult to comb when dries.

ASSESS

Condition of the hair and scalp, is the hair straight, curly, kinky? Is the hair matted or tangled? Is the scalp

dry?Evenness of hair growth over the scalp, in particular, any patchy loss of hair; hair texture, oiliness,thickness, or thinness; presence of lesions, infections, or infestations on the scalp; presence of hirsutismSelf-care abilities (e.g. any problem managing hair care)

PLANNING

Delegation

Brushing and combing hair, shampooing hair, shaving facial hair can be delegated to UAP unless client has acondition in which the procedure would be contraindicated (e.g. cervical spinal injury or trauma). The nurse needsto assess the UAPs knowledge and experience of hair care for clients of other cultures, if appropriate

EQUIPMENTS

Clean brush and combA wide-toothed comb is usually used for many black-skinned people because finer combs pull the hair intoknots and may also break the hairTowelHair oil preparation, if appropriate


she can cooperate2 Wash hands and observe other appropriate infection control procedures3 Provide client privacy by drawing the curtain around the bed or closing the door to

the room. Some agencies provide signs indicating the need for privacy. Hygiene is apersonal matter

4 Position and prepare the client appropriatelyAssist the client who can sit to move to a chair. Hair is more easily brushedand combed when the client is in a sitting position. If health permits,assists a client confined to a bed to a sitting position by raising the head ofthe bed. Otherwise, assists the client to alternate side-lying positions, anddo one side of the head at a time

If the client remains in bed, place a client towel over the pillow and theclients shoulders. Place it over the sitting clients shoulder. The towelcollects any removed hair, dirt, and scaly material

5 Remove any mats or tangles graduallyMats can usually be pulled apart with fingers or worked out with repeatedbrushingIf the hair is very tangled, rub alcohol or an oil, such as mineral oil, on thestrands to help loosen the tanglesComb out tangles in a small section of hair toward the ends. Stabilize the


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hair with one hand and comb toward the ends of the hair with the otherhand. This avoids scalp trauma

6 Brush and comb the hairFor short hair, brush and comb one side at a time. Divide long hair into twosections by parting it down the middle from the front to the back, if thehair is very thick, divide each section into front and back subsections or

into several layers7 Arrange the hair as neatly and attractively as possible, according to the individuals

desireBraiding long hair help prevent tangles

8 Document assessments and special nursing interventions. Daily combing andbrushing of the hair are not normally recordedVARIATION: HAIR CARE FOR AFRICAN AMERICAN CLIENTS

Position and prepare the clientUntangle the hair first, if appropriateUse fingers to reduce hair breakage and discomfort. Move fingers in acircular motion starting at the roots and gently moving up to the tip of thehair

Comb the hairApply hair oil preparation as the client indicatesUsing a large and open toothed comb, grasp a small section of hair and,holding the hair at the tip, start untangling at the tip and work downtoward the scalp

OIL SHAMPOOAn oil shampoo is composed of one part alcohol and four parts mineral oil. Thealcohol is an antiseptic and both the alcohol and mineral oil are cleansing agent

Warm the mixturePour it into the hair and gently massageComb the hairRemove excess oil with a towel

OILING THE HAIRIf a water based shampoo was used it may be necessary to oil and massage thescalp.

Part the hair in sectionsPlace a small amount of hair oil on the scalp. The hair is so dense thatoiling the top of the hair will not help a dry scalpAsk the client if he or she would like the hair braided. Braiding willdecrease tangling, however, the choice is the clients .

EVALUATIONConduct ongoing assessments for problems such as dandruff, alopecia,pediculosis, scalp lesions or excessive dryness or matting

Evaluate effectiveness of medication (e.g. for treating pediculosisi), ifappropriate


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Shampooing the Hair of a Client Confined to Bed

Purposes

To stimulate blood circulation through massage To clean the hair and increase the clients sense of well -being

ASSESSMENT

Determine routinely used shampoo products Assess

Any scalp problems Activity tolerance if the client

PLANNING

Delegation

Brushing and combing hair, shampooing hair, shaving facial hair can be delegated to UAP unless client has acondition in which the procedure would be contraindicated (e.g. cervical spinal injury or trauma). The nurse needsto assess the UAPs knowledge and experience of hair care for clients of other cultures, if appropriate

EQUIPMENT

Comb and brush Plastic sheet or pad Two bath towels Shampoo basin Washcloth or pad

Bath blanket Receptacle for the shampoo water Cotton balls (optional) Pitcher of water Bath thermometer Liquid or cream shampoo Hair dryer

PREPARATION

Determine whether the physici ans order is needed before a shampoo can be given. Some agenciesrequire an order

Determine the type of shampoo to be used (e.g. medicated shampoo). Discuss with the client. A personwho must remain in bed may find the shampoo tiring. Choose a time when the client is rested and canrest after the procedure


she can cooperate2 Wash hands and observe other appropriate infection control procedures


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3 Provide client privacy by drawing the curtain around the bed or closing the door tothe room. Some agencies provide signs indicating the need for privacy. Hygiene is apersonal matter

4 Position and prepare the client appropriately Assist the client to the side of the bed which you will work Remove pins and ribbons from the hair, and brush and comb it to remove

any tangles5 Arrange the equipment

Put the plastic sheet or pad on the bed under the head. Plastic keeps thebedding dry

Remove the pillow from under the clients head, and place it under theshoulders unless there is some underlying conditions 9e.g. neck surgery,arthritis of the neck). This hyperextends the neck

Tuck a bath towel around the clients shoulders. This keeps the shouldersdry

Place the shampoo basin under the head, putting a folded washcloth orpad where the clients neck rests on the edge of the basin, if the client ison a stretches, the neck can rest on the edge of the sink with the

washcloth as padding. Padding supports the muscles of the neck andprevents undue muscle strain and discomfort

Fanfold the top bedding down to the waist, and over the upper part of theclient with the bath blanket. The folded bedding will stay dry, and the bathblanket, which can be discarded after the shampoo, will keep the clientwarm

Place the receiving receptacle on a table or chair at the bedside. Out thespout of the shampoo basin over the receptacle

6 Protect the clients eyes and ears. Place a damp washcloth over the clients eyes. The washcloth protects the

eyes from soapy water. A damp washcloth will not slip Place cotton balls in the clients ear if indicated. These keep water from

collecting in ear canals7 Shampoo the hair

Wet the hair thoroughly with the water Apply shampoo to the scalp. Make a good lather with the shampoo while

massaging the scalp with the pads of your fingertips. Massage all areas ofthe scalp systematically, for example, starting at the front and workingtoward the back of the head. Massaging stimulates the blood circulation inthe scalp. The pads of the fingers are used so that the fingernails will notscratch the scalp.

Rinse the hair briefly, and apply shampoo again Make a good lather and massage the scalp as before Rinse the hair thoroughly this time to remove all shampoo remaining in

the hair may dry and irritate the hair and scalp. Squeeze as much water as possible out of the hair with your hands8 Dry the hair thoroughly

Rub the client hair with the dryer. Set the temperature at warm Continually move the dryer to prevent burning the clients scalp

9 Ensure client comfort Assists the person confined to bed to a comfortable position Arrange the hair using a clean brush and comb

10. Document the shampoo and any assessments


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EVALUATIONConduct ongoing assessment such as any scalp or intolerance to the procedure.Report any problems noted to the nurse in charge

USING A SAFETY RAZOR TO SHAVE FACIAL HAIR Wear gloves in case facial nicks occur and you come in contact with blood Apply shaving cream or soap and water to soften the bristles and make the

skin more pliable Hold the skin taut, particularly around creases, to prevent cutting of the

skin Hold the razor so that the blade is at a 45 degree angle to the skin, and

shave in short, firm strokes in the direction of hair growth After shaving the entire area, wipe the clients face with wet washcloth to

remove any remaining shaving cream and hair Dry the face well, then apply aftershave lotion or powder at the client

prefer To prevent irritating the skin, pat on the lotion with the fingers and avoid

rubbing the face


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Removing, Cleaning, and Inserting a Hearing Aid

Purpose

To maintain hearing aid function

ASSESSMENT

Determine if the client has experienced any problems with the hearing aid and hearing aid practices. Assess for thepresence of inflammation, excessive wax, drainage or discomfort in the external ear

PLANNING

Delegation

A nurse can delegate the task for a hearing aid to the UAP. It is important, however, for the nurse to firstdetermine that UAP knows the correct way to care for a hearing aid. Inform the UAP to report the presence of earinflammation, discomfort, excess wax or drainage to the RN

EQUIPMENT

Clients hearing aid Soap, water, and towels or a damp cloth Pipe cleaner or toothpick (optional) New battery (if needed)


she can cooperate2 Wash hands and observe other appropriate infection control procedures3 Provide client privacy by drawing the curtain around the bed or closing the door to

the room. Some agencies provide signs indicating the need for privacy. Hygiene is apersonal matter

4 Remove the hearing air Turn the hearing aid off and lower the volume. The on/off switch may be

labelled O (off), M (microphone), T (telephone), TM(Telephone/Microphone). The batteries continue to run if the hearing aidis not turned off

Remove the earmold by rotating it slightly forward and pulling it outward If the earing aid is not to be used for several days, remove the battery.

Removal prevents corrosion of the earing aid from battery leakage. Store the earing aid in a safe place and label with clients name. Avoid

exposure to heat and moisture. Proper storage prevents loss or damage5 Clean the earmold

Detach the earmold if possible. Disconnect the earmild from the receiverof the body hearing aid or from the earing aid case of behind-the-ear andeyeglass hearing aids where the tubing meets the hook of the case. Do notremove the earmold if it is glued or secured by a small metal ring. Removalfacilitates cleaning and prevents inadvertent damage to other parts


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If the earmold is detachable, soak it in a mild soapy solution. Rinse and dryit well. Do not use isopropyl alcohol. Alcohol can damage the hearing aid

If the earmold is not detachable or is for an in-the-ear aid, wipe theearmold with a damp cloth

Check the earmoild opening is patent. Blow any excess moisture throughthe opening or remove debris (e.g. earwax) with a pipe cleaner or

toothpick Reattach the earmold if it was detached from the rest of the hearing aid

6 Insert the hearing aid Determine form the client if the earmold is for the left or the right ear Check that battery is inserted in the hearing aid. Turn off the hearing aid

and make sure the volume is turned all the way down. A volume that is tooloud is distressing

Inspect the earmold to identify the ear canal portion. Some earmolds arefitted for only the ear canal and concha; others are fitted for all thecontours of the ear. The canal portion, common to all, can be used as aguide for correct insertion

Line up the parts of the earmold with the corresponding parts of theclients ear

Rotate the earmold slightly forward and insert the ear canal portion Gently press the earmold into the ear while rotating it backward Check that the earmlod fits snugly by asking the client if it feels secure and

comfortable Adjust the other components of a behind the ear or body hearing aid Turn the earing aid on, and adjust the volume according to the clients

need7 Correct problems associated with improper functioning

If the sound is weak or there is no sound A. Ensure that the volume is turned high enough. B. Ensure that earmold opening is not clogged C. Check the battery by turning the hearing aid on, turning up the volume,

cupping your hand over the earmold, and listening. A constant whistlingsound indicates the battery is functioning. If necessary, replace thebattery. Be sure that the negative (-) and positive (+) signs on the batterymatch those where indicated on the hearing aid

D. Ensure that the ear canal is not blocked with wax, which can obstructsound waves

If the client reports a whistling sound or squeal after insertion: A. Turn the volume down B. Ensure that the earmold is properly attached to the receiver C. Reinsert the earmold

8 Document pertinent data The removal and the insertion of hearing aid are not normally recorded Report and record any problems the client has with the hearing aid

EVALUATION Speak to the client in a normal conversational tone and observe client

behaviors Compare the clients hearing ability to previous assessments Report to the physician any deviations from normal for the client


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Documents

Bathing on Adult or Pediatric Client