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Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier, RN MSN Revkburger906,707

Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

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Page 1: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Nursing Management of Clients with Stressors that Affect HYGIENE

NUR101Lecture # 5Fall 2009

K. Burger, MSED, MSN, RN, CNEPPP by: Sharon Niggemeier, RN MSN Revkburger906,707

Page 2: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Hygiene Principles of skin care

Healthy intact skin and mucous membranes are the body’s first line of defense against pathogensAdequate circulation, nutrition, hydration and resistance to injury are necessary to maintain intact skin

Page 3: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Assessing Personal Hygiene

Skin

Hair

Nails

Oral

Shaving

Page 4: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Skin Assessment

ColorTemperatureTurgorTextureDrynessLesionsRashes

Page 5: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Factors Affecting Hygiene Needs

DevelopmentalCulturalSpiritualKnowledgePhysical healthSocioeconomicPersonal preference

Page 6: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

BathingCleanses skinRelaxes clientPromotes circulationPromotes comfortSensory inputIncreases self imagePromotes nurse-pt. relationship

Page 7: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

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

Page 8: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Bedbaths

Bath given in bed for those onCBR (complete bed rest)

Provide privacy/Use a bath blanketAllow pt. to complete as much aspossible, assist as needed

Page 9: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Nursing Interventions Bathing

Monitor skin integrityWater temp.110-115 FUse lotions and omit soap if skin is dryUse powder/deodorant as per personal preferenceProvide massage

Page 10: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Shampooing-Interventions

Wet hair, lather, rinse, dry

Shampoo in bed-utilize trough and basin

Dry/spray shampoos

Style as best to pt. likes

Page 11: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Shaving-Interventions

Anticoagulant therapy?Wear glovesPull skin tauntLet soap/shave cream soften hairShave in direction hair growsUse electric razors if possible

Page 12: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Oral Hygiene-Interventions

Wear gloves

Assess oral hygiene

Assist brushing teeth

Assist flossing

Denture care

Teaching oral care

Oral care dependent client

Page 13: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

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

Page 14: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Assessing Skin Integrity

Risk assessment scale BradenNote 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

Page 15: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

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

Page 16: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Factors Affecting Pressure Ulcer Development

Mobility

Nutrition & hydration

Moist skin

Physical health

Age

Friction

Shearing force

Mental status

Page 17: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

THINK-PAIR-SHARE60,000 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.

Page 18: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Stages of Pressure UlcersStage I- reddened area

Non-blanchable erythema

Stage II – partial-thickness skin loss,abrasion,blister or shallow craterStage III- full thickness skin loss, open lesion crater exposing subcutaneuos tissueStage IV- full thickness skin loss, extensive tissue necrosis, damage to muscles and bone possible.

Page 19: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Skin Integrity- Nursing Interventions

PREVENTION of pressure ulcersAssess skin especially bony prominences dailyIncrease mobility and activityT & P q2hLinens dry & wrinkle freeSkin and clothing dry

Page 20: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Skin Integrity-Nursing Interventions

Avoid friction/shearing

Protective positioning:Thirty degree lateral position

Maintain proper nutrition/hydrationRedistribute pressure by applying specialty mattress ie: air mattress, Clinitron bed; PUP mattress(Specialty mattress requires physician order)

Page 21: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Therapeutic Mattress / Bed

Alternating Pressure Mattress

Example: PUP

Air-fluidized Mattress

Example: Clinitron

Page 22: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

Evaluation Hygiene

Has all clients hygiene needs been met?

Is client more comfortable?

Have potential problems been resolved?

Page 23: Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier,

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