Safety, Comfort, Hygiene

7/27/2019 Safety, Comfort, Hygiene

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SAFETY, COMFORT,

HYGIENE


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Characteristics of Safety

Pervasiveness safety is integrated or

permeates throughout mans life and

affects everything he does

Perceptionperception of safety and

danger can influence the integration of

safety into his activities of daily living.

Management knowledge or

awareness of safety issues can allow aperson to take measures to prevent

dangers.


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Causes of Altered Safety

Hazards poorly lighted stairways, slippery floors,

cluttered areas, unstable ladder, medications and

substances left within reach of children, careless

smoking, lack of supervision of children at play,

defective equipment, procedural errors

Invasive trauma overloading of electrical outlets,

faulty and defective appliances and equipment,

radiation

Disease microorganisms, impaired immune

system

Pollution air, water, land, noise pollution, toxic

substances

Disregard for safety not wearing protective gear

and accessories


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Manifestations of

Safety Alterations

Falls result in pain, permanent disability, and even

death

Firescaused by careless smoking practices, faulty

electrical equipment among others

Burnsdue to scalds, fires, playing with matches orcandles, among others

Poisoning ingestion, inhalation or absorption of

potentially hazardous substances

Suffocation due to drowning smothering, strangling,

airway obstruction or from entrapment in a confinedspace

Motor-vehicular accidents because of hazardous

driving practices


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Manifestations of

Safety Alterations

Electrical shock occurs when an electrical current

travels to the ground through the body instead of

through the electrical wiring; it can also occur from

static electricity that builds up on the surface of the

body

Radiation injuries excessive exposure to radiation

Infection - especially among persons who have high-

risk health behaviors, debilitated patients, immune-

compromised and Immuno-suppressed patients, and

those with chronic illnesses, among others

Stress-related illnesses may include peptic ulcer

disease, anxiety, depression, and psoriasis, among

others, often due to fear of the environment which is

unfamiliar to them


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Nursing Assessment

Intrinsic Factors

Biochemical

Regulatory functioning sensory, integrative and

effector dysfunction, tissue hypoxia

Malnutrition Immune-autoimmune conditions

Abnormal blood profile leukocytosis, leucopenia,

altered clotting factors, thrombocytopenia, sickle

cell, thalassemia, hypohemoglobinemia

Physical broken skin, altered mobility

Developmental age physiologic, psychosocial

Psychologic affective, orientation


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Nursing Assessment

Extrinsic Factors

Biologic immunization status, herd immunity,

microorganisms

Chemical pollutants, poisons, drugs,

pharmaceutical agents, alcohol, caffeine, nicotine,preservatives, cosmetics, dyes

Nutrients vitamins, food types

Physical design, structure and arrangement of

the community, buildings, and/or equipment

Mode of transport or transportation Person or provider nosocomial agents, staffing

patterns, cognitive, affective, psychomotor factors


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Nursing Interventions for Safety

Orient client to the unit including immediate

environment, use of call light system, bed controls (if

any), location of supplies in bedside stand, location

of bathroom, operation of lights, schedule of unit and

activities, among others.

Ensure the clients room is free from clutter and

obstacles especially between the bed and the

bathroom.

Ensure bedrails and night lights are in proper

working order.

Instruct client as to activity limitations

Assist client with ambulation and ADLs, as needed


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Review client on the hospitals fire safety precautions

Limited smoking facilities

Location of fire extinguishers and fire alarms

including emergency numbers, evacuation

equipment and exits Use of non-flammable materials

Evacuation routes

Institute electrical safety precautions

Keep hands dry when manipulating machinery

and equipment

Immediately mop up spilled fluid

Ensure all electrical plugs are grounded (3 pins)

Report any electrical equipment damage


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Institute radiation safety precautions

Minimize exposure to radiation source

Maximize distance from the source

Use appropriate shielding

Institute effective infection control

Perform handwashing before and after every

procedure and patient contact

Perform disinfection, sterilization, isolation

precautions and immunizations according to

hospital guidelines

Teach about timely vaccination among at-risk

individuals

Teach about safe sex especially among

adolescents


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Nursing Interventions

to Prevent Falls

Keep the clients room free from clutter, well-lit

during transfers and ambulation, and the side rails

firmly anchored.

Ensure that all surfaces are flat, even, and non-skid

Ensure that the brakes of wheelchairs, beds andcommode chairs are working properly

Ensure that wheelchairs, beds and commode chairs

do not have sharp edges and have a comfortable

support surface

Teach clients with orthostatic hypotension to changeposition slowly

Use restraints only when necessary and as provided

for in the hospital protocol


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to Prevent Falls

Teach parents about preventing falls in infants

Not to leave an infant unattended in a bath, bed,

or table where the infant may roll or fall off

Keep the crib side rails up Use guard rails or gates at the top and bottom of

the stairs when the infant begins to crawl

Supervise the infant in a walker, swing, jumper

or high chair


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to Prevent Falls

Teach the elderly client

Remove throw rugs and clutter from stairways

and walkways

Make sure that the stairways are adequately

lighted and in good condition

Install handrails wherever needed

Do not use unstable ladders and stepstools

Do not attempt to do anything beyond reach or

physical ability


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for Child Safety

Cover unused electrical outlets with plastic safety

plugs

Secure window screens within reach of the toddler

on a chair

Cover controls of appliances with tamper-proof locksor covers

Keep hot water temperature at no more than 115oF

Place non-skid mats in showers and tubs

Fence yard for outdoor play within safe perimeters

Use only age-appropriate toys

Do not use pillows and restrictive blankets on infants

and toddlers

Do not prop feeding bottles during feeding


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for Child Safety

Keep the following out of reach of children,

Electrical cords and handles of pots and

appliances

Matches and cigarette lighters

Plastic bags Medications, household cleansers, other chemicals

and potentially-toxic substances

Pails or basins of water

Do not hang pacifiers around babys neck

Take extra caution in using harness restraints on

infants and toddlers

Teach children to wear protective gear in activities

such as riding a bicycle.


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to Prevent Burn Injuries

Test bath water temperature first before bathing client,

especially someone who has sensory impairment

Check heating pads, heat lamps, and other electrical

equipment for proper functioning

Assist clients in handling hot drinks when required Do not allow clients to smoke in bed

Teach parents to turn hot pot handles away from the

front of the stove top where children can reach

Teach parents not to leave children unsupervised in the

kitchen near burning places, barbecue grills, or nearcontainers of flammable materials like gasoline or

kerosene

Teach parents to use sunscreen on their children when

playing outdoors


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Sleep and Rest

Sleep a naturally occurring altered

state of consciousness that is

characterized by decreased

awareness and responsiveness to

stimuli

Rest a state of consciousness

where awareness of the environment

is maintained but motor or cognitive

responses are decreased.


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Characteristics of Sleep

Awareness of need to sleep/rest

Restoration and protection facilitate physical

restoration through anabolic processes

Psychological function

Sorting and discarding of neurophysiologicdata (short-term memory)

Character reinforcement and adaptation for

mental and emotional stability REM is

required for reprocessing of knowledge and

memories Circadian rhythm 24-hour biologic rhythms;

sleep-wake cycle


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Causes of Sleep/Rest Alterations

Distractions noise, light, temperature,

environment, caregiving, disruptions in

relationships, work shifts

Illness loss of stage 3 sleep, pain, etc

Drugs sedatives, alcohol, caffeine, nicotine Mood states anxiety, depression


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Manifestations of Sleep/Rest

Alterations

Sleep deprivation

Insomnia

Narcolepsy excessive daytime sleeping

Sleep apnea

Nocturnal myoclonus - repetitive dorsiflexion of thefoot and the flexion of the knee during sleep once

every 15-20 seconds

Altered sleep-wake patterns jet lag syndrome,

delayed sleep phase syndrome

Parasomnias somnambulism, enuresis, sleep-talking, night terrors, nightmares


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Nursing Assessment

Subjective Data

Verbalization of difficulty falling asleep, of awakening

earlier or later than desired, of interrupted sleep, and

of not feeling well-rested

Objective Data Changes in behavior and performance increased

irritability, restlessness, disorientation, lethargy,

listlessness

Physical signs mild fleeting nystagmus, slight hand

tremor, ptosis or eyelids, expressionless face, darkcircles under eyes, frequent yawning, changes in

posture

Thick speech with mispronunciation and incorrect

word usage


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Provide Modification of Clients Environment

Reserve sleeping room for sleep and

encourage children to play in other areas

Provide client with opportunities to get out of

his room during the day, if feasible Remove items associated with work, conflict,

pain or sleeplessness


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Provide for Intimacy and Security

Assist client in making social contacts

Provide backrub before sleep

Allow and encourage family members to sit on

clients bedside and bring with them theirfavorite items for enhancing security (blankets,

stuffed toys)

Reassure client of frequent checks and

prompt response to call bell by the nurse

Allow for prayer, Scripture-reading and/ormeditation


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Allow for Sleep Rituals

Assist with settling in

Assist with washing of hands and face

Provide gentle massage

Plump pillows and provide extra blanket ifneeded

Help clients focus on small goals

accomplished during the day


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Assist clients in assessing the individual sleep

pattern needs and to anticipate developmental

changes

Provide adequate rest

Administer sedative hypnotics as ordered Identify factors that affect quality of sleep

Reduce factors affecting safety by having call

light near at hand, bed in the lowest position

and using a nightlight


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Teach client about

Getting up at the same time each day and

avoiding sleeping in on days off

Eating sensibly and regularly

Avoiding alcohol and caffeine whichdisturb sleep because of longer effects

Exercising daily but not too late in the day

Setting the mind at rest before going to

bed using relaxing music, books or a

companion Enjoying the kind of sleep he gets


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Comfort and Pain Relief

Pain has been roughly described by

McCaffrey (1968) as whatever the

experiencing persons says it is, existing

whenever he says it does.

It is a very individualized experience and oneof the most complex human experiences,

often involving the interaction of physiologic,

psychological, social, cultural, and spiritual

factors.

Pain is one of the primary reasons whyclients seek healthcare.


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Characteristics of Pain

Location localized, diffuse, proximal, distal,

medial, lateral, etc

Intensity mild, moderate, severe, intermittent,

spasmodic, constant

Quality boring, burning, cramping, crushing,dull, excruciating. Hammering, intermittent,

stabbing, lancinating, penetrating, piercing,

pounding, radiating, sharp, shooting, spasms,

tearing, throbbing, tingling

Onset acute, chronic, intractable Associated characteristics


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Factors affecting Pain

Pain threshold

Pain tolerance

Fear Fatigue

Lack of knowledge

Cultural values and beliefs


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Causes of Pain/Discomfort

Biologic disease, microorganisms, cell

injury; tissue damage due to alterations in

essential cellular life processes

Chemical substances released by

disease processes and cytotoxic agents

Physical trauma, extremes in

temperature, electrical burns, radiation

injuries

Psychological emotional factors that bring

distress to the person; anxiety in acute pain

and depression in chronic pain


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Manifestations of Pain

Physiologic

Low to moderate pain pallor, increased BP,

dilated pupils, increased skeletal muscle tone,

tachypnea, tachycardia, increased perspiration,

decreased urine output, decreased GI

peristalsis, increased mental activity and BMR Severe pain pallor, decreased BP, pupil

constriction, decreased muscle tone,

bradycardia, increased GI peristalsis

Behavioral

Verbalization of pain, crying, moaning Rubbing of painful parts, frowning, grimacing,

fatigue

Increased muscle tension


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Nursing Assessment

Subjective Data report or verbalization of pain

Objective Data

Guarding, protective behavior

Self-focusing

Narrowed focus altered time perception,withdrawal from social contacts, impaired thought

processes

Distraction behavior moaning, crying, pacing,

restlessness, seeking out other people and/ or other

diversional activities Facial mask of pain lack-luster eyes, beaten

look, fixed or scattered movement, grimacing

Autonomic responses


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Promote Comfort and Prevent Pain

Encourage the appropriate use of body position and

body mechanics during work and recreation

Assist in identifying factor that can bring about or

make the pain worse Provide comfort measures for a bed-ridden client

Eliminate wrinkles in bed sheets

Avoid constrictive clothing

Change position at least every 2 hours

Provide backrub while listening attentively and

continuing the ongoing pain assessment

Provide meticulous skin hygiene to prevent pain due

to pressure, excoriation and/or irritation


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Promote Comfort and Prevent Pain

Give anticipatory guidance on the amount of pain that

the client can expect from a particular procedure or

activity

Splinting the surgical incision with pillows todecrease muscle tension at the surgical site

Positioning techniques as moving side to side,

transferring to one side of the bed and to the chair,

and proper posture in walking

Premedication with narcotics before activities;teach client to request for pain medication when

the pain begins in order for the medication to be

more effective in preventing the aggravation of

pain


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Manage the Acute Pain Experience of the Client

Listen actively to the clients description of the pain

experience

Formulate a plan of care managing pain together with the

client

Teach client on how to minimize pain by splinting the painfularea with a pillow before activities such as moving or

coughing

Encourage client to use non-invasive, non-pharmacologic

management of pain

Administer pain medications as ordered, give adequatemedication to relieve pain, use medication when pain begins

to maximize its efficacy, and monitor the effectiveness of the

medication

Promote periods of uninterrupted rest after pain relief

measures


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Manage the Chronic Pain Experience of the Client

Acknowledge clients pain experience

Encourage client to maintain a list of factors relating to

pain including activities that precipitate pain, the

length and duration of the pain, and the therapiesused to relieve pain

Teach client on non-pharmacologic, non-invasive pain

management techniques

Promote a schedule of rest and activity during the day

to minimize pain Refer client to appropriate community resources and

social support services for evaluation


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Administer Pain Medications as Ordered

Determine if and when analgesics are given because

they are usually ordered prn

Select appropriate analgesic when more than one is

prescribed, taking into consideration the drugspotency and rate of absorption

Evaluate the effectiveness of analgesic after

administration via sound pain assessment skills

Observe for analgesic side effects through close

observation of client Report promptly and accurately to physician when a

change in medication is needed


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Give aspirin and corticosteroids on a full stomach to

minimize gastric irritation

Do not give aspirin together with oral anticoagulants,

methotrexate, probenecid, sulfinipyrazone Use acetaminophen with caution in clients with liver

disease

Inform physician of a client taking corticosteroids for

reduction of inflammation if excessive weight gain,

edema, hypertension, bone pain, sore throat, fever,cold, infection, mood changes, or visual disturbances

develop


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Be ready with a narcotic antagonist (naloxone,

levallorphan) to counteract respiratory depression in

clients receiving narcotic analgesics

Teach client on the use of patient-controlled analgesia(PCA)


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Non-Invasive, Non-Pharmacologic

Pain Management

Distraction - useful in brief periods of sharp, intense

pain such as during wound dressing changes, wound

debridement, or biopsy.

Cutaneous stimulation includes massage, heat and

cold applications, contralateral stimulaton,

acupuncture, and transcutaneous electrical nerve

stimulation for acute and chronic pain.

Massage - rubbing the painful area in order to relax

muscles and reduce tension; not be used over broken

skin, mucous membranes, or rashes.

Heat increases inflammation, blood flow, edema

and bleeding at site; for joint and muscle pain

Cold opposite heat effects; useful in chronic

migraine headache and back pain


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Non-Invasive, Non-Pharmacologic

Pain Management

Contralateral stimulation area opposite the painful

one is stimulated with heat or cold applications or

massage (example: R hand painful, stimulate L hand);

useful for muscle cramps, spasms, itching.

Acupuncture insertion of stainless steel needles

near nerves in a painful area or at certain body points

(dermatomes)

Acupressure like acupuncture but instead of

needles inserted, the acupuncture points are pressed

and massaged

Transcutaneous electrical nerve stimulation as an

adjunct in the overall pain management.


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Self-Care and Hygiene

Bathing and hygiene keeps skin intact and

healthy by removing excess oil, perspiration,

and bacteria

Hair care removes dirt and oil from hair and

scalp

Feet and nail care requires comfortable and

properly-fitting footwear

Care of the eyes, ears, and nose special

care for clients with glasses, contact lenses,

prostheses

Oral care prevent deterioration of the gums

as well as tooth loss


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Feeding allows independence in making food

choices and being able to feed oneself

Desire to make food choices and eat

Energy and muscular coordination to move

food from plate to the mouth

Ability to chew and swallow

Toileting feeling the urge to void and moving

to the toilet or bedpan, independently or with

assistance; rearranging clothing, voiding, and

effectively cleaning areas of excretion Dressing and grooming ability to get clothes

from closet, put them on, manage the fasteners,

and put on socks and shoes


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Levels of Self-Care

Level 0 client is fully independent in self-care activities

(a healthy college student living in a pad by herself)

Level 1 the client uses equipment of devices to

perform self-care activities independently ( an elderly

man with a cane to assist for walking)

Level 2 client needs assistance or supervision fromanother person to complete the self-care activities (client

needing help in taking a bath 1 day postoperatively)

Level 3 client needs assistance or supervision from

another person as well as the use of devices or

equipment (client who ambulates using a walker and a

physical therapist for supervision)

Level 4 client is fully dependent on another person to

perform self-care (comatose client)


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Index of Independence in ADLs

Bathing

Independent client bathes self completely or

needs assistance only in bathing a single part

of the body (the back or a disabled extremity)

Dependent client does not bathe self or

needs assistance in getting in or out of tub and

in bathing more than one body part

Dressing

Independent client gets clothes from closets

and drawers; puts on clothes, outer garments,braces, manages fasteners

Dependent client does not dress self or

remains partly undressed


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Toileting

Independent client gets to, on, and off the

toilet; arranges clothes, cleans organs of

excretion

Dependent client uses bedpan or commode

or needs assistance in getting to and using the

toilet

Transferring

Independent - Client independently moves in

and out of bed and chair Dependent client needs assistance in

moving in and out of bed and/or chair or client

does not perform one or more transfers


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Continence

Independent client has self-control of

urination and defecation

Dependent client has partial or total

incontinence in urination or defecation;

partially controlled by catheters, enemas, or

the regulated use of urinals and/or bedpans

Feeding

Independent client gets food from plate and

into mouth Dependent client needs assistance in

feeding, does not eat at all, or uses parenteral

feeding


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Causes of Alterations in


Decreased energy - response to medication,

compromised cardiopulmonary functioning, fluid

and electrolyte imbalance, disruption in diet,

infection, disturbed GI function

Sensorimotor deficits - visual and hearingimpairments due to surgery, injury, infection

Pain can cause immobility or decreased

willingness to move, some analgesics cause

lightheadedness or drowsiness


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Neuromuscular impairment stroke, spinal cord

injury, Parkinsons disease, cerebral palsy,

myasthenia gravis, muscular dystrophy, other

neurologic problems; muscle weakness and/or

atrophy, lack of coordination, spasticity, paralysis,

joint contractures; immobility due to casts, splints,pain, weakness

Acute illness and surgery confusion and

drowsiness from analgesics, fluid and electrolyte

imbalance, and hypoxemia; nausea and vomiting;

weakness due to anesthesia, hypovolemia, lowhematocrit level, atelectasis; casts, IV lines,

incisions, splints, urinary catheters, NGT, surgical

drains, anxiety


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Cognitive dysfunction decreased level of

consciousness, confusion

Emotional disturbance and depression

inattention due to side effects of medications,

unfamiliar environment, psychosis, schizophrenia;autism; depression

Dysfunctional environment poverty, poor living

conditions, limited access to facilities required for

self-care; attitude of other people


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Alterations in Self-Care

and Hygiene

Poor hygiene and grooming

Soiled, dry, flaky skin with or without rashes

and excoriated areas

Oily, unwashed, uncombed, smelly hair, dirty

and broken nails, generally offensive body

odor, soiled, torn, inappropriate clothing

Mouth sores, dental caries, inflamed gums,

dental plaque buildup, stained teeth, bad

breath or halitosis, soiled pants with urine or

feces

Inability to demonstrate self-care activities

Reporting of reluctance to perform self-care due

to depression, cognitive alteration, a dependent

personality, fear of pain or anxiety


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Nursing Assessment

Subjective Data - verbalization of reluctance to performself-care

Objective Data

Inability to wash boy or body part

Inability to obtain water

Inability to regulate temperature or flow of water Impaired ability to fasten clothing

Inability to maintain appearance at a satisfactory level

Inability to get to toilet or commode

Inability to sit on toilet or commode

Inability to manipulate clothing for toileting Inability to carry out proper toilet hygiene

Inability to flush toilet or to empty commode

Inability to cut food

Inability to bring food from receptacle to mouth


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Nursing Interventions: Bathing

Plan to render hygiene measures when the

client is well-rested

Gather supplies as necessary such as basin,

water, soap, toilet articles

Offer pain medications as prescribed and if

necessary before hygiene measures

Encourage client to sit by the sink or shower

when endurance is limited

Check and adjust water temperature to avoid

burns Use caution when moving in and out of bathtub

or shower by using handrails or other support

measures


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Move slowly when changing body positions toallow circulation changes and avoid falls

Use leg exercises to stimulate circulation

before rising from a sitting position

Do not leave infants or young children

unattended in or near the bathtub or shower

Teach client about prevention of skin dryness

Assist client with perineal care

Provide client with a soothing backrub

Provide care of the feet and nails Provide hair shampooing

Assist male client with shaving, if needed


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Assist client with toothbrushing and flossing

Assist client in the care of dentures

Assist client in the care of the eyes, eye

glasses, contact lenses

Assist client in the care of the ears and hearingaids

Work with an occupational therapist to teach

re-learning of skills when new cognitive or

physical impairments occur

Use verbal cuing if necessary Praise client for accomplishments

Assist with hygiene measures that the client

cannot perform independently


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Methods of bathing

Sitz bath cleanse, soothe and reduce

inflammation of the perineum after

childbirth, vaginal or rectal surgery, or local

irritation of hemorrhoids and fissures; water

temperature = 105o-113oF

Hot-water bath - relieve muscle spasms

and soreness by total body immersion;

water temperature = 113o-114.8oF; watch

out for vasodilation, orthostatic

hypotension, and scadling

Warm-water bath - cleanse, promote

relaxation, and relieve tension; water

temperature = client preference


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Nursing Interventions: Feeding

Provide appropriate food as needed

Provide utensils that aid feeding

Use verbal cuing and positive encouragement

Work with speech therapists or occupational

therapists to individualize the teaching plan for

clients with new physical or cognitive impairments

N i I t ti


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Nursing Interventions:

Dressing and Grooming

Provide rest period before dressing or grooming

activities

Space different grooming activities throughout the

day to avoid fatigue

Assemble all necessary clothing or grooming aids

Assist client with brushing and combing the hair

Ensure that clothing is loose-fitting and easy to fasten

Perform activities in a sitting position, if possible

Ask client preferences if he is unable to perform

activities independently so the client will feel

involved

Work with occupational therapists to individualize the

teaching plan for clients with new physical or

cognitive impairments


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Nursing Interventions: Toileting

Encourage routine toileting to avoid urgent need to

reach toilet facilities

Provide with needed toileting supplies

Ensure clear and easy access to toilet or bedsidecommode by removing clutter

Encourage clothing that is easy to remove

Provide equipment to ensure safety

Provide ambulation aids or bedside commode if

ambulation is difficult


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Nursing Interventions: Toileting

Assist the client in urination

Turn on the bathroom tap

Have the client visualize his bathroom at home

Warm the bedpan Have the client assume a comfortable position

Provide analgesia for pain, if needed

Pour warm water over perineum

N i I t ti


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Care of the Patients Room

Ensure all equipment are in good working order

and supplies are adequate to meet clients needs

Ensure call light is functioning

Ensure that the bed is properly made whether it isan occupied bed, unoccupied bed, or a surgical

bed

Maintain asepsis in bed-making

Assemble all required linens before starting to

conserve energy

N i I t ti


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Care of the Patients Room

Change bed positions according to the clients

therapeutic needs

Flat mattress is completely flat

Fowlers upper part of the bed is raised to asemi-sitting position (15o to 45o; low or semi-

Fowlers) or to an almost upright position (90o;

high Fowlers)

Trendelenburg entire bed is tilted with the

head of the bed downward

Documents

Safety, Comfort, Hygiene