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Shurouq Qadose

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... The client s usual nail care practices Self care abilities Any problems associated with them. Physical assessment: inspection of the nails ... – PowerPoint PPT presentation

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Title: Shurouq Qadose


1
  • Shurouq Qadose
  • 29/3/2009

2
Personal hygiene
  • Is the self-care by which people attend to such
    functions as bathing, toileting, general body
    hygiene, and grooming.
  • It involves care of the skin, hair, nails, teeth,
    oral and nasal cavities, eyes, ears, and perineal
    genital areas.

3
Factors influencing individual hygienic practices
  • Culture
  • Religion
  • Environment
  • Developmental level
  • Health and energy
  • Personal preference
  • See table 33-1

4
Types of hygienic care
  • Early morning care
  • Morning care
  • Hour of sleep (HS) or PM
  • As needed care (prn)

5
Anatomy of the skin
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Functions of the Skin
  • The largest organ of the body.
  • Protection from injury by preventing the passage
    of MO, considered the first line of defense.
  • Regulation of body temperature
  • Secretory function sebum, an oily that softens
    and lubricates the hair and skin.
  • Sensations nerve receptors are sensitive to
    pain, temperature, touch, and pressure.
  • Absorption of vitamin D.

8
Nursing Management
  • Assessment, includes
  • (a) A nursing history to determine the clients
    skin care practices, self-care abilities, and
    past or current skin problems
  • (b) Physical assessment of the skin
  • (c) Identification of clients at risk for
    developing skin impairments

9
Nursing History
  • Assessment of the clients self-care abilities
    determines the amount of nursing assistance and
    the type of bath best suited for the client.
  • Important considerations include
  • The clients balance
  • Activity tolerance
  • Coordination
  • Adequate muscle strength
  • Appropriate joint range of motion
  • Vision
  • The clients preference
  • Cognition and motivation .
  • See Table 33-2

10
Physical Assessment
  • Involves inspection
  • Palpation.

11
Diagnosing
  • Self- care Deficit diagnoses are used for clients
    who have problems performing hygiene care.
  • Self- care Deficit Bathing / Hygiene
  • Self- care Deficit Dressing/Grooming
  • Self- care Deficit Toileting

12
Etiologies of self-care deficit
  • Decreased or lack of motivation
  • Weakness or tiredness
  • Pain or discomfort
  • Perceptual or cognitive impairment
  • Inability to perceive body part
  • Neuromuscular or musculoskeletal impairments
  • Medically imposed restriction
  • Therapeutic procedure restraining mobility
  • Severe anxiety
  • Environmental barriers

13
Planning
  • The nurse and the client and /or family set
    outcomes for each nursing diagnosis.
  •  
  • Implementation
  • The nurse applies the general guidelines for skin
    care while providing one of the various types of
    baths available to clients.

14
General guidelines for skin care
  • An intact, healthy skin is the body's first line
    of defense. Ensure that all skin care measures
    prevent injury and irritation.
  • The degree of the skin protection depends on the
    general health of the cells, the amount of
    subcutaneous tissue, and the dryness of the skin.
  • Body odors are caused by resident skin bacteria
    acting on body secretions
  • Skin sensitivity to irritation and injury varies
    among individuals.
  • Agents used for skin care have selective actions
    and purposes.
  • Moisture in contact with the skin can result in
    increased bacterial growth and irritation.

15
Bathing
  • Bathing removes accumulated oil, perspiration,
    dead skin cells and some bacteria.
  • Two categories of baths are given to clients
  • Cleaning baths are given for hygiene purposes and
    include
  • Complete bed bath
  • Self-help bed bath
  • Partial bath
  • Bag bath
  • Tub bath
  • Shower

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Therapeutic bath
  • Baths are given for physical effects
  • To soothe irritated skin
  • To treat an area such as perineum
  • Medication may be placed in the water.
  • Perineal-genital care is also referred to as
    perineal care or pericare.

20
Nursing Management
  •  Feet
  • The feet are essential for ambulation and merit
    attention even when people are confined to bed.
  • Assessing it includes the following
  •  Nursing Health History of
  • Normal nail and foot practices
  • Type of foot wear worn
  • Self-care abilities
  • Presence of risk factors for foot problems
  • Any foot discomfort
  • Any perceived problems with foot mobility.

21
Physical Assessment
  • Each foot and toe is inspected for
  • Shape
  • Size
  • Presence of lesions
  • Palpated to
  • Assess areas of tenderness
  • Edema
  • Circulatory status.
  • Normally, the toes are straight and flat.

22
Common foot problems include-
  • Callus is a thickened portion of epidermis, a
    mass of keratotic material.
  • Most calluses are painless and flat and are found
    on the bottom or side of the foot over a bony
    prominence
  • Usually caused by pressure from shoes.
  • Corn is a keratosis caused by friction and
    pressure from a shoe. It commonly occurs on the
    forth or fifth toe, usually on a bony prominence
    such as a joint.

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Common foot problems include-
  • Unpleasant odors occur as a result of
    perspiration and its interaction of
    microorganisms.
  • Planter warts appear on the sole of the foot.
  • Fissures or deep grooves frequently occur
    between the toes as a result of dryness and
    cracking of the skin.

25
Common foot problems include-
  • Athletes foot or tinea pedis (ringworm of the
    foot) it is caused by a fungus.
  • The symptoms are scaling and cracking of the
    skin, particularly between the toes.
  • Sometimes small blisters form, containing a thin
    fluid.

26
Common foot problems include-
  • Ingrown toenail the growing inward of the nail
    into the soft tissues around it, most often
    results from improper nail trimming.

27
Clients at Risk
  • Diabetes
  • Peripheral vascular disease
  • Are prone to infection if skin breakage occurs
    because of reduced peripheral circulation to the
    feet, clients with.

28
Diagnosing
  • Self care deficit Hygiene (foot care) R/T
  • - Visual impairment
  • - Impaired hand coordination
  • Risk for impaired skin integrity R/T
  • Poorly fitting shoes
  • Risk for infection R/T
  • - Impaired skin integrity (trauma, corn)
  • - Deficient nail or foot care
  • Deficient knowledge (diabetic foot care) R/T
  • - Lack of teaching/learning activities about
    diabetic foot care
  • - Newly established medical diagnosis (diabetes)

29
Planning
  • (a) identifying nursing interventions that will
    help the client maintain or restore healthy foot
    care practices
  • (b) establishing desired outcomes for each
    client.
  • Implementation
  • In Skill lab

30
NailsNursing Management
  •  Assessing
  • Health history the nurse explores
  • The clients usual nail care practices
  • Self care abilities
  • Any problems associated with them.
  • Physical assessment inspection of the nails
    (shape and texture, nail bed color, and tissues
    surrounding the nails).

31
Diagnosing
  • Self care Deficit Grooming related to impaired
    vision
  • Risk for infection around the nail bed related
    to
  • - Impaired skin integrity of cuticles
  • - Altered peripheral circulation

32
Planning
  • The nurse identifies measures that will assist
    the client to develop or maintain healthy nail
    care practices.
  • Implementation
  • In Skill lab

33
Evaluation
  • Examples of desired outcomes
  • The client being able to
  • Demonstrate healthy nail care practices as shown
    by
  • Clean, short nails with smooth edges
  • Intact cuticles and hydrated surrounding skin
  • Describe factors contributing to the nail
    problems
  • Describe preventive interventions for the
    specific nail problem
  • Demonstrate nail care as instructed

34
Mouth
  • Each tooth has three parts the crown, the root,
    and the pulp cavity.
  • Nursing Management
  •  Assessing
  •  Assessment of the clients mouth and hygiene
    practices includes-
  •  Nursing history
  • The nurse obtains data about the clients oral
    hygiene practices, including dental visits, self
    care abilities, and past or current mouth
    problems.

35
Physical assessment
  • Most common problems affect the teeth.
  • Tarter is a visible, hard deposit of plaque and
    dead bacteria that forms at the gum lines.
  • Gingivitis "red, swollen gingival", bleeding,
    receding gum lines, and the formation of pockets
    between the teeth and gums.
  • Pyorrhea the teeth are loose and pus is evident
    when the gums are pressed.

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Plaque is an invisible soft film that
adheres to the enamel surface of teeth , it
consist of bacteria, molecules of saliva.
39
Identifying Clients at risk
  • Clients who lack of knowledge
  • Clients who has inability to maintain oral
    hygiene
  • Seriously ill clients.
  • Confused clients.
  • Comatose clients.
  • Depressed clients.
  • Dehydrated clients.
  • Clients with nasogastric tubes
  • Clients receiving oxygen
  • Clients who have had oral or jaw surgery must
    have meticulous oral hygiene care to prevent the
    development of infections.

40
Identifying Clients at risk
  • Clients in long-term care settings.
  • A dry mouth can be aggravated by
  • Poor fluid intake
  • Heavy smoking
  • Alcohol use
  • High salt intake
  • Anxiety
  • Medications.
  • Clients who are receiving or having radiation
    treatments to the head and neck may have
    permanent damage to salivary glands

41
Diagnosing
  • Self care deficit oral hygiene will be used
    for clients unable to perform oral care
    independently.
  • Impaired oral mucous membrane related to
  • - Ineffective oral hygiene
  • - Physical injury or drying effect (mouth
    breathing, oxygen therapy)

42
Planning
  • Specific detailed nursing activities taken by the
    nurse may include the following
  • Monitor every shift to dryness of the oral mucosa
  • Monitor for signs and symptoms of glossitis"
    inflammation of the tongue" and stomatitis"
    inflammation of the mouth.
  • Assist dependent clients with oral care.
  • Provide special oral hygiene for clients who are
    debilitated, unconscious, or have lesions of the
    mucous membrane or other oral tissues.

43
  • Teach clients about good oral hygiene practices
    and other measures to prevent tooth decay.
  • Reinforce oral hygiene regimen as part of
    discharge teaching.

44
Implementation
  • Good oral hygiene includes daily stimulation of
    the gums, brushing, flushing of the mouth.
  • Promoting Oral Health through the Life Span
  • Infant and Toddler
  • The nurse should give parents the following
    instructions to promote and maintain dental
    health
  • Beginning at about 18 months of age, brush the
    child's teeth with a soft toothbrush

45
Infant and Toddler
  • Give a fluoride supplement daily or as
    recommended
  • Schedule an initial dental visit for the child at
    about 2-3 years of age.
  • Some dentists recommend an inspection type of
    visit when the child is about 18 months old to
    provide an early pleasant introduction to the
    dental examination.
  • Seek professional dental attention for any
    problem such as discoloring of the teeth.

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  • Preschools and School-Age Children
  • Adolescents and Adults
  • Assisting clients with oral care
  • Clients with special oral hygiene needs

48
Caring for artificial dentures
49
Brushing and flossing the teeth
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A foam Swab
51
Hair
  • Developmental Variations
  • Newborn may have lanugo" fine hair on the body of
    the fetus.
  • In older adults the hair is generally thinner,
    grows more slowly and loses its color as a result
    of aging.

52
Nursing Management
  • Assessing
  •  Nursing history
  • The nurse collect data about usual hair care,
    self care abilities, history of hair or scalp
    problems.
  • Physical assessment
  • Problems include

53
Hair problems
  • Scabies
  • Is a contagious skin infestation by the itch
    mite.
  • Treatment involves through cleansing of the body
    with soap and water to remove scales and debris
    from crusts, and then an application of the
    scabicide lotion.
  • All bed linens and clothing should be washed in
    very hot or boiling water.

54
Hair problems
  • Hirsutism the growth of excessive body hair. The
    cause is not always known.
  • Dandruff Often accompanied by itching.
  • Pediculosis (Lice)
  • Hair loss

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Nursing diagnosing related to hair hygiene and
hair and scalp problems include
  • Self care deficit Grooming related to
  • - Activity intolerance
  • - Immobility
  • - Pain in upper extremities
  • - Altered level of consciousness
  • - Lack of motivation associated with depression

57
  • Nursing diagnosing related to hair hygiene and
    hair and scalp problems include
  • Self care deficit Grooming related to
  • - Activity intolerance
  • - Immobility
  • - Pain in upper extremities
  • - Altered level of consciousness
  • - Lack of motivation associated with depression
  •  

58
Nursing diagnosing related to hair hygiene and
hair and scalp problems include
  • Impaired skin integrity related to
  • - Scalp laceration
  • Insect bite
  • Risk for infection related to
  • - Scalp laceration
  • - Insect bite
  • Disturbed body image related to alopecia

59
  • Implementing
  • Brushing and Combing Hair
  • Shampooing the hair.
  • Beard and mustache care

60
Nursing Management of the eyes
  • Assessing
  • Assessment of the clients eyes includes-
  • - Nursing health history
  • The nurse obtains data about the clients
    eyeglasses or contact lenses, recent examination
    by an ophthalmologist, and any history of eye
    problems.
  • - Physical assessment
  • Inspection of the external eye structures

61
Nursing diagnosing related to eye problems may
include
  • Self care deficit (insertion and removal
    contact lens, cleaning) related to
  • - Deficient Knowledge
  • - Impaired vision associated with cataracts
  •  

62
Nursing diagnosing related to eye problems may
include
  • Risk for infection related to
  • - Improper contact lens hygiene
  • - Accumulation of secretions on eyelids
  •  
  • Risk for injury related to
  • - Prolonged wearing of contact lenses
  • - Absence of blink reflex associated with
    unconsciousness

63
Implementing
  • Nursing activities may include-
  • Eye Care dried secretions that have accumulated
    on the lashes need to be softened and wiped away.
  • Eyeglass Care
  • Removing Contact Lenses
  • Inserting Contact Lenses

64
General Eye Care
  • Avoid home remedies for eye problems.
  • If dirt or dust gets into the eyes, clean them
    copiously with clean, tepid water as an emergency
    treatment.
  • Take measures to guard against eyestrain and to
    protect exertion.
  • Schedule regular eye examinations, particularly
    after age 40 to detect problems such as
    cataracts.

65
Evaluation
  • Conjunctiva and sclera free of inflammation
  • Eyelids free of secretions
  • No tearing
  • No eye discomfort
  • Demonstrate appropriate methods of caring for
    contact lenses
  • Describe interventions to prevent eye injury and
    infection

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EARS
  • Normal ears require minimal hygiene. Clients who
    have excessive earwax and dependent clients who
    have hearing aids may require assistance from the
    nurse.
  • Cleaning the Ears
  • Care of Hearing Aids

68
  • NOSE
  • Nurses usually need not provide special care for
    the nose, because clients can ordinarily clear
    nasal secretions by blowing gently into a soft
    tissue.
  • Supporting A Hygienic Environment
  • When providing a comfortable environment it is
    important to consider the clients age, severity
    of illness, and level of activity
  • Room Temperature
  • Ventilation.
  • Noise

69
  • Hospital Beds
  • Commonly used bed positions
  • - Flat
  • - Fowlers position (semisitting position in
    which head of bed is raised to angle of at least
    45.)
  • - Semi- Fowlers position (head of bed is raised
    only to 30 angle.)
  • - Trendelenburgs position (head of bed is
    lowered and the foot raised in a straight)
  • - Reverse Trendelenburgs position (head of bed
    raised and the foot lowered).

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