Chapter 15

Fundamentals of Nursing Care: Fundamentals of Nursing Care: Concepts, Connections, & SkillsConcepts, Connections, & Skills

Copyright © 2011 F.A. Davis Company

Chapter 15

Personal Care



Activities of Daily Living (ADLs) Related to Personal Care

Bathing Washing and styling hair Brushing and flossing teeth Dressing Shaving



Routine Care Who’s job is it? Delegate? Responsibility



Routine Care Delegate or not?

Patient’s condition is unstable Need more information on patient’s skin Need to evaluate the patient’s capabilities to

assist with their own personal care Need to develop or strengthen rapport with

patient



Scheduled Care A.M. Care

Before or after breakfast ADL’s

Bathing, teeth, hair, dressing, shaving….. Linen’s

Changed as needed



Scheduled Care P.M. Care

Address any needs Straighten sheets Back rub?



Hourly Rounding

The five P’s: Pain—adequately controlled? Position—comfort/care/prevention Potty—need to use restroom/urinal available? Po—require drink/water within reach Placement—safety



Hourly Rounding Purpose

Provide care in a Timely manner Improve quality Emphasis on safety



Hourly Rounding Must be completed every hour and

documented Decreases call bell use Decreases incidence of falls Sense of security Detection of a deteriorating patient condition



Scheduled Care Bedtime (hs) Care

Prepare for sleep Brush teeth, remove dentures Remove glasses, remove hearing aid Back rub? Extra blanket Dim lights



Benefits of Bathing Patients Patient

Cleansing the skin Increasing circulation and sensation Providing comfort and relaxation Improving self-esteem

Nurse Opportunity for skin assessment Nurse–patient relationship



Benefits of Bathing Skin assessment

Look for redness, cracking, and maceration Crevices, under breasts and scrotum, axilla and

groin, between toes, and between buttocks Excoriation or scrapes on skin Temperature Breakdown



Benefits of Bathing Gain your patient’s trust and respect

Respect Preserve modesty Demonstrate care and compassion More time spent with patient=ability of patient to

confide in you



Factors to Consider Prior to Bathing

Condition of patient Weakness Pain Mental status

Confused Emotionally upset

Limited mobility



Factors to Consider When Planning Patient Care and Bathing

Patient preferences Patient’s culture Timing of the care Patient’s abilities

Understands directions Moves and turns enough to assist Tolerates physical demands of a bath



Approach is Important Positive attitude Do not rush patient Do not make their care seem like a chore to

you How would you like to be treated or your

family member



Supplies Basin or bag Several towels, washcloths, bath blanket Linens Laundry bag or somewhere to place dirty linen



Bath Test water temperature Provide privacy Position bed to appropriate height Lower siderail nearest you Place bath blanket Remove gown



Three Categories of Personal Care

Self-care: patients who are able to perform ADLs without assistance

Assisted care: patients who need some assistance with ADLs

Total care: patients who are able to do very little or nothing for themselves



Types of Baths Complete bed bath Assisted or help bath Partial bath Tub bath* Shower* Therapeutic bath Towel or blanket bath* Bag bath*



Complete Bed Bath View video Skill 15-1 pg. 294



Assisted Bath Bed or chair Patient participates as much as possible Nurse completes what patient can not reach

or if becomes fatigued



Partial Bath Only selected areas are washed Patient condition Post-op Dryness Face, hands, axilla, buttocks, and perineal

area, or parts of the patient that would cause odor if not washed



Special Considerations Older adults

Sebaceous and sweat glands produce less oil and sweat

Optional daily full bath—cleanse areas of necessity

Prevent dryness Keep patient warm



Tub Bath Sits in tub Whirlpool Disadvantages—difficult to get in and out of

tub, risk of falls



Shower Shower chair

↓ risk of falling Lock wheels Never leave patient Monitor temperature of water Cleanse all areas Wash hair



Key Points Tub baths, showers, or therapeutic baths

Monitor water temperature Warm water dilates blood vessels (vasodilatation) Lowers blood pressure Possible dizziness or fainting Stay with patient or in close proximity Inform patient of emergency call system



Bag Bath

12-15 washcloths saturated with no-rinse skin cleanser

Heat bag in microwave Each washcloth washed one part of body—

then discard



Guidelines Use of bath blanket Fold washcloth into a mitt Move cleanest to dirtiest areas—prevent

transferring bacteria Extremities—distal to proximal Start with extremity farthest away from you—

prevent contamination



Guidelines Change water

Dirty Soapy Cool After bathing buttocks and rectal area

Perform perineal care during bath and anytime patient is incontinent



Nurse Responsibilities When Bathing Patients

Assess the skin for rashes, bruises, and lesions Complete the bathing process in timely

manner Be alert to signs of patient fatigue Intervene in ways to conserve patient energy

during the bath



Oral Care Freshens mouth Decrease bacterial count Assess mouth for problems

Teeth—decaying, broken, or missing Reddened or bleeding gums Ulcerations Coating on the tongue



Examples of Patients Needing Special Mouth Care

Patients who are NPO Patients receiving oxygen by cannula or mask Patients having a nasogastric or feeding tube

in place Patients who are unconscious



Unconscious Patient Oral care needs to be provided Highest priority—Prevent aspiration of fluids Proper positioning Availability of suction Assess for lesions and sordes (dried mouth

secretions) Skill 15-4, pg. 298



Oral Care Unconscious Patient Assess mouth Check for gag reflex Increased risk for aspiration Position patient Equipment—suction Padded tongue blade



Oral Care Unconscious Patient Clean all areas

Teeth Tongue Between cheeks and gums

Use multiple swabs If using toothbrush-toothpaste-irrigate-drain



Oral Care Unconscious Patient Water-soluble lip balm

Oxygen Aspiration

Upon completion assess mouth



Conscious Patient Independent—help with necessary supplies Assistance needed—use small amount of

toothpaste, circular motion on inner and outer surface of teeth, and back and forth motion on chewing surfaces

Possible swallowing difficulties*--stay with patient and position patient properly



Denture Care Be careful! Expensive Interfere with nutrition Pad cleaning surface Use cool rather than hot water Follow policy or patient’s preference



Denture Care—Skill 15-6 Supplies

Denture cup, toothbrush, toothpaste, denture cleanser, towel, mouthwash, toothettes, gauze 4x4’s

Don gloves—grasp upper dentures with gauze 4x4 Rock dentures gently from side to side to loosen

and pull down and out



Denture Removal Sometimes need to place gloved finger along gum

and press downward to break seal Grasp lower dentures with gauze 4x4 and lift up and

out Place in denture cup Pad work surface Rinse with cool, not hot water Clean dentures as desired by patient or facility



Dentures Rinse with cool water Do not dry—easier to insert moist dentures If patient capable—have patient rinse mouth

with water or diluted mouthwash If unable to rinse mouth—cleanse mouth with

toothettes moistened with water or diluted mouthwash



Denture Insertion If used—apply denture adhesive Slide upper denture into mouth and push up

with thumb on the palate of the denture to obtain a good seal

Slide lower denture into mouth and press gently downward into place



Dressing Underwear? Limited mobility?

Affected extremity first to apply clothes Affected extremity last to remove clothes

Intravenous line? Size of patient Don’t forget their HAIR!



Let them select outfit Any limitations? Style hair Apply makeup if desired

Dressing



Hair Care Keep patient well groomed Improves self-esteem Comb or brush—eliminate bed head—style age

appropriate Shampoo if needed or desired Shower or no rinse shampoo Shampoo board—Skill 15-9



Shaving Shave in direction of hair growth Electric razor—circular motion—clean razor

when finished to prevent clogging Safety: DO NOT USE a razor blade for any

patient on anticoagulation therapy (blood thinning medication) A cut can cause excessive, difficult to control bleeding





Contraindications Thrombolytic agents High doses of aspirin Blood disorders Liver disease Rashes, lesions, inflamed lesions Suicidal patients



Nail Care Follow facility policy Do not cut nails on diabetics or patients with

circulatory problems—Podiatrist Clip nails straight then file—stay away from

skin





Observations Made During Nail Care

Discoloration Ridges Redness Infections Thick yellow toenails (fungal infection)



Care of Piercings New piercings

Keep clean—soap, water, and alcohol S/S of infection—redness, swelling, pain, or

drainage



Situations Requiring Removal of Jewelry From Piercings

Surgery Intubation Diagnostic testing Catheterization Table 15-1, pg. 289



Eye Care Glassess

Clean with warm water and soft cloth Inform patient of placement of glasses Safe but accessible site



Removing Contact Lenses Wash hands; put on gloves Pull down on lower lid; place finger across

upper lid; apply gentle pressure Ask patient to blink Grasp lens with fingers Hold lens carefully and put in well Fill the well with saline or soaking solution



Contact Lenses Properly labeled containers (R and L) Place in correctly Saline or special soaking solution



Procedure for Removing a Prosthetic Eye

Wash your hands and put on gloves Dip the end of the suction cup in saline Lift the upper eyelid Squeeze the suction cup and place it on the iris of

the prosthesis Stop squeezing Use the handle of the suction cup to lift the

prosthesis out of the socket



Cleansing Prosthesis Cleanse prosthesis with sterile water or saline Irrigate the eye socket with eye irrigating

solution Small amounts of mucus may accumulate Observe for thick yellow or green mucus



Removing a Hearing Aid

Turn off the hearing aid Turn the earmold slightly toward the nose and

lift out Store the aid in its case or moisture-control

container



Inserting a Hearing Aid Check the battery by turning the hearing aid

on to full volume and listening for it to whistle, which indicates that it is working

If you do not hear a whistle, check the battery and replace as needed

Turn off the hearing aid and lower the volume Insert the hearing aid into the ear and adjust

the volume as needed



Types of Unoccupied Beds

Open bed: made with top linens fan folded to foot of bed

Surgical bed: made with top linens fan folded to side of bed

Closed bed: only used when patient is discharged; top linens are spread to the head of the bed



Nurse Responsibility in Bed Making

Often delegated to a CNA or UAP Must be made tightly without wrinkles Number one concern is patient safety Use side rails appropriately Apply drawsheet according to policy Miter corners



Common Bed Positions

Flat Fowler’s—45 to 60° Semi-Fowler’s or low-fowler’s—30° High Fowler’s—sitting upright in bed Trendelenburg Reverse Trendelenburg

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