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7/29/2019 Oral Care_dep and Indep_foot and Toenail Care
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ORAL CARE- Independent
-Dependent
FOOT AND TOENAIL CARE
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ORAL CARE FOR INDEPENDENT
PATIENTS
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Oral Hygiene includes cleansing of the mouth,
gums and teeth or dentures. This procedure
should be done before breakfast, after all
meals and at bedtime.
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Purpose:
To improve appetite, communication and
dental health.
To give the patient a feeling of well-being.
To decrease mouth odor.
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Equipments:
Fresh Water
Cup
Straw, if necessary
Toothbrush and toothpaste
Emesis basin
Face towel
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ASSESSMENT
1. Check the chart for any information related to
the patients ability to participate in the
procedure being planned.To know your limitations & to know the condition
of the patient.
Assess the patient for specific symptoms related
to diagnosis, for fatigue and for hygiene
preferences.PLANNING
3. Wash your hands To break the cycle of infection.4. Assemble the equipments
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IMPLEMENTATION
5. Identifies the patient and explains theprocedure An explanation facilitates cooperation
6. Provides for privacy The patient may be embarrassed if cleansinginvolves removal of dentures.
7. Raises the bed to a working height Promotes good body mechanics8. Assists the patient to sit up A sitting or side-lying position prevents aspiration
of fluids into the lungs.
9. Spreads the towel across the patients chest
The towel protects the patient from dampness.Raising the bed promotes efficient body
mechanics.
10. Offers the client water to rinse his mouth The nurse should encourage the patient toexercise as much independence as possible.
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11. Moistens the toothbrush with water from theglass. Spreads a small amount of toothpasteonthe toothbrush.
Water softens the bristles.
12. Offers the toothbrush to the patient if
he/she is able. If unable, brushes patients
teeth using gentle motion starting above thegum line and going down the teeth. Repeats
the stroke until to all the teeth.
Brushing facilitates the removal of plaque and
tartar.
13. Offers water to rinse patients mouth. Vigorous swishing helps remove loosed debris
14. Wipes the patients mouth and makes
patient comfortable.
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15. Returns bed to its comfortable position.
Opens curtains or screens.
16. Cleans equipments and places them
properly.
17. Washes hands
18. Documents pertinent observations.
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ORAL FOR DEPENDENT PATIENTS
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Purpose:
Due to high level of dependence, some patients mayrequire special oral hygiene methods. Unconsciouspatients are prone to drying of salivary secretionsdue to their incapacity to eat or drink and renderingthem unable to swallow salivary secretions. Theadverse effect of certain procedures (i.e.,chemotherapy, radiation and nasogastric tubeintubation) may cause the patient to develop
stomatitis. In cases like this, gentle brushing isrecommended and use of commercial mouthwashshould be avoided.
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Equipments:
Gloves
Paper Towels
Suction (if necessary)
Emesis basin
Tongue depressor
Toothbrush
Toothpaste
KY Jelly
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ACTIONS RATIONALE
1. Wash hands. Wear gloves Reduces transmission of microorganisms
2. Assess patient for the presence of gag reflex. Gag reflex may cause aspiration
3. Examine patients oral cavity. Determines frequency and extent of oral hygiene
needed.
4. Assess patient for risk of oral hygiene
problems.
Alterations in the oral cavity indicate frequency or
precautions in oral care.
5. Remove gloves and wash hands. Hand washing and gloving deters the spread ofmicroorganisms.
6. Position the client to lie on side with head
turned toward dependent side.
Prevents risk of aspiration
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7. Explain procedure to the patient. Reduces anxiety and promotes cooperation
8. Wash hands and don gloves. Reduces transmission of microorganisms
9. Assemble equipment on over bed table the
bedside table. Prepare suction if necessary.
Organization facilitates task performance. Suction
may be needed to prevent aspiration.
10. Raise bed to working height. Elevate head of
bed, as high as possible
11. Lower side rail on working side and turn
patients head toward you. (If patient can not lean
forward, position head slightly forward.
To facilitates drainage of fluid and secretions
during procedure
12. Place a towel across the chest and an emesis
basin against patients chin.
A towel and kidney basin protect the patient from
dampness
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13. Gently open patients mouth and insert a
padded tongue depressor between the back
morals.
A padded tongue depressor keeps the mouth
open for easier cleaning and prevents the patient
from biting down on the nurses hands or
utensils
14. Moistens toothbrush very lightly and brush all
tooth surfaces. Dip applicator into water of
mouthwash and wipe gums, teeth, tongue and
inside of mouth with applicator. (repeat if
necessary)
An applicator or toothbrush provides friction to
clean areas accumulated by tartar and plaque.
15. Discards used applicators appropriately into
plastic bag.
To prevent spread of microorganisms
16. Rinses the patients mouth with small
amounts of water, either allowing it to drain into
the emesis basin or used an asepto-syringe to
aspirate it.
Rinsing helps to remove debris from the mouth.
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17. If secretions accumulated, use suction. Prevents aspiration.
18. Wipe the patients mouth. To prevent skin irritation.
19. Apply lubricant to tips. Uses a water
soluble lubricant
Lubricants prevent drying and cracking of lips.
20. Leave the patient in a lateral position with
head toward the side for 30 60 minutes afteroral hygiene. Removes towel and raises side rail.
Prevents aspiration.
21. Lowers height of bed. Return patient to a
comfortable position.
Restores patients comfort.
22. Clean equipments and put away. To maintain medical asepsis.
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23. Remove gloves and discard appropriately.
Washes hands.
Hand washing deters the spread of microorga-nisms.
24. Document procedure and pertinent
observations.
Documentation facilitates communication to other
health personal and may also serve for legalpurposes.
21. Lowers height of bed. Return patient to a
comfortable position.
22. Clean equipment and put away. To maintain medical asepsis.
23. Remove gloves and discard appropriately.
Washes hands.
Hand washing deters the spread ofmicroorganisms.
24. Document procedure and pertinent
observations.
Documentation facilitates communication to other
health personal and may also serve for legal
purposes.
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PROVIDING FOOT AND TOENAIL CARE
Purposes:
To cleanse the feet
To stimulate circulation to the lower extremities.
To prevent injury.
To maintain the integrity of the integument.
To promote comfort to the feet.
To treat local infections by soaking the feet in amedicated solution.
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Equipment:
Wash basin
Soap
Warm water in pitcher
Hand towels, 2
Nail cutter or scissors
Nail file
Lotion (optional)
Powder (optional)
Paper lining (as the case may be)
Working gloves
Nail brush
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ACTIONS RATIONALE
1. Assess the condition of the feet and toenails. An appropriate plan for foot care cannot beindividualized.
2. Discuss any identifiable foot and nail problems
with the client. The client should be informed of potential andactual health problems.
3. Explain the procedure to the client. An explanation allays tear and aid in acquiringthe clients cooperation.
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4. Wash your hands Hand washing deters the spread ofmicroorganisms.
5. Gather the equipment Organization promotes efficient timemanagement.
6. Provide privacy to the client Providing privacy shows respect for the clientsfeeling
7. Do your working gloves
8. Protect the bed linen with towel beneaththe clients feet. - Dead cells and dirt trapped between the nail andthe toe may require mechanical removal.
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9. Soak each foot one at a time in warm (40C or
104F) of water for approximately 3-5 minutes. Soaking softens nails and helps to loosen dryskin and debris. Warm water dilates circulationsand promotes comfort.
10. Wash each foot with liberal amount of
lathered soap.
11. Brush the toenails.
12. Changes the water between the care of
each foot. The water should be clean and maintained at atemperature that promotes comfort.13. Cut the nails straight across ensuring thatthey are even with the tip of the toes. Cutting straight across is less likely to result ininjury to adjacent tissues or to potentiate the risk
of ingrown nails.
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14. Dry each foot thoroughly. Moisture allows the growth of fungi and can alsotend to lacerate skin if it cannot evaporate
15. Apply lotion or powder to the legs or
feet if needed. Powder absorbs perspiration.Lotion lubricates dryskin
16. Discard the water and do after care of
equipment.
Caring for soiled articles supports the principle of
medical asepsis.
17. Remove gloves then wash hands. Hand washing deters the spread of themicroorganisms
18. Document the care given, the response of theclient. And the necessary observations you made. Written information is a permanent record of thecare provided for the client.