REIMBURSEMENT ISSUES

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CHAPTER 18Hygiene and Care of the Patients
Environment
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Hygiene and Care of the Patients Environment

• Personal Hygiene
• The self-care measures persons use to maintain
  their health
• Hygiene
• The science of health
• Includes care of the skin, hair, hands, feet,
  eyes, ears, nose, mouth, back, and perineum
• Conscientious personal hygienic practices are
  essential for the nurse nurses are role models.

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Hygiene and Care of the Patients Environment

• Factors Influencing Personal Hygiene
• Social practices
• Body image
• Socioeconomic status
• Knowledge
• Personal preference
• Physical condition
• Cultural variables

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Patients Room Environment

• Maintaining Comfort
• Room temperature 68 to 74 F
• Good ventilation
• Bedpans and urinals that are emptied and rinsed
  promptly
• Monitored noise level
• Proper lighting

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Figure 18-1
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
A typical hospital room.
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Patients Room Environment

• Room Equipment
• Bedside stand
• Used to store the patients personal articles and
  hygienic equipment
• Overbed table
• On wheels is adjustable to various heights over
  the bed or a chair
• Chairs
• Straight chairs and lounge chairs

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Patients Room Environment

• Room Equipment (continued)
• Lights
• Lights provide comfort, safety, and ease.
• Call light signal indicates that a patient needs
  assistance.
• Bed
• Bed is designed for comfort, safety, and
  adaptability to position changes.
• It has a number of safety features.

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Bathing

• Sitz Bath
• Cleanses and aids in reducing inflammation of the
  perineal and anal areas of the patient who has
  undergone rectal or vaginal surgery or childbirth
• Water temperature 98 to 102 F
• Cool Water Tub Bath
• May be given to relieve tension or lower body
  temperature
• Water temperature tepid, not cold98.6 F

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Figure 18-2
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
The sitz bath.
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Bathing

• Warm Water Tub Bath
• Given to reduce muscle tension
• Water temperature 109.4 F
• Hot Water Tub Bath
• Given to assist in relieving muscle soreness and
  muscle spasms
• Water temperature 113 to 115 F

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Bathing

• Other Baths
• Complete Bed Bath
• For patients who are totally dependent and
  require total assistance
• Tepid Sponge Bath
• Administered to reduce an elevated temperature
• Medicated Bath
• May include agents such as oatmeal, cornstarch,
  Burows solution, and soda bicarbonate
• To reduce tension and relax the patient and to
  relieve pruritus caused by certain skin disorders

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Skill 18-1 Steps 8e(1) 8e(2)
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Bed bath.
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Skill 18-1 Steps 8e(3) 8e(4)
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Bed bath.
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Skill 18-1 Steps 8h 8i
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Bed bath.
15
Skill 18-1 Steps 8r 8u
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Bed bath.
16
Skill 18-1 Steps 10d(1) 10d(2)
Towel bath.
17
Skill 18-1 Step 10e
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Towel bath.
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Bathing

• Back Care/Backrub
• Usually administered after the patients bath
• Promotes relaxation, relieves muscular tension,
  and stimulates circulation
• Nurse massages for 3 to 5 minutes
• Contraindicated if the patient has such
  conditions as fractures of the ribs or vertebral
  column, burns, pulmonary embolism, or open wounds

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Skill 18-1 Steps 14e 14f
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Back rub.
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Components of the Patients Hygiene

• Care of the Skin
• When a persons physical condition changes, the
  skin often reflects this through alterations in
  color, thickness, texture, turgor, temperature,
  and hydration.
• As long as the skin remains intact and healthy,
  its physiological function remains optimal.

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Components of the Patients Hygiene

• Care of the Skin (continued)
• Collection of Data
• Normal skin has the following characteristics
• Intact without abrasions
• Warm and moist
• Localized changes in texture across surface
• Good turgor generally smooth and soft
• Skin color variations from body part to body part

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Components of the Patients Hygiene

• Care of the Skin (continued)
• Impaired Skin Integrity
• A patient who stays in one position without
  relief of pressure can develop a pressure sore.
• Patients especially at risk are the chronically
  ill, debilitated, older, disabled, or incontinent
  patient and the patient with spinal cord
  injuries, limited mobility, or poor overall
  nutrition.

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Figure 18-5
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Thirty-degree lateral position to avoid pressure
points.
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Figure 18-6
Using a rolled bath blanket as a
pressure-reducing device.
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Components of the Patients Hygiene

• Care of the Skin (continued)
• Impaired Skin Integrity
• Pressure ulcers occur when there is sufficient
  pressure on the skin to cause the blood vessels
  in an area to collapse.
• The flow of blood and fluid to the cells is
  impaired, resulting in ischemia to the cells.
• When the external pressure against the skin is
  greater than the pressure in the capillary bed,
  blood flow decreases to the adjacent tissue.
• If the pressure continues for longer than 2
  hours, cell necrosis may occur.

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Components of the Patients Hygiene

• Care of the Skin (continued)
• Impaired Skin Integrity
• Shearing force
• The tissue layers of skin slide onto each other,
  resulting in kinking or stretching of
  subcutaneous blood vessels this results in an
  interruption of blood flow to the skin.
• Friction
• Rubbing of skin over a surface produces friction,
  which may remove layers of tissue.

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Figure 18-3
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Diagram of shearing force exerted against sacral
area.
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Components of the Patients Hygiene

• Care of the Skin (continued)
• Stages of Pressure Ulcers
• Stage I nonblanchable erythema of the skin
• Stage II partial-thickness skin loss epidermis
• Stage III full-thickness skin loss, damage or
  necrosis of subcutaneous
  tissue
• Stage IV full-thickness skin loss with
• extensive destruction, tissue
  necrosis,
• or damage to muscle, bone, or
• supporting structures

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Figure 18-4, A
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
A, Stage I pressure ulcer.
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Figure 18-4, B
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
B, Stage II pressure ulcer.
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Figure 18-4, C
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
C, Stage III pressure ulcer .
32
Figure 18-4, D
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
D, Stage IV pressure ulcer .
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Components of the Patients Hygiene

• Care of the Skin (continued)
• Nursing Interventions
• Assess improvement.
• Assess size and depth of the ulcer, the amount
  and color of any exudate, the presence of pain or
  odor, and the color of the exposed tissue.
• Specific interventions are determined by the
  stage of the ulcer.

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Components of the Patients Hygiene

• Oral Hygiene
• Care of the oral cavity
• Helps maintain a healthy state of the mouth,
  teeth, gums, and lips
• Brushing the teeth removes food particles,
  plaque, and bacteria massages the gums and
  relieves discomfort resulting from unpleasant
  odors and tastes.

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Skill 18-2 Steps 9a 9c
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Administering oral hygiene.
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Components of the Patients Hygiene

• Oral Hygiene (continued)
• Dentures
• A set of artificial teeth not permanently fixed.
• Should be stored in an enclosed, labeled cup for
  soaking or when they are not worn
• Should be cleaned as often as for natural teeth
  to prevent infection and irritation
• Oral care provided on a regular basis

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Skill 18-2 Step 10c
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Administering oral hygiene.
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Components of the Patients Hygiene

• Hair Care
• Combing, brushing, and shampooing are basic
  hygiene measures for all patients.
• Patient may shampoo in the shower or tub, use a
  portable chair in front of a sink, or in bed.
• Shaving the Patient
• Patient may prefer to shave at the time of
  bathing.
• Patients who have a bleeding disorder or are
  taking anticoagulants should use electric razors.
• Do not allow a disoriented or depressed patient
  to use a razor with a blade.

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Skill 18-3 Steps 9a 10e
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Care of the hair, nails, and feet.
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Components of the Patients Hygiene

• Hand, Foot, and Nail Care
• Hands and feet often require special attention to
  prevent infection, odors, and injury.
• Assessment
• Examine all skin surfaces.
• Carefully assess between the toes.
• Observe for adequate circulation.

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Components of the Patients Hygiene

• Perineal Care
• Care of the genitalia
• Part of the complete bed bath
• Assess for signs of vaginal or urethral exudate,
  skin impairment, unpleasant odors, complaints of
  burning during urination, or localized tenderness
  or pain of the perineum
• Catheter care is to be performed twice daily on
  all patients with indwelling catheters.
• Includes cleansing of the meatal-catheter
  junction with a mild soap and water and sometimes
  application of a water-soluble microbial ointment

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Skill 18-4 Step 9b
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Female perineal care.
43
Skill 18-4 Steps 9e 9g
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Female perineal care.
44
Skill 18-4 Step 10c/10d
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Male perineal care.
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Components of the Patients Hygiene

• Eye, Ear, and Nose Care (continued)
• Care of the eyes
• Cleansing of the circumorbital area of the eyes
  is usually performed during the bath.
• Case involves washing with a clean washcloth
  moistened with clear water.
• The use of soap is omitted because it may cause
  burning and irritation.
• The eye is cleansed from the inner to the outer
  canthus.
• Patient may need assistance with care of
  eyeglasses or contact lenses.

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Components of the Patients Hygiene

• Eye, Ear, and Nose Care (continued)
• Care of the ears
• The ears are cleansed by the nurse during the bed
  bath.
• A clean corner of a moistened washcloth rotated
  gently into the ear canal works best for
  cleaning.
• A cotton-tipped applicator is useful for
  cleansing the pinna.
• The nurse should teach patients never to use
  bobby pins, toothpicks, or cotton-tipped
  applicators to clean the internal auditory canal.

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Components of the Patients Hygiene

• Eye, Ear, and Nose Care (continued)
• Care of the ears (continued)
• Hearing aids
• This involves routine cleaning, battery care, and
  proper insertion technique.
• When not in use, the hearing aid should be stored
  where it will not become damaged.

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Figure 18-8
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Hearing aid.
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Components of the Patients Hygiene

• Eye, Ear, and Nose Care (continued)
• Care of the nose
• The patient can usually remove secretions from
  the nose by gently blowing into a soft tissue.
• Teach the patient that harsh blowing causes
  pressure capable of injuring the tympanic
  membrane, nasal mucosa, and even sensitive eye
  structures.
• If the patient is not able to clean the nose, the
  nurse will assist, using a saline-moistened
  washcloth or cotton-tipped applicator for
  excessive secretions, suctioning may be required.

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Components of the Patients Hygiene

• Bedmaking
• The patients bed is usually made in the morning
  after the bath.
• When possible, the bed is made while it is not
  occupied when the patient is unable to be out of
  bed, the nurse will make an occupied bed.
• The patients safety is always foremost in the
  nurses mind comfort and privacy are also
  important.
• Use side rails, keep the call light within easy
  reach, and maintain the bed in the proper
  position.

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Skill 18-5 Step 8i
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Bedmaking occupied bed.
52
Skill 18-5 Step 8j
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Bedmaking occupied bed.
53
Skill 18-5 Step 8m
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Bedmaking occupied bed.
54
Skill 18-5 Step 8o
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Bedmaking occupied bed.
55
Skill 18-5 Step 8q
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Bedmaking occupied bed.
56
Skill 18-5 Step 8r
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Bedmaking occupied bed.
57
Components of the Patients Hygiene

• Bedmaking (continued)
• It is the nurses responsibility to keep the bed
  as clean and comfortable as possible.
• This may require frequent inspections to make
  sure the bedding is clean, dry, and wrinkle free.
• Check the linens for food particles after meals
  and for urine incontinence or involuntary stool.
• Use proper body mechanics raise bed to a working
  level.

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Figure 18-9
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
The postoperative bed.
59
Figure 18-10
(From Potter, P.A., Perry, A.G. 2005.
Fundamentals of nursing. 6th ed.. St. Louis
Mosby.)
Selected equipment and supplies for elimination.
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Figure 18-11
The bedside commode has a toilet seat with a
container underneath.
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Components of the Patients Hygiene

• Assisting the Patient with Elimination
• Bedpan
• A device for receiving feces or urine from either
  male or female patients confined to the bed
• Urinal
• A device for collecting urine from male patients
  urinals for females also available
• Bedpans or urinals are used when a patient is
  unable to get up to go to the bathroom for the
  purpose of urination or defecation.

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Components of the Patients Hygiene

• Assisting the Patient with Elimination
  (continued)
• The nurse should offer the bedpan or urinal
  frequently, because patients may accidentally
  soil bedclothes if their elimination needs are
  not met.
• Report any abnormalities and record in the
  nurses notes.
• Flow sheets are usually provided for
  documentation of normal voidings and stools.

63
Skill 18-6 Steps 11(2) 11(3)
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Positioning the bedpan.
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Components of the Patients Hygiene

• Care of the Incontinent Patient
• Incontinence is a very common problem, especially
  among older adults.
• Incontinence occurs because pressure in the
  bladder is too great, sphincters are weak, or the
  innervation has been compromised due to illness
  or injury.
• Incontinence may involve a small leakage of urine
  when the person laughs, coughs, or lifts
  something heavy.

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Components of the Patients Hygiene

• Care of the Incontinent Patient (continued)
• Care requires the use of disposable adult
  undergarments or underpads.
• Cleansing the skin thoroughly after each episode
  of incontinence with warm soapy water and drying
  it thoroughly help to prevent skin impairment.
• When urinary incontinence results from decreased
  perception of bladder fullness or impaired
  voluntary motor control, bladder training can be
  helpful.

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Nursing Process

• Nursing Diagnoses
• Oral mucous membranes, impaired
• Mobility, impaired physical
• Skin integrity, impaired
• Self-care deficitbathing/hygiene,
  dressing/grooming