The science of health and its meaintenance | Hygiene |
Is the self-care by which people attend to such functions as bathing, toileting, general body hygiene, and grooming | Personal hygiene |
Factors affecting personal hygiene behavior: | 1 culture
2 Socio-economic status
3 Religion
4 Developmental level
5 Health status
6 Personal references |
Hygenic care: | Early morning care
Morning care
Hour of sleep (HS) or PM Care
As-needed (prn) Care |
Integrate nursing knowledge
Consider developmental and cultural influences
Think creatively
Be nonjudgmental and confident
Draw on your own experiences
Rely on professional standards | Critical thinking |
Common diagnoses associated with hygiene: | Activity intolerance
Bathing self-care deficit
Dressing self-care deficit
Impaired physical mobility
Impaired oral mucous membrane
Ineffective health maintenance
Risk for infection |
Use the patients' ??? for which they are at risk | actual alteration or the alteration |
You are caring for a non-English-speaking male patient. When preparing to assist him with personal hygiene, you should:
A. use soap and water on all types of skin
B. ensure that culture and ethnicity influence hygiene practices.
C. shave facial hair to make the patient more comfortable.
D. Know that all patients need to be bathed daily. | B. ensure that culture and ethnicity influence hygiene practices |
Parts of the body which problems related to hygienic care are common: | 1. skin
2. feet
3. nails
4. mouth
5. hair |
Is the largest organ of the body
5 major functions:
1. it is the first line of defense against injury and microorganisms
2. It maintains body temperature.
3. It is a secretory organ.
4. It is a sensory organ.
5. It produces and absorbs vitamin D through the action of ultraviolet rays from sun which activities vitamin D precursor present in the skin. | Skin |
Are all on body surfaces except the lips and parts of the genitals
Most numerous on the palms of the hands and the soles of the feet
The body has from 2-5 M, which are all present at birth
Two types of it:
1. Apocrine glands
2. Eccrine glands | Sudoriferous (sweat) glands |
Skin: Assessment: | Nursing history
Physical Assessment of the skin
Identification of clients at risk for developing skin impairments |
Physical exam: A: best assessed under natural light and on areas not exposed to the sun) | Inspect skin color |
Physical exam: Inspect skin color: Normal findings: | Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive. |
Physical exam: Deviations from normal skin color: | 1. Pallor
2. Jaundice
3. Cyanosis
4. Erythema |
Physical exam: Deviations from normal skin color: | Pallor |
Physical exam: Deviations from normal skin color: | Jaundice |
Physical exam: Deviations from normal skin color: | Erythema |
Physical exam: Deviations from normal skin color: | Cyanosis |
Physical exam: B | Inspect uniformity of skin color |
Physical exam: Normal findings: | Generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nail beds) in dark-skinned people |
Physical exam: Deviations from normal: | 1. Hyperpigmentation
2. Hypopigmentation (e.g., vitiligo, albinism, edema) |
Physical exam: Deviations from normal: 1: | Hyperpigmentation |
Physical exam: Deviations from normal: 2: e.g., vitiligo, albinism, edema | Hypopigmentation |
Physical exam: c: If present (i.e., location, color, temperature, shape and the degree to which the skin remains indented or pitted when pressed by a finger) | Assess edema |
Physical exam: Is the extravasation and accumulation of interstitial fluid in tissues. Edema is gravitational and will develop in dependent areas of the body, for example, in feet and legs when one is standing for prolonged periods.
Is a type of edema in which the skin surface, when pressed by a finger, leaves an indentation. | Pitting edema |
Physical exam: Scale for describing edema: 1+ | Barely detectable |
Physical exam: Scale for describing edema: 2+ | Indentation of less than 5 mm |
Physical exam: Scale for describing edema: 3+ | Indentations of 5 to 10 mm |
Physical exam: Scale for describing edema: 4+ | Indentations of more than 10 mm |
Physical exam: Scale for describing edema: | 1+ Barely detectable
2+ Indentation of less than 5 mm
3+ Indentation of 5 to 10 mm
4+ Indentation of more than 10 mm |
Describing skin lesions: 1: Type or structure: A | primary type |
Describing skin lesions: 1: Type or structure: B | Secondary |
Describing skin lesions: 2: | Color |
Describing skin lesions: 3: | Distribution |
Describing skin lesions: 4: | Configuration |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A flat, circumscribed area of color with no elevation of its surface; 1mm to 1cm
Examples: Freckles, flat nevi | Macule |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A circumscribed, solid elevation of skin, less than 1 cm
Examples: Warts, acne, pimples | Papules |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A vesicle or bulla filled with pus
Example: Acne vulgaris, impetigo | Pustules |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: Small as macule but larger than 1 cm
Example: portwine birthmark | Patch |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: Same as papule but larger than 1 cm
Example: Eczema | Plaque |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A relatively reddened, elevated, localized collection of edema fluid, irregular in shape
Example: Mosquito bites, hives | Wheal |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A solid mass that extends deeper into the dermis than does a papule
Example: Pigmented nevi | Nodule |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A solid mass larger than a nodule
Example: Epitheliomas | Tumor |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A circumscribed elevation containing serous fluid or blood; less than 1 cm
Example: Blister, chickenpox | Vesicle |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A larger, fluid-filled vesicle
Example: Blister, second-degree burns | Bulla |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: Dilated capillary; fine red lines
Example: Seen chiefly in pregnancy and cirrhosis of the liver | Telengiectasia |
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: Pinpoint red spots
Example: May indicate a problem in blood-clotting mechanism | Petechiae |
Is part of the new WHO case definition for dengue.
The test is a marker of capillary fragility and it can be used as a triage tool to differentiate patients with acute gastroenteritis, for example, from those with dengue. | Tourniquet test |
Even if a tourniquet test was previously done, it should be repeated if: | It was previously negative
There is no bleeding manifestation |
How to do a Tourniquet test: 1 | Take the patient's blood pressure and record it, for example, 100/70. |
How to do a Tourniquet test: 2 | Inflate the cuff to a point midway between SBP and DBP and maintain for 5 minutes (100+70) divided by 2 = 85 mm Hg |
How to do a Tourniquet test: 3 | Reduce and wait 2 minutes |
How to do a Tourniquet test: 4: A positive test is 10 or more petechiae per 1 square inch | Count petechiae below antecubital fossa. See image at right |
Bath guidelines: | Provide privacy
Maintain safety
Maintain warmth
promote independence
Anticipate needs |
Describing skin lesions: 1: Type or structure: B: Thickened epidermal cells that flake off
Example; Dandruff, psoriasis | Scale |
Describing skin lesions: 1: Type or structure: B: A linear crack
Example: Athlete's foot | Fissure |
Describing skin lesions: 1: Type or structure: B: Dried serum or pus on the skin surface
Example: Impetigo, scab on abrasion | Crust |
Describing skin lesions: 1: Type or structure: B: Loss or all part of the epidermis
Example: Chicken pox and small pox following rupture. | Erosion |
Describing skin lesions: 1: Type or structure: B: Linear or hollowed out crusted area exposing dermis
Example: Scratch, abrasion | Excoriation |
Describing skin lesions: 1: Type or structure: B: An excavation extending into the dermis or below
Example: Stasis ulcer | Ulcer |
Describing skin lesions: 1: Type or structure: B: A decrease in the volume of epidermis
Example: Striae, aged skin | Atrophy |
Describing skin lesions: 1: Type or structure: B: A formation of connective tissue
Example: Healed wound | Scar |
Describing skin lesions: 2: Color: 1: | Ecchymosis |
Describing skin lesions: 2: Color: 1: Ecchymosis: 1: | Circumscribe |
Describing skin lesions: 2: Color: 1: Ecchymosis: 2: | Diffuse |
Describing skin lesions: 3: Distribution: 1: Affecting one side of the body but not the other. Example: Fixed drug eruption | Asymmetrical |
Describing skin lesions: 3: Distribution: 2: Occurring or appearing on both sides of the body. Example: Stasis dermatitis | Bilateral |
Describing skin lesions: 3: Distribution: 3: Dispersed or spread widely through out the whole body. Example: Viral exanthem | Disseminated |
Describing skin lesions: 3: Distribution: 4: Widespread, affecting many body regions. Example: Generalized pustular | Generalized |
Describing skin lesions: 3: Distribution: 5: Limited to a discreet area of the body. Example: Bowen's disease | Localized |
Describing skin lesions: 4: Configuration: 1: Circular | Annular |
Describing skin lesions: 4: Configuration: 2: | Grouped |
Describing skin lesions: 4: Configuration: 3: | Linear |
Describing skin lesions: 4: Configuration: 4: | Targetoid |
Describing skin lesions: 4: Configuration: 5: | Reticular |
Describing skin lesions: 4: Configuration: 6: | Follow the course of cutaneous nerves; or meshed in the form of a network |
Describing skin lesions: 4: Configuration: | 1. Annular
2. Grouped
3. Linear
4. Targetoid
5. Reticular
6. Follow the course of cutaneous nerves; or meshed in the form of a network |
Describing skin lesions: 5: Observe and palpate skin moisture: Normal | Moisture in skinfolds and the axillae (varies with environmental Temperature and humidity, body temperature |
Describing skin lesions: 5: Observe and palpate skin moisture: Deviations from normal: | Excessive moisture (hyperthermia)
Excessive dryness (in dehydration) |
Describing skin lesions: 6: Palpate skin temperature: Compare the? | two feet and the two hands |
Describing skin lesions: 6: Palpate skin temperature: In palpation, Use the back of? | your hands |
Describing skin lesions: 6: Palpate skin temperature: Normal: | Uniform; within normal range |
Describing skin lesions: 6: Palpate skin temperature: Deviations from normal: | Generalized hyperthermia (in fever);
Localized hyperthermia (in infections);
Localized hypothermia (in arteriosclerosis) |
Describing skin lesions: 7: Note skin turgor: | fullness or elasticity by lifting and pinching the skin on extremity |
Describing skin lesions: 7: Note skin turgor: Normal: | When pinched, skin springs back to previous state |
Describing skin lesions: 7: Note skin turgor: Deviations from normal: | Skin stays pinched or tented or moves back slowly (in dehydration) |
Diagnosis: 1: | Self-care Deficit: bathing/hygiene |
Diagnosis: 2: | Self-Care Deficit: Dressing/Grooming |
Diagnosis: 3: | Self-Care Deficit: Toileting |
Diagnosis: 4: | Self-Care Deficit: Feeding |
Implementation: Abrasion: | Superficial layers of the skin are scraped or rubbed away.
Area is reddened and may have localized bleeding or serous weeping. |
Implementation: Abrasion: Nursing implications: 1: | Prone to infection; therefor, wound should be kept clean and dry. |
Implementation: Abrasion: Nursing implications: 2: | Do not wear rings or jewelry when providing care to avoid causing abrasions to clients |
Implementation: Abrasion: Nursing implications: 3: | Lift, do not pull, a client across a bed |
Implementation: Abrasion: Nursing implications: 4: | Use two or more people keme keme |
Implementation: Excessive dryness: | Skin can appear flaky and rough |
Implementation: Excessive dryness: Nursing implications: 1: | Prone to infection if the skin cracks; therefore, provide alcohol-free lotions to moisturize the skin and prevent cracking. |
Implementation: Excessive dryness: Nursing implications: 2: | Bathe client less frequently; use no soap, or use nonirritating soap and limit its use. Rinse skin thoroughly because soap can be irritating and drying. |
Implementation: Excessive dryness: Nursing implications: 3: | Encourage increased fluid keme keme permits to prevent dehydration |
Implementation: Ammonia Dermatitis (Diaper rash): | Caused by skin bacteria reacting with urea in the urine
The skin becomes reddened and is sore |
Implementation: Ammonia Dermatitis (Diaper rash): Nursing implications: 1: | Keep skin dry and clean by applying protective ointments containing zinc oxide to areas at risk (e.g., buttocks and perineum). |
Implementation: Ammonia Dermatitis (Diaper rash): Nursing implications: 2: | Boil an infant's diaper or wash hem with an antibacterial detergent to prevent infection. Rinse diapers well because this is irritating to an infant |
Implementation: Acne: | Inflammatory condition with papules and pustules |
Implementation: Acne: Nursing implications: | 1. Keep the skin clean to prevent secondary infection
2. Treatment varies widely. |
Implementation: Erythema: | Redness associated with a variety of conditions such as rashes, exposure to sun, elevated body temperature. |
Implementation: Erythema: Nursing implications: | 1. Wash area carefully to remove excess microorganisms
2. Apply antiseptic spay or lotion to prevent itching, promote healing, and prevent skin breakdown |
Implementation: Hirsutism: | Excessive hair on a person's body and face, particularly in women |
Implementation: Hirsutism: Nursing implications: | 1. Remove unwanted hair by using depilatories, shaving, electrolysis, or tweezing
2. Enhance client's self concept |
are essential for ambulation and merit attention even when people are confined to bed | Feet |
Each foot contains ???, which functions together for both standing and walking: | 26 bones, 107 ligaments, and 19 muscles |
Feet: Assessment: | 1. Nursing Health History
2. Physical Assessment |
Common Foot Problem: 1: | Callus |
Common Foot Problem: 2: | Corn |
Common Foot Problem: 3: | Plantar warts |
Common Foot Problem: 4: | Fissures |
Common Foot Problem: 5: | Athlete's Foot, or Tinea Pedis |
Common Foot Problem: 6: | Ingrown toenail |
Feet: Diagnosis: | Self-Care Deficit: Hygiene (foot care) r/t:
Risk for Impaired Skin Integrity r/t:
Risk for Infection r/t:
Deficient Knowledge (diabetic foot care) r/t: |
Feet: Diagnosis: Self-Care Deficit: Hygiene (foot care) r/t: | a. Visual Impairment
b. Impaired hand coordination |
Feet: Diagnosis: Risk for Impaired Skin Integrity r/t: | a. Altered Tissue Perfusion: peripheral (associated with edema, inadequate arterial circulation)
b. Poorly fitting shoes |
Feet: Diagnosis: Risk for infection r/t: | a. Impaired skin integrity (ingrown toenail, corn, trauma)
b. Deficient nail or foot care |
Feet: Diagnosis: Deficient knowledge (diabetic foot care) r/t: | a. lack of teaching/ learning activities about diabetic foot care
b. Newly established medical diagnosis (diabetes) and necessary foot hygiene |
Feet: Planning: | (a) Help the client maintain or restore healthy foot care practices
(b) Establishing desired outcomes for each client |
Implementing: Foot Care: | Wash the feet daily, and dry them well, especially between the toes
Use warm after for foot soak, to soften the nails and loosen debris under them
Caution: soaking the feet of diabetic clients is no longer encouraged because excessive moisture can contribute to skin breakdown.
Use cream or lotion to moisten the skin and soften calluses
Use deodorant sprays or foot powder to prevent or control unpleasant odor.
File toenails straight across to avoid tissue injury
Change socks or stocking daily
Wear comfortable, well-fitted pair of shoes
Do not go barefooted
Exercise the feet to improve circulation
Avoid using constricting clothing which may decrease circulation
Avoid crossing the legs
Avoid self-treatment for corns and calluses |
Are normally present at birth
They continue to grow throughout life and change very little until people are older
At the time, they tend to be tougher, more brittle, and in some cases thicker.
The ??? of an older person normally grow less quickly than those of a younger person and may be ridged and grooved | Nails |
Nail: Assessment: 1: | Inspect nail plate shape to determine its curvature and angle |
Nail: Assessment: 1: Inspect nail plate shape to determine its curvature and angle: Normal findings: | Convex curvature; angle between nail and nail bed of about 160 degrees |
Nail: Assessment: 1: Inspect nail plate shape to determine its curvature and angle: Deviations: | From normal: Spoon nail; clubbing (180 degrees or greater) |
Nail: Assessment: 2: | Inspect nail texture |
Nail: Assessment: 2: Inspect nail texture: Normal findings | Smooth texture |
Nail: Assessment: 2: Inspect nail texture: Deviations from normal: | Excessive thickness (e.g., result of poor circulation, iron deficiency anemia) (ONYCHAUXIS)
Excessive thinness or presence of grooves;
or furrows (e.g., in iron deficiency anemia)
Beau's lines (transverse white lines or grooves) |
Nail: Assessment: 2: Inspect nail texture: Deviations from normal: are horizontal lines of darkened cells and linear depression. | Beau's lines |
Nail: Assessment: 3: | Inspect nail color |
Nail: Assessment: 3: Inspect nail color: Normal findings | highly vascular and pink in light skinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks |
Nail: Assessment: 3: Inspect nail color: Deviations from normal: | Bluish or purplish tint (may reflect cyanosis), pallor (may reflect poor arterial circulation) |
Nail: Assessment: 4: | Inspect tissue surrounding nails |
Nail: Assessment: 4: Inspect tissue surrounding nails: Normal findings | Intact epidermis |
Nail: Assessment: 4: Inspect tissue surrounding nails: Deviation from normal: | hangnails, paronychia (inflammation of the tissue surrounding nails) |
Nail: Assessment: 5: Press two or more nails between your thumb and index finger; look for blanching and return of usual color to nail bed. | Perform blanch test to test capillary refill. |
Nail: Assessment: 5: Perform blanch test to test capillary refill: Normal findings: | prompt return of pink or usual color |
Nail: Assessment: 5: Perform blanch test to test capillary refill: Deviations from normal: | Delayed return of pink or usual color (may indicate circulatory impairment) |
Nail: Diagnosis: Self-Care Deficit: Grooming related to: | Impaired Vision |
Nail: Diagnosis: Risk for infection around the nail bed related to: | Impaired integrity of cuticles |
Nail: Planning: | Maintain healthy nail care practices
Establish a schedule of Nail Care |
Nail: Implementing: Nail Care: | Trim nails straight across, or follow the contour of the fingers.
File nails to have smooth edges
Do not trim nails at the lateral corners to prevent ingrown.
Diabetic clients are advised against cutting hangnails or cuticles.
Ingrown is also called unguis incarnate
Separation of the nail form the nailbed is onycholysis |
Nail: Evaluating: Demonstrate healthy nail care practices, as evidenced by: | a. Clean, short nails with smooth edges
b. Intact cuticles and hydrated surrounding skin
Demonstrate nail care as instructed |
The appearance of the hair often reflects a person's? | feelings of self-concept and sociocultural well-being. |
Growth, distribution, and pattern indicate general health status.
Hormonal changes, nutrition, emotional stress, physical stress, aging, infection, and other illnesses can affect hair characteristics.
The shaft itself is lifeless, and physiological factors do not directly affect it.
However, hormonal and nutrient deficiencies of the hair follicle cause changes in hair color or condition | Hair |
Hair: Assessing: 1: | Inspect the evenness of growth over the scalp |
Hair: Assessing: 1: Inspect the evenness of growth over the scalp: Normal findings: | Evenly distributed hair |
Hair: Assessing: 1: Inspect the evenness of growth over the scalp: Deviations from normal: | patches of hair loss (alopecia) |
Hair: Assessing: 2: | Inspect hair thickness or thinness |
Hair: Assessing: 2: Inspect hair thickness or thinness: Normal findings: | Thick hair |
Hair: Assessing: 2: Inspect hair thickness or thinness: Deviations from normal: | Very thin hair as in hypothyroidism |
Hair: Assessing: 3: | Inspect hair texture and oiliness |
Hair: Assessing: 3: Inspect hair texture and oiliness: Normal findings: | Silky, resilient hair |
Hair: Assessing: 3: Inspect hair texture and oiliness: Deviations from normal: | brittle hair (in hypothyroidism); excessively oily or dry |
Hair: Assessing: 4: | Note presence of infections or infestations by parting the hair in several areas |
Hair: Assessing: 4: Note presence of infections or infestations by parting the hair in several areas: Normal findings: | No infection or infestation |
Hair: Assessing: 4: Note presence of infections or infestations by parting the hair in several areas: Deviations from normal: | Flaking, sores, lice, nits (louse eggs) and ringworm |
Hair: Assessing: 5: | Inspect amount of body hair |
Hair: Assessing: 5: Inspect amount of body hair: Normal findings: | Variable |
Hair: Assessing: 5: Inspect amount of body hair: Deviations from normal | hirsutism (excessive hairiness) in women and in children |
Hair: Implementing: hair care: | The appearance of the hair may reflect a person's sense of well being and health status
Brushing and combing the air stimulate secretion of blood in the scalp; distribute the oil along the hair shaft; help arrange the hair. |
Hair: Implementing: hair care: | Shaving, mustache, and beard care |
Quick quiz: A young girl with long hair is experiencing a problem with matting. The most appropriate action to take would be:
A. cutting the matted hair away.
B. braiding the hair to reduce tangles
C. Using a grease-type product to tame the hair.
D. Keeping the hair oil free by applying powder every morning | C. using a grease-type product to tame the hair. |
Each tooth has 3 parts: | The crown, the root and the pulp cavity |
Each tooth has 3 parts: Is the exposed part of the tooth, which is outside the gum. It is covered with a hard substance called ENAMEL.
DENTIN is the ivory-colored internal part of it | Crown |
Each tooth has 3 parts: Is embedded in the jaw and covered by a bony tissue called CEMENTUM | The root |
Each tooth has 3 parts: contains the blood vessels and nerves | The pulp cavity in the center of the tooth |
Is lined with mucous membranes
Normal oral mucosa is light pink, soft, moist, smooth, and without lesions
Medications, exposure to radiation, and mouth breathing can impair salivary secretion. | The oral cavity |
The oral cavity: dry mouth | Xerostomia |
The oral cavity: Inflammation of the gums | Gingivitis |
The oral cavity: Tooth decay | Dental caries |
Mouth care: | Brush the teeth thoroughly after meals and at bedtime.
Floss the teeth daily.
Ensure adequate intake of food rich in Calcium, Phosphorus, Vitamins A, C, and D and fluoride.
Avoid sweet foods and drinks between meals
Eat coarse, fibrous foods (cleansing foods) such as fresh fruits and raw vegetables.
Have dental check up every 6 months
Have topical fluoride applications as prescribed by the dentists.
Brushing and Flossing the Teeth |
Mouth care: Purposes: | (a) To remove food particles from around and between the teeth
(b) To remove dental plaque
(c) To enhance the client's feeling of well-being
(d) To prevent sordes and infection of the oral tissues |
Nursing Interventions When Providing Oral Care | Inform the client and explain purpose of the procedure
Provide privacy
Assist in sitting or side-lying position
Place towel under the client's chin.
Moisten bristles of toothbrush and apply dentrifice.
Hold kidney basin under the chin.
Allow the client to brush his teeth, if possible.
Use downward strokes for upper front teeth; upward strokes for lower front teeth; back and forth strokes for the biting surfaces of the teeth; and hold the brush against the teeth with bristles at 45 degrees angle to penetrate and clean under the gingival margins.
Rinse the mouth with adequate amount of water. Floss the teeth.
Keep the client comfortable.
Do after-care of equipment and articles.
Document relevant data |
Common Problems of the Mouth: An invisible soft film of bacteria, saliva, epithelial cells and leukocytes that adhere to the enamel surface of the teeth. | Plaque |
Common Problems of the Mouth: A visible, hard deposit of plaque and bacteria that forms at the gum lines | Tartar |
Common Problems of the Mouth: Bad breath | Halitosis |
Common Problems of the Mouth: Inflammation of the tongue | Glossitis |
Common Problems of the Mouth: Inflammation of the gums | Gingivitis |
Common Problems of the Mouth: Inflammation and dryness of the oral mucosa | Stomatitis |
Common Problems of the Mouth: Inflammation of the parotid salivary glands (mumps) | Parotitis |
Common Problems of the Mouth: Accumulation of foul matter (food, microorganisms, and epithelial elements) on the gums and teeth | Sordes |
Common Problems of the Mouth: Cracking of the lips | Cheilosis |
Common Problems of the Mouth: Teeth have darkened area, may be painful | Dental carries |