Fundamental of Nursing Lab

• Perestalsis


  Science of the preservation of health and healthy living
• Nurses


  • Assess the client's ability to perform their activities such as personal hygiene, mobility, ambulation, toileting, personal care and hygiene, grooming, dressing, and eating
  • Some clients are wholly compensatory in terms of their self-care activities
  • Other clients are partly compensatory and they can perform their activities of daily living with the help and assistance of another
  • Still more are considered independent in terms of performing the activities of daily living and these clients may only need the support of others in terms of their activities of daily living including hygiene, according to Dorothea Orem's Self Care Theory
• Nurse assessing client's ability to perform hygiene measures

  1. Compare the client's actual performance with established standards relating to these tasks

  2. Educate the client about the proper methods of performing the particular task, including safety measures and the use OF ASSISTIVE DEVICE to facilitate their self-care hygiene
• Daily hygiene needs


  • Bathing
  • Skin care
  • Back care - Massage
  • Oral hygiene
  • Shaving
  • Shampooing hair
  • Hair care
  • Nail care
  • Perineal care
  • Dressing and undressing
• Influencing factors for hygiene

  • Social practice
  • Body image
  • Socioeconomic status
  • Knowledge
  • Personal preference
  • Physical condition
  • Cultural variables
  • Age
• Factors that affect hygiene practices

  • Culture - Family practices
  • Illness - Individual preferences such as: Bath in the morning or before going to bed, Frequency of bathing, shaving, Shampooing hair daily or weekly
  • Economics - Unable to afford deodorant, shampoo etc., Unable to afford utilities
• Role of the nurse aide

  • Assist to follow their personal hygiene practices
  • Encourage to do as much of their daily care as possible
  • Assist residents to select their own clothing
  • Promote independence and self esteem
  • Encourage use of deodorant, perfume,aftershave lotion, and cosmetics
  • Be patient and encouraging
• Equipment for hygiene care

  • Bedside stand
  • Bed
  • Over table
  • Chairs lights
• Hygiene care schedule


  • Early morning
  • After breakfast
  • Afternoon
  • Afternoon care
• Purpose of hygiene


  • Maintain skin integrity
  • Prevent skin impairment
  • Promote adequate circulation
  • Promote hydration
  • Promotes communication
• Intact skin


  • Defense against infection
  • Defense of awareness
  • Controls body temperature
• Skin assessment


  • Color
  • Texture
  • Thickness
  • Turgor
  • Temperature
  • Hydration
  • Skin with decreased turgor remains elevated after being pulled up and released
• Nursing goal is to prevent complication or skin impairment
• The patient should be encouraged to assist in personal hygiene, if possible, to promote independence and self-esteem
• Daily skin inspection and documentation is an important part of the skin care and prevention of decubitus ulcers
• Decubitus ulcers/pressure sores


  Bedsores - also called pressure ulcers and decubitus ulcers -are injuries to skin and underlying tissue resulting from prolonged pressure on the skin, Bedsores most often develop on skin that covers bony areas of the body, such as the heels ankles hips and tailbone
• Common sites of pressure ulcers for people who use wheelchairs

  • Tailbone or buttocks
  • Shoulder blades and spine
  • Backs of arms and legs where they rest against the chair
• Common sites of pressure ulcers for people who need to stay in bed

  • The back or sides of the head
  • The shoulder blades
  • The hip, lower back or tailbone
  • The heels, ankles and skin behind the knees
• Stages of bedsores


  Bedsores fall into one of several stages based on their depth, severity and other characteristics. The degree of skin and tissue damage ranges from changes in skin color to a deep injury involving muscle and bone
• People most at risk of bedsores

  • Have medical conditions that limit their ability to change positions or cause them to spend most of their time in a bed or chair
• Friction


  Occurs when the skin rubs against clothing or bedding. It can make fragile skin more vulnerable to injury especially if the skin is also moist
• Shearing force


  Shear occurs when two surfaces move in the opposite direction. For example, when a bed is elevated at the head, you can slide down in bed. As the tailbone moves down, the skin over the bone might stay in place- essentially pulling in the opposite direction
• Pressure


  Constant pressure on any part of your body can lessen the blood flow to tissues. Blood flow is essential for delivering oxygen and other nutrients to tissues. Without these essential nutrients, skin and nearby tissues are damaged and might eventually die
• Risk factors for bedsores

  • Poor nutrition and hydration
  • Immobility
  • Incontinence
  • Impaired circulation/medical conditions affecting blood flow
  • Sensory deficit/ Lack of sensory perception
  • Under or over weight
• Complications of pressure ulcers

  • Cellulitis
  • Bone and joint infections
  • Cancer
  • Sepsis
• Treatment/Prevention of pressure ulcers

  1. Assessment - Size, Depth, Color, Exudate, pain

  2. Surgical asepsis during wound care

  3. Promote nutrition and hydration

  4. Repositioning

  5. Use pressure relieving devices
• Tips for repositioning


  • Shift your weight frequently. Ask for help with repositioning about once an hour
  • Lift yourself, if possible. If you have enough upper body strength, do wheelchair pushups-raising your body of the seat by pushing on the arms of the chair
  • Look into a specialty wheelchair. Some wheelchairs allow you to tilt them, which can relieve pressure
  • Select cushions or a mattress that relieves pressure. Use cushions or a special mattress to relieve pressure and help ensure that your body is well positioned. Do not use doughnut cushions, as they can focus pressure on surrounding tissue
  • Adjust the elevation of your bed. If your bed can be elevated at the head, raise it no more than 30 degrees. This helps prevent shearing
• Tips for skin care

  • Keep skin clean and dry. Wash the skin with a gentle cleanser and pat dry. Do this cleansing routine regularly to limit the skin's exposure to moisture, urine and stool
  • Protect the skin. Use moisture barrier creams to protect the skin from urine and stool. Change bedding and clothing frequently if needed. Watch for buttons on the clothing and wrinkles in the bedding that irritate the skin
  • Inspect the skin daily. Look closely at your skin daily for warning signs of a pressure sore
• Common skin problems


  • Dry skin
  • Acne
  • Hirsutism
  • Rashes
  • Abrasions
  • Contact dermatitis
• Medical asepsis


  • Known as clean technique
  • Inhibits growth and spread of pathogenic microbes
• Bathing


  • Apply lotion after bathing to prevent drying of skin
  • Gather necessary supplies
  • A bed bath is done to help wash someone who cannot get out of bed. You may need to give the entire bath or just help wash certain areas
• Bathing standards


  • The primary purpose of bathing is to cleanse the body of all dirt, sweat, germs, exfoliated skin, and other things
  • This cleansing protects our first level defense against infection, and it also promotes good circulation and client comfort
• Preparation for bath


  1. Close the windows or turn up the heat to keep the room warm

  2. Fill the water basin with warm water. Check the water temperature to make sure it is not warmer than 110- 115° F (46° C). If you do not have a bath thermometer, it should be comfortably warm to your elbow

  3. Place towels under the person to keep the bed dry. Cover the person with a blanket or towel and help him undress. Keep the blanket or towel over the person during the bath to keep him warm
• Giving bed bath


  1. Always make sure the person cannot fall out of bed if you need to walk away

  2. Wet the washcloth without soap. Gently wipe one eyelid by wiping from the inner corner of the eye to the outer comer. Pat the eyelid dry and repeat on the other eyelid

  3. With soap and water, wash and dry the person's face, neck, and ears

  4. Wash 1 side of the body from head to toe and then repeat on the other side. Pull the blanket or towel back while you wash, and cover when you are done. Start by washing the shoulder, upper body, arm, and hand. Move to the hip, legs, and feet. Rinse each area free from soap and pat dry before moving to the next. Check for redness and sores during the bed bath

  5. Change the bath water before you wash the genital area

  6. The genital area is the last area to be washed. You may need to bend the person's knees to help reach the area better. For women, wash the genital area from front to back. For men, make sure you wash around the testicles. To clean between the buttocks, you may need to help the person roll onto his side
• For a complete bath and a partial bath, identify the client, introduce yourself and explain the bathing procedure to the client, provide privacy, raise the client's bed to a height that is the most comfortable and safe, in terms of body mechanics, for you to work at, make sure that the side rail on the side of the bed opposite to you is up and locked in place, raise the head of the bed to a height that is comfortable for the client, remove the client's blankets, place towels under the areas that are being washed to protect the fitted bottom sheet from moisture and only uncover the areas that are being washed rather than the entire area to maintain client warmness
• If a bath mitt is not available

  Wrap a washcloth around your hand in a mitt like fashion
• Bathing a client


  1. Wash each part of the client's body

  2. Rinse each part of the client's body

  3. Dry each part of the client's body

  4. Cover each part of the client's body with a bath towel or blanket
• Maintaining the bath


  1. Rinse the wash mitt or washcloth after each part of the body is washed

  2. Change the bath water in the basin when it cools off or becomes too soapy
• Areas to thoroughly wash, rinse and dry

  • Face
  • Behind the ears
  • Chest
  • Back
  • Arms
  • Legs
  • Hands
  • Fingernails
  • Perineal area
  • Feet
• Order of bathing


  1. Wash inner canthus of each eye

  2. Wash face and neck

  3. Wash downwards towards the toes