M12-13

• Personal hygiene


  • Affects patients' comfort, safety, and well-being
  • When people are ill, they often require assistance with their self-care
  • A variety of personal, social, and cultural factors influence hygiene practices
• Skin


  • Functions include protection, secretion, excretion, temperature regulation, and sensation
  • Primary layers: Epidermis, Dermis, Subcutaneous tissue
• Feet, hands, and nails

  • Require special attention to prevent infection, odor, and injury
  • The condition of a patient's hands and feet influences his or her ability to perform hygiene care
  • The normal nail is transparent, smooth, and convex, with a pink nail bed and a translucent white tip
• Oral cavity


  • 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
  • Xerostomia—dry mouth
  • Gingivitis—inflammation of the gums
  • Dental caries—tooth decay
• Hair


  • 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
• Eyes, ears, and nose

  • Require careful attention during hygiene care to prevent injury and discomfort
  • The sense of smell is an important aid to appetite
• Implementation: Hygiene care


  1. Use caring to reduce anxiety, promote comfort

  2. Administer meds for symptoms before hygiene

  3. Be alert for patient's anxiety or fear

  4. Assist and prepare patients to perform hygiene as independently as possible

  5. Discuss signs and symptoms of problems

  6. Inform patients about community resources
• Implementation: Health promotion


  1. Make instructions relevant

  2. Adapt instruction to patient's facilities and resources

  3. Teach the patient ways to avoid injury

  4. Reinforce infection control practices
• Implementation: Hygiene measures


  1. Vary by patient needs and health care setting

  2. Consider normal grooming routines, and individualize care

  3. Bathing and skin care: therapeutic, complete bed bath, shower, partial bed bath, soap and water vs. Chlorhexidine Gluconate (CHG), perineal care

  4. Bath guidelines: provide privacy, maintain safety and warmth, promote independence, anticipate needs, back rub

  5. Foot and nail care

  6. Oral hygiene: brushing, flossing, rinsing

  7. Denture care

  8. Hair and scalp care: brushing, combing, shampooing

  9. Shaving: mustache and beard care

  10. Care of the eyes, ears, and nose

  11. Patient's room environment: maintaining comfort, room equipment
• Safety guidelines for nursing skill

  • Identify the patient with two identifiers
  • Move from the cleanest to less clean areas
  • Use clean gloves for contact with non-intact skin, mucous membranes, secretions, excretions, or blood
  • Test the temperature of water or solutions
  • Use principles of body mechanics and safe patient handling
  • Give proper direction to NAP when delegating
• The skin is the body's largest organ, accounting for 15% of the total body weight. The skin provides a protective barrier against disease-causing organisms, a sensory organ for pain, temperature, and touch, and vitamin D synthesis.
• Injury to the skin poses risks to safety and triggers a complex healing response. Knowing the normal healing pattern will help students recognize alterations that require intervention.
• Skin layers


  • Epidermis: top layer of skin
  • Dermis: inner layer of skin, collagen
  • Dermal: epidermal junction, separates dermis and epidermis
• Pressure ulcers


  • Also called pressure sore, decubitus ulcer, or bed sore
  • Pathogenesis: pressure intensity, tissue ischemia, blanching, pressure duration, tissue tolerance
• Risk factors for pressure ulcer development

  • Impaired sensory perception
  • Impaired mobility
  • Alteration in LOC
  • Shear
  • Friction
  • Moisture
• Partial-thickness wounds are shallow in depth, moist and painful, and the wound base generally appears red. Full-thickness wounds extend into the subcutaneous layer, and the depth and tissue type will vary depending on body location.
• Primary intention wound healing


  Edges are approximated
• Secondary intention wound healing


  Wound edges are not approximated
• Partial-thickness wound repair


  Inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers
• Full-thickness wound repair


  Hemostasis, inflammatory, proliferative, and maturation
• Complications of wound healing

  • Hemorrhage
  • Hematoma
  • Infection
  • Dehiscence
  • Evisceration
• Nursing knowledge base for skin integrity and wound care

  • Prediction and prevention of pressure ulcers
  • Risk assessment: Braden scale
  • Prevention: economic consequences, no additional reimbursement for stage III and IV pressure ulcers
  • Factors influencing pressure ulcer formation and wound healing: nutrition, tissue perfusion, infection, age, psychosocial impact
• Critical thinking in skin integrity and wound care

  • Integrate knowledge from nursing and other disciplines, previous experiences, and information gathered from patients
  • Use Wound, Ostomy and Continence Nurses Society (WOCN) guidelines when planning care
  • Be disciplined, creative, and diligent
• Nursing process: Assessment of skin and wounds

  1. Continually assess skin for signs of breakdown and/or ulcer development

  2. Assess for pressure ulcer risk factors: mobility, nutritional status, body fluids, pain

  3. Assess wounds in emergency and stable settings: appearance, drains, wound closures, palpation, gram stains, biopsy, wound drainage character, wound cultures
• Dressings protect from microorganisms, aid in hemostasis, and promote healing by absorbing drainage or debriding a wound.
• Nursing and other disciplines

  • Previous experiences
  • Information gathered from patients
  • Used to understand the risk to skin integrity and wound healing
• Use Wound, Ostomy and Continence Nurses Society (WOCN) guidelines


  When planning care
• Nursing


  • Be disciplined
  • Be creative
  • Be diligent
• Nursing Process: Assessment


  1. Skin

  2. Pressure ulcers

  3. Wounds
• Skin


  Continually assess for signs of breakdown and/or ulcer development
• Pressure ulcers


  • Predictive measures
  • Mobility
  • Nutritional status
  • Body fluids
  • Pain
• Wounds


  • Emergency setting
  • Stable setting
  • Wound appearance
  • Drains
  • Wound closures
  • Palpation of wound
  • Gram stains
  • Biopsy
  • Character of wound drainage
  • Wound cultures
• Purposes of dressings


  • Protects from microorganisms
  • Aids in hemostasis
  • Promotes healing by absorbing drainage or debriding a wound
  • Supports wound site
  • Promotes thermal insulation
  • Provides a moist environment
• Types of dressings


  • Gauze
  • Transparent film
  • Hydrocolloid
  • Hydrogel
  • Foam
  • Composite
• Changing dressings


  1. Know the type of dressing, placement of drains, and equipment needed

  2. Prepare the patient

  3. Review previous wound assessment

  4. Evaluate pain and administer analgesics

  5. Describe procedure steps to lessen patient anxiety

  6. Gather all supplies

  7. Recognize normal signs of healing

  8. Answer questions about the procedure or wound
• Packing a wound


  Negative-pressure wound therapy
• Securing dressings


  • Tape
  • Ties
  • Binders
• Comfort measures


  • Administer analgesic medications 30 to 60 minutes before dressing changes
  • Carefully remove tape
  • Gently clean wound edges
  • Carefully manipulate dressings and drains to minimize stress on sensitive tissues
  • Turn and position patient carefully
• Cleaning skin and drain sites

  1. Clean from least contaminated to the surrounding skin

  2. Use gentle friction

  3. When irrigating, allow the solution to flow from the least to most contaminated area
• Suture care


  1. Staple removal

  2. Suture removal