Health Assessment: RLE

• Hygiene - science of healthy and its maintenance
• Personal maintenance - self care by which people attend to such functions as bathing, toileting, general body hygiene & grooming
• Hygiene - Is personal matter determined by individual values and practices

  • Care of the skin
  • Nails
  • Oral
  • Nasal
  • Teeth
  • Hair
  • Eyes
  • Ears
  • Perineal
• Hygiene - Nurses often describe as hygienic care
• Hygiene - is a highly personal matter determined by individual values and practices.
• Hygienic care - It is important for nurses to know exactly how much assistance a client needs for ________.
• North american - Cleanliness is highly valued in ______ culture.
• Many North Americans bathe or shower once or twice a day, whereas people in other cultures bathe once or twice a week.
• Some cultures believe that privacy is necessary for bathing, while others believe that communal bathing is preferable.
• In some cultures, body odor is considered offensive, while in others, it is considered normal.
• Religion - Some ________ engage in ceremonial washings.
• Environment - The availability of bathing facilities may be influenced by financial constraints.
• Developmental level - In the home, children learn about hygiene. Practices differ depending on the age of the individual; for example, preschoolers can complete most tasks independently with encouragement.
• Health & energy - People who are sick may lack the motivation or energy to take care of their hygiene. Some clients with neuromuscular impairments may be unable to care for themselves.
• Professional preference - Showers are preferred by some people over tub baths. The length of time spent bathing varies (e.g., morning versus evening).
• Morning care - Provides to client as they awaken in the morning after breakfast
• Provided before breakfast :

  • Elimination needs
  • Oral care
  • Nail care
  • Hair care
  • Back massage
• Hours of sleep or PM care – provided to clients before they go to sleep

  • Elimination need
  • Washing of face and hands
  • Oral care
  • Giving a back massage
• As needed care – provided as required by the client
• Diaphoretic -Sweating profusely. May need more frequent bathing and change of clothes and linen
• Early morning care - It is provided to clients as they awaken in the morning. This care consists of providing a urinal or bedpan to the client confined to bed, washing the face and hands, and giving oral care.
• Morning care - It is often provided after clients have breakfast, although it may be provided before breakfast. It usually includes providing for elimination needs, a bath or shower, perineal care, back massages, and oral, nail, and hair care.
• Morning - Making the client’s bed is part of ______ care.
• Hour of sleep or PM care - It is provided to clients before they retire for the night. It usually involves providing for elimination needs, washing face and hands, giving oral care, and giving a back massage.
• Skin - is the largest organ of the body.
• Skin - It protects underlying tissues from injury by preventing the passage of microorganisms.
• Skin & mucous membrane - The ____ and _____ membranes are considered the body’s first line of defense.
• Skin - It regulates the body temperature. Cooling of the body occurs through the heat loss processes of evaporation of perspiration, and by radiation and conduction of heat from the body when the blood vessels of the skin are vasodilated. Body heat is conserved through lack of perspiration and vasoconstriction of the blood vessels.
• Skin - It secretes sebum, an oily substance that (a) softens and lubricates the hair and skin, (b) prevents the hair from becoming brittle, and (c) decreases water loss from the skin when the external humidity is low. Because fat is a poor conductor of heat, sebum (d) lessens the amount of heat lost from the skin. Sebum (e) also has a bactericidal (bacteria-killing) action.
• skin - It transmits sensations through nerve receptors, which are sensitive to pain, temperature, touch, and pressure.
• Skin - It produces and absorbs vitamin D in conjunction with ultraviolet rays from the sun, which activate a vitamin D precursor present in the skin.
• The normal skin of a healthy person has transient and resident microorganisms that are not usually harmful.
• Sudoriferous glands - are on all body surfaces except the lips and parts of the genitals. The body has from 2 to 5 million, which are all present at birth. They are most numerous on the palms of the hands and the soles of the feet. Sweat glands are classified as apocrine and eccrine.
• apocrine glands - located largely in the axillae and anogenital areas, begin to function at puberty under the influence of androgens. Although they produce sweat almost constantly, _____ glands are of little use in thermoregulation. The secretion of these glands is odorless, but when decomposed or acted on by bacteria on the skin, it takes on a musky, unpleasant odor.
• Eccrine glands - are important physiologically. They are more numerous than the apocrine glands and are found chiefly on the palms of the hands, soles of the feet, and forehead. The sweat they produce cools the body through evaporation.
• Sweat - is made up of water, sodium, potassium, chloride, glucose, urea, and lactate.
• Bed bath - Type of bath where the nurse washes the entire body of a dependent patient in bed
• Purposes of bed bath

  • To cleanse, refresh and give comfort to the patient who must remain in bed
  • To stimulate circulation and aid in elimination
  • To provide an opportunity to inspect the patient’s body for any sign of abnormality
  • To help the patient have some movement and exercise
• Complete bath - Nurse washes the entire body of a dependent client in bed
• Self-help bed bath - Nurse washes the entire body of a dependent client in bed