Bathing on Adult or Pediatric Client Purposes To remove transient microorganism body secretions and excretions, and dead skin

cells. To stimulate circulation of the skin To produce sense of well being To promote relaxation and comfort To prevent or eliminate unpleasant body odor Assessment Condition of the skin, texture, turgor, presence of pigmented sports, temperature, lesions, excoriations and abrasions Fatigue Presence of pain and need for adjunctive measures (e.g. an analgesic) before the bath Range of motion of the joints Any other aspect of health that may affect the clients bathing process (e.g. mobility, strength, cognition) Need for use of clean gloves during the bath Planning Delegation The nurse often delegates the skills of bathing to UAP. However, the nurse remain responsible for the assessment and client care. The nurse needs to do the following: Inform the UAP of the type of bath appropriate for the client and precautions, if any specific to the needs of the client Remind UAP to notify the nurse of any concerns or changes (e.g. redness, skin breakdown, rash) so the nurse can assess, intervene if needed , and document. Instruct the UAP to encourage the client to perform as much self care as appropriate in order to promote independence and self-esteem Obtain a complete report about the bathing experience form the UAP Equipment Basin or sink with warm water (between 43 to 46C or 110 and 135f) Soap and soap dish Linens: bath blanket, two bath towels, washcloth, clean gown or pajamas or clothes as needed, additional bed linen and towels, if required Gloves, if appropriate (e.g. presence of body fluids or open lesions) Personal hygiene articles (e.g. deodorant, powder, lotions) Shaving equipment for male clients Table for bathing equipment Laundry hamper Implementation

Preparation Before a client bathing determine: a. the purpose and type of bath the client needs b. Self care ability of the client c. any movement or positioning precautions specific to the client d. Other care of the client may be receiving such as physical therapy or x-rays, in order to coordinate all aspects of health care and prevent unnecessary fatigue e. Clients comfort level with being bathed by someone else, and f. necessary bath equipment and linens Performance Explain the what you are going to do, why is it necessary, and how she or he can cooperate. Discuss with client the plan of bathing and explain any unfamiliar procedures to the client. Wash hands and observe other appropriate infection control procedures. Provide for client privacy by drawing the curtains around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Hygiene is personal matter Prepare the client and the environment Invite a family member or significant other to participate if desired Close the windows and doors to ensure the room is a comfortable temperature. Air currents increase loss of heat from the body by convection Offer a client bedpan or urinal or ask the client wishes to use the toilet or commode. Warm water and activity can stimulate the need for void. The client will be more comfortable after voiding, and voiding before cleaning the perineum is advisable Encourage the client to perform as much personal self-care as possible . This promotes independence, exercise, and self esteem During the bath, assess each area of the skin carefully For a BED BATH Prepare the bed and position the client appropriately Position the bed at a comfortable working height. Lower the side rail on the side close to you. Keep the other side rail up. Assist the client to move near you. This avoids undue reaching and straining and promotes good body mechanics Place the bath blanket over the top sheet from under the bath blanket by starting a clients shoulders and moving linen down towards the clients feet. Ask the client to grasp and hold the top of the bath blanket while pulling linen to the foot of the of the bed. The bath linen provides comfort, warmth, and privacy. Note, if the bed linen is to be reused, place over the bedside chair. If it is to be changed, place it in the linen hamper Remove clients gown while keeping the client covered with the b ath blanket. Place gown in linen hamper Make a bath mitt with the washcloth. A bath mitt retains water and heat better Yes No Remarks

2 3

10

than a cloth loosely held and prevents ends of washcloth from dragging across the skin. Used triangular or rectangle methods) Wash the face. Begins the bath at the cleanest area and downward toward the feet Place the towel under clients head Wash the clients eye with water only and dry them well. Use a separate corner of the washcloth for each eye. Using separate corners prevents transmitting microorganisms from one eye to the other. Wipe from the inner to the outer canthus. Theses prevent secretions from entering nasolacrimal ducts Ask whether the clients wants soap used on the face. Soap has a drying effect, and the face, which is exposed to the air more than, body parts tend to be drier Wash, rinse, and dry the clients face, ear and neck Remove the towel from under the clients head Wash the arm and hands. (Omit the arms for a partial bath) Place a towel lengthwise under the arm away from you. It protects the bed becoming wet Wash, rinse, and dry the arm elevating the clients arm supporting the clients wrists and elbow. Use long, firm strokes from wrists to shoulder, including the axillary area. Form, strokes from distal to proximal areas promote circulation by increasing venous blood return Apply the deodorant or powder if desired (Optional) Place a towel on the bed and put a wash basin on it. Place the clients hands in the basin. Many clients enjoy immersing their hands in the basin and washing themselves. Soaking loosens dirt under the nails. Assist the client as needed to wash, rinse, and dry the hands, paying particular attention to the spaces between the fingers Repeat for hand and arm nearest you. Exercise caution if an intravenous infusion is present, and check its flow after moving the arm Wash the chest and abdomen. (Omit) the chest and abdomen for partial bath. However, the areas under a womens breast may require bathing if this area is irritated or if the client has significant perspiration under the breast) Place bath towel lengthwise over chest. Fold bath blanket down to the clients pubic area. Keeps the clients warm while preventing unnecessary exposure of the chest. Lift the bath towel off the chest and abdomen with your mitted hand using long, firm stokes. Gives special attention to the skin folds particularly if the client is over weight. Rinse and dry well Replace the bath blanket when the area have been dried. Wash the legs and feet. (omit legs and feet for a partial bathing) Exposed the leg farthest from you by folding the bath blanket toward you the other leg being careful to keep the perineum covered. Covering the perineum promotes privacy and maintains the clients dignity Lift leg and place the bath towel lengthwise under the leg. Wash, rinse, and dry the leg using long, smooth, strokes from the ankle to the knee to the thigh. Washing from the distal to proximal areas promotes circulation by stimulating venous blood flow Reverse the covering and repeat for the other leg Wash the feet by placing them in them in the basin of water Dry each foot, Pay particular attention to the spaces between the toes. If you prefer that leg before washing the leg Obtain fresh, warm bathwater now or when necessary. Water may

11

12

13

14

15

16

become dirty or cold. Because surface skin cells are removed with washing the bathwater from dark skinned clients may be dark. However this does not mean the client is dirty. Raise side rails when refilling basin. This ensures the safety of the client. Wash the back and then the perineum Assist the client into a prone or side lying position facing away from you. Place the bath towel lengthwise alongside the back and buttocks while keeping the client covered withy the bath blanket as much as possible. This provides warmth and undue exposure Wash and dry the clients back, moving from the shoulders to the buttocks and upper tights paying attention to the gluteal fold Perform back massage now or after completion of bath Assist the client to the supine position and determine whether the client can wash the perineal area independently. If the client cannot do so, drape the client and wash the area Assist the client with grooming aids such as powder, lotion, or deodorant Use powder sparingly. Release as little as possible into the atmosphere. This will avoid irritation of nthe respiratory tract by powder inhalation. Excessive powder can cause caking, which leads to skin irritation Help the client put on a clean gowns or pajamas Assists the client to care fro hair, mouth and nails. Some people prefer or need mouth care prior to their bath For a TUB BATH OR SHOWER Prepare the client and the tub Fill the tub about 1/3 rd to one half full of water at 43 to 46C. Sufficient water is needed to cover the perineal are Cover all intravenous catheters or wound dressings with plastic coverings, and instruct the client to prevent wetting these areas as possible Put a rubber bath mat or towel on the floor of the tub if safety stips are not on the tub floor. These prevent slippage of the client during the bath or shower Assist the client into the shower or tub Assist the patient taking standing shower with the initial adjustment of the water temperature and water flow pressure as needed . Some clients need a chair to sit on the shower because of weakness. Hot water can cause elderly people to feel faint If the client requires considerable assistance with a tub bath, a hydraulic bathtub chair may be required Explain how the patient can signal for help, leave the client for 2 to 5 minutes, and place an occupied sign on the door. For safety reasons, d o not leave a client with decreased cognition or clients s who may be at risk (e.g. history of seizures, syncope) Assist the client washing and getting out of the tub Wash the clients back, lower legs ,and feet if necessary Assist the client out of the tub. If the client is unsteady, place bath towel over the clients shoulders and drain the tub of water before the client attempts to get out of it. Draining the water first lessens the likelihood of a fall. The towel prevents chilling Dry the client, and assist with follow up care Follow step 12 Assist the client back to his or her room

17

Clean the tub or shower in accordance with agency practice, discard the used linen in the laundry hamper and place the unoccupied: sign on the door Document Type of bath given (i.e. complete, partial, or self help) This is usually recorded on a flowsheet Skin assessment, such as excoriation, erythema, exudates, rashes, drainage or skin breakdown Nursing interventions related to skin integrity Ability of the client to assists or cooperate with bathing Client response for bathing Educational needs regarding hygiene Information or teaching shared with the client and their family VARIATION: BATHING USING A HYDRAULIC BATHTUB CHAIR A hydraulic lift, often used in long-term care or rehabilitation setting can facilitate the transfer of the client who is unable to ambulate to a tub. The lift also help eliminate strain on the nurses back Bring the client to the tub room in a wheelchair or a shower chair Fill the tub and check the water temperature with a bath thermometer to avoid thermal injury in the client Lower the hydraulic chair lift to its lowest point, outside the tub Transfer the client to the chair lift and secure the seat belt Raise the chair lift above the tub Support the clients legs down into the water and slowly lower the chair lift into the tub Assist in bathing the client, if appropriate Reverse the procedure when taking the client out of the tub Dry the client and transport him or her to the room

Providing Perineal-Genital Care Purposes To remove perineal secretions and odors To promote client comfort Assessment Assess the presence of

Irritation, excoriation, inflammation, swelling Excessive discharge Odor, pain or discomfort Urinary or fecal incontinence Recent rectal or perineal surgery Indwelling catheter Determine Perineal-genital hygiene practices Self-care abilities Planning Delegation Perineal-genital care can be delegated to UAP, if the client has recently had perineal, rectal, or genital surgery, the nurse needs to assess if it appropriate for the UAP to perform perineal-genital care.

Equipment Perineal-genital care in conjunction with the bedbath Bath towel Bath blanket Clean gloves Bath basin with water at 43 to 46C Soap Wash cloth Special Perineal-genital care Bath towel Bath blanket Clean gloves Cotton balls or swabs Solution bottle, pitcher, ot container filled with warm water or a prescribed solution Bedpan to receive rinse water Moisture-resistant bag or receptacle for used cotton swabs Perineal pad Implementation Preparation Determine whether the client is experiencing any discomfort in the perineal-genital area Obtain and prepare the necessary equipment and supplies

1 2 3

Performance Explain to-the client what you are going to so, why is it necessary , and how he/she can cooperate, being particularly sensitive to any embarrassment felt by the client Wash hands and observe other appropriate infection control procedures (e.g. clean gloves) Provide for client privacy by drawing the curtains around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Hygiene is personal matter. Prepare the client Fold the top bed linen to the foot of the bed and fold the gown up to expose the genital area Place a bath towel under the clients hips. The bath towel prevents the bed from becoming soiled Position and drape the client and clean the upper inner thighs FOR FEMALES Position the female in aback lying position with the knees flexed and spread well apart Cover her body and legs with the blanket. Drape the legs by tucking the bottom corners of the bath blanket under the inner sides of the legs. Minimum exposure lessens embarrassment and helps to provide warmth. Bring the middle portion of the base of the blanket up over the pubic area Put gloves, wash hands and dry the upper inner thighs FOR MALES Position the male client in a supine position with knees slightly flexed ans hips slightly externally rotated Put on gloves, wash and dry the upper inner thighs Inspect the perineal area Note particular areas of inflammation, excoriation, or swelling especially between the labia in females and the scrotal folds in males Also note excessive discharge or secretions from the orifices and the presence of odors FOR FEMALES Clean the labia majora. Then spread the labia to wash the folds between the labia majora and the labia minora. Secretions that tend to collect around the labia minora facilitate bacterial growth Use separate quarters of the wash cloth for each stroke, and wipe from the pubis to the rectum. For menstruating women and clients with indwelling catheters, use clean wipes, cotton balls, or gauze. Take a clean ball for each stroke,. Using separate quarters of the wash cloth or new cotton balls or gauzes prevents the transmission of microorganism from one area to the other. Wipe from the area of least contamination (the pubis) to that greatest (the rectum) Rinse the area well. You may place the client on bedpan and use a peri wash or solution bottle to pour warm water over the area. Dry the perineum thoroughly, paying particular attention to the folds between the labia. Moisture supports the growth of any microorganism FOR MALES Wash and dry the penis, using firm strokes, using firm strokes. Handling the penis firmly may prevent an erection If the client is uncircumcised , retract the prepuce (Foreskin) to expose the glans penis (the tip of the penis) for cleaning. Replace the foreskin after

Yes

No

Remarks

10

cleaning the glans penis. Retracting the foreskin is necessary to remove the smegma that collects under the foreskin and facilitates bacterial growth. Replacing the foreskin prevents constriction of the penis, which may cause edema Wash and dry the scrotum. The posterior folds of the scrotum may need to be cleaned when the buttocks are cleaned. The scrotum tends to be more soiled that the penis because of its proximity to the rectum; thus it is usually cleaned after the penis Inspect perineal orifices for intactness Inspect particularly around the urethra in clients with indwelling catheter. A catheter may cause excoriation around the urethra. Clean between the buttocks Assist the client to turn onto the side facing away from you Pay particular attention to the anal area posterior folds of the scrotum in males. Clean the anus with toilet tissue before washing it, if necessary Dry the area well For post delivery or menstruating females, apply a perineal pad as needed from front to back. This prevents contamination of the vagina and urethra from the anal area Document any unusual findings such as redness, excoriation, skin breaks down, discharge and any localized areas of tenderness EVALUATION Relate current assessments to previous assessments Conduct appropriate follow up such as prescribed ointment for excoriation Report any deviation from normal to the physician

Providing Foot Care Purposes To maintain the skin integrity of the feet To prevent foot infection To prevent foot odors To assess or monitor foot problems ASSESSMENT

History of any problem s with foot odor, foot discomfort, foot mobility, circulatory problems (e.g. swelling, changes in skin color and/or temperature, and pain) structural problems (e.g. bunion, hammer toe, or overlapping digits) Usual foot care practices (e.g. frequency of washing feet and cutting nails, foot hygiene products used, how often socks are changed, whether the client ever goes barefoot, whether the client see a podiatrist) ASSESS Skin surfaces for cleanliness, odor, dryness, and intactness Each foot and toe for shape, size, presence of lesions (e.g. corn, callus, wart, or rash), and areas of tenderness, ankle edema Skin temperatures of the feet to assess circulatory status and the dorsalis pedis pulses Self-care abilities (e.g. any problems managing foot care PLANNING Delegation Foot care for no diabetic client can be delegated to UAP. Remind the UAP to notify the nurse of anything that looks out of the ordinary. Review UAP agency policy about cutting or trimming nails. EQUIPMENT Washbasin containing warm water Pillow Moisture-resistant disposable pad Towels Soap Washcloth Toenail cleaning and trimming g equipment Lotion or foot powder

1 2 3

Performance Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Wash hands and observe other appropriate infection control procedures Provide client privacy by drawing the curtains around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Hygiene is personal matter Prepare the equipment and the client Fill the washbasin with warm water at about 40 to 43C. Warm water promotes circulation, comforts and refreshes Assist the ambulatory client to a sitting position in a chair, or the bed client to a supine or semi fowlers position Place a pillow under the bed clients knees. This provides support and prevent muscle fatigue Place the washbasin on the moisture-resistant pad at the foot of the bed for a bed client or on the floor infront of the chair for an ambulatory client For a bed client, pad the rim of the washbasin with a towel. The towel

Yes

No

Remarks

prevents undue pressure on the skin Wash the foot and soak it Place one of the clients feet in the basin and wash it with soap, paying particular attention to the interdigital area. Prolonged soaking is generally not recommended for diabetic clients or individuals with peripheral vascular disease. Prolonged soaking may remove natural skin oils, thus drying the skin and making it more susceptible to cracking and injury Rinse the foot well to remove soap. Soap irritates the skin if not properly removed Rub callused areas of the foot with the washcloth. This helps remove dead skin layers If the nails are not brittle or thick and require trimming, replace the water and allow the foot to soak for 10 to 20 minutes. Soaking softens the nails and loosens debris under them Clean the nails as required with an orange stick. This removes excess debris that harbours microorganisms Remove the foot from the basin and place it on powders Dry the foot thoroughly and apply lotion or foot powder Blot the foot gently with the towel to dry it thoroughly, particularly between the toes. Harsh rubbing can damage the skin. Thorough drying reduces the risk of infection Apply lotion or lanolin cream. This lubricates dry skin or Apply a foot powder containing a nonirritating deodorant if the feet tend to perspire excessively. Foot powder have greater absorbent properties than regular bath powders; some also contain menthol which makes the feet feel cool If agency policy permits, trim the nails of the first foot while the second foot is soaking Document any foot problems observed Foot care is not generally recorded unless problems are noted Record any signs of inflammation , infection, breaks in the skin, corns, troublesome calluses , bunions and pressure areas. This is of particular importance for clients with peripheral vascular disease, and diabetes EVALUATION Inspect nails and skin after the soak Compare to prior assessment data Report any abnormalities to the physician

Brushing and Flossing the Teeth Purposes To remove food particles from around and between the teeth TO remove dental plaque To enhance the clients feelings of well being To prevent sores and infection of the oral tissues ASSESSMENT

Determine the extent of the clients self-care abilities Assess the clients usual mouth care practices Inspect lips, gums, oral mucosa, and tongue for deviations from normal Indentify presence of oral problems such as tooth caries, halitosis, gingivitis and loose or broken teeth Check if the client has bridgework or wear dentures, if the client has dentures, ask if any tenderness or soreness is present and, if so, the location of the areas for on going assessment PLANNING Delegation Oral care brushing and flossing of teeth, and denture care can be delegated to the UAP. After performing the above assessment, the nurse should instruct the UAP as to the type of oral care and amount of assistance needed by the client. Remind the UAP to report changes in the clients oral mucosa. EQUIPMENT BRUSHING AND FLOSSING Towel Disposable gloves Curve basin (emesis basin) Toothbrush Cup of tepid water Detrifrice (toothpaste) Mouthwash Dental floss, at least two pieces 20 cm ( 8 inches) in length Floss holder (optional) FOR CLEANING ARTIFICIAL DENTURES Disposable gloves Tissue or piece of gauze Denture container Clean washcloth Toothbrush or stiff bristle brush Dentrifice or denture cleaner Tepid water Container of mouthwash Curved basin (emesis basin) Towel PREPARATION Assemble all the necessary equipment Performance Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Yes No Remarks

Wash hands and observe other appropriate infection control procedures (e.g. disposable gloves). Wearing gloves while providing mouth care prevents the nurse from acquiring infections. Gloves also prevent transmission of microorganism to the client Provide client privacy by drawing the curtain around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Hygiene is a personal matter Prepare the client Assist the client to a sitting position in bed if health permits. If not, assist the client to a side-lying position with the head turned so liquid may be prevented from draining down the clients throat Prepare the equipment Place the towel under the clients Put on disposable gloves Moisten the bristles of the toothbrush with tepid water and apply the dentrifice to the toothbrush Use a soft toothbrush (a small one for a child ) and the clients choice of dentrifice For the client who must remain in bed, place or hold the curved basin under the clients chin, fitting the small curve around the chin or neck Inspect the mouth and teeth Brush the teeth Hand the toothbrush to the client or brush the clients teeth as follows: A. Hold the brush against the teeth with bristle at a 45 degree angle. The tip of the outer bristle should rest against and penetrate under the gingival sulcus . The brush will clean under the sulcus of two or three teeth at one time . this sulcular technique removes plaque and cleans under the gingival margins B. Move the bristles up and down using a vibrating or jigging motion from the sulcus to the crowns of the teeth C. Repeat until outer and inner surfaces of the teeth and sulci of the gums are cleaned D. Clean the biting surfaces by moving the back and forth over them in short strokes E. If the tongue is coated, brush it gently with the toothbrush. Brushing removes accumulated materials and coatings. A coated tongue may be caused by poor oral hygiene and how fluid intake. Brushing gently and carefully helps prevent gagling or vomiting Hand the client the water cup or mouthwash to rinse the mouth vigorously. Then ask the client to spit the water and excess dentrifice into the basin. Some agencies supply a standard mouthwash. Alternatively, a mouth rinse of normal saline can be an effective cleaner and moisturizer. Vigorously rinsing loosens food particles and washes out already loosened particles Repeat the preceding steps until the mouth is free or dentrifice and food particles Remove the curved basin and help then client wipe the mouth Floss the teeth Assist the client to floss independently, or floss the teeth as follows. Waxed floss is less likely to fray than unwaxed floss; particles between the teeth attach more readily to unwaxed floss than to waxed floss. Some believe that waxed floss leaves a residue on the teeth and that plaque

then adheres to the wax A. Wrap the end of the floss around the third finger of each hand B. To floss the upper teeth, use your thumb and index finger to stretch the floss. Move the floss up and down between the teeth form the tops of the crowns to the gum along the gum lines as far as possible. Make C with the floss around the tooth edge being flossed. Start at the back on the right side and work around to the back of the left side or work form the center teeth to the back of the jaw on the either side C. To floss the lower teeth, use your index fingers to stretch the floss Give client tepid water or mouthwash to rinse the mouth and a curved basin in which to spit the water Assist the client in wiping the mouth Remove the disposable equipment appropriately Remove and cleaned the curved basin Remove and discard the gloves Document assessment of the teeth, tongue, and oral mucosa include any problems such as sores or inflammation, bleeding and swelling. Brushing and flossing teeth are not usually recorded VARIATION: ARTIFICIAL DENTURES Remove the dentures Put on the gloves. Wearing gloves protects the nurse and the client from infection If the client cannot remove the dentures take the tissue or gauze, grasp the upper plate at the front teeth with your thumb and second finger, and move the denture up and down slightly. The slight movement breaks the suction that holds the place on the roof of the mouth Lower the upper plate, move it out of the mouth, and place it in the denture container Lift the lower plate, turning it so that the left side. For example, is slightly lower that the right, to remove the plate from the mouth without stretching the lips. Place the lower plate in the denture container Remove a partial denture by exerting equal pressure on the boarder of each side of the denture, not on the claps, which can be bend or break Clean the dentures Take the denture container to a sink. Take care not to drop the dentures as they may break. Place a washcloth in the bowel of the sink to prevent damage if the dentures are dropped Using a toothbrush or special stiff bristled brush, scrub the dentures with the cleaning agent and tepid water. Hot water is not used because heat will change the shape of some dentures Rinse the dentures with tepid running water. Rinsing removes the cleaning agent and food particles A. If the dentures are stained, soak them in a commercial cleaner. Be sure to follow the manufacturer s directions. To prevent corrosion, dentures with metal parts should not be soaked overnight Inspect the dentures and the mouth Observe the dentures afor any rough, sharp, or worn areas that could irritate the tongue or mucous membranes of the mouth, lips and gums Inspect the mouth for any redness, irritated areas, or indications of infections Assess the fit of the dentures. People who have them should see a dentist

6 7

at least once a year to check the fit and the presence of any irritation to the soft tissues of the mouth. Clients who need repairs to their dentures may need a referral for financial assistance Return the dentures to the mouth Offer some mouthwash and a curved basin to rinse the mouth. If the client cannot insert the dentures independently, insert the plates one at a time. Hold each plate at a slight angle while inserting it, to avoid injuring the lips Assist the client as needed Wipe the clients hand and mouth with the towel If the client does not want to or cannot wear the dentures, store them in a denture container with water. Label the container with the clients name and identification number Remove and discard gloves Document all assessments and include any problems such as an irritated area on the mucous membrane

Providing Special Oral Care Purposes To maintain the intactness and health of the lips, tongue, and mucous membranes of the mouth To prevent oral infection To clean and moisten the membranes of the mouth and lips ASSESSMENT Inspect lips, gums, oral mucosa, and tongue for deviations from normal Identify presence of oral problems such as tooth carries, halitosis, gingivitis, and loose or broken teeth Assess for gag reflex, when appropriate

PLANNING Delegation Special oral care may delegated to UAP, however, the nurse needs to assess for the gag reflex. Dependent on this assessment, the nurse needs to inform the UAP of the correct positioning of the client and how to use the oral suction catheter, if needed. Remind the UAP to report changes in the clients oral mucosa. EQUIPMENT Towel Curved basin (emesis basin) Disposable clean gloves Bite-block to hold the mouth open and teeth apart (optional) Toothbrush Cup of tepid water Dentrifice or denture cleaner Tissue or piece of gauze to remove dentures (optional) Denture container as needed Mouthwash Rubber-tipped bulb syringed Suction catheter with suction apparatus (optional) Foam swabs and cleaning solution for cleaning mucus membranes Petroleum jelly (Vaseline)

1 2 3

Performance Explain to the client what you are going to do, why it is necessary. Wash hands and observe other appropriate infection control procedures (e.g. disposable gloves). Provide client privacy by drawing the curtain around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Hygiene is a personal matter Prepare the client Position the unconscious client in side-lying position, with the head of the bed lowered. In this position, the saliva automatically run out by gravity rather than being aspirated into the lungs. This position is the one of the choice for unconscious client receiving mouth care. If the clients head cannot be lowered, turn it to one side. The fluid will readily run out of the mouth or pool in the side of the mouth, where it can be suctioned Place the towel under the clients chin Place the curved basin against the clients chin and lower cheek to receive the fluid from the mouth Put on gloves Clean the teeth and rinse the mouth If the person has natural teeth, brush gently and carefully to avoid injuring gums, if the client has artificial teeth, clean them. Rinse the clients mouth by drawing about 10 ml of water or alcohol free mouthwash into the syringe and injecting it gently into each side of the

Yes

No

Remarks

mouth. If the solution is injected with forced, some of it may flow down the clients throat and be aspirated into the lungs. Watch carefully to make sure that all the rinsing solution has run out of the mouth into the basin. If not suction the fluid from the mouth. Fluid maintaining in the mouth may be aspirated into the lungs Repeat rinsing until the mouth is free of dentrifice, if used Inspect and clean the oral tissues If the tissues appear dry or unclean, clean them with the foam swabs or gauze and cleaning solution following agency policy: Picking up a moistened foam swab, wipe the mucous membrane of one cheek. If no foam swabs are available, wrap a small gauze square around a tongue blade in a waste container; use a fresh one to clean the next area. Using separate applicators for each area of the mouth prevents the transfer of microorganisms from one area to another Clean all mouth tissues in an orderly progression, using separate applicators: the cheeks, roof of the mouth, base of the mouth and tongue Observe the tissues closely for inflammation and dryness Rinse the clients mouth as described in step 5 Remove and discard gloves Ensure client comfort Remove the basin, and dry around the clients mouth with the towel. Replace artificial dentures, if indicated Lubricate the clients lips with petroleum jelly. Lubrication prevents cracking and subsequent infections. If the client is on oxygen therapy, do not used petroleum jelly, because it can cause burns to the skin and mouth. Use another mouth care products that does not have petroleum in it. Document assessment of the teeth, tongue, gums, and oral mucosa. Include any problems such as sores or inflammation and swelling of the gums EVALUATION Consider the client medical diagnosis and treatment (e.g. chemotherapy, oxygen) and the necessary nursing interventions related to oral hygiene Conduct an ongoing assessment, if appropriate of the oral mucosa, gums, tongue, and lips Report deviations from normal to the physician Conduct appropriate follow-up such as a referral to a dentist for dental caries

Providing Hair Care for Clients Purposes To stimulate the blood circulation to the scalp To distribute hair oils and provide a healthy sheen To increase the clients sense of well-being To assess or monitor hair or scalp problems (e.g. matted hair or dandruff) ASSESSMENT History of the following conditions or therapies; recent chemotherapy, hypothyroidism, radiation of the head, unexplained hair loss, and growth of excessive body hair Usual hair care practices and routinely used hair care products (e.g. hair spray, shampoo, conditioners, hair oil preparation, hair dye, curling or straightening preparations)

Whether wetting the hair will make it difficult to comb. Kinky hair is easier to comb when wet, however, it is very difficult to comb when dries. ASSESS Condition of the hair and scalp, is the hair straight, curly, kinky? Is the hair matted or tangled? Is the scalp dry? Evenness of hair growth over the scalp, in particular, any patchy loss of hair; hair texture, oiliness, thickness, or thinness; presence of lesions, infections, or infestations on the scalp; presence of hirsutism Self-care abilities (e.g. any problem managing hair care) PLANNING Delegation Brushing and combing hair, shampooing hair, shaving facial hair can be delegated to UAP unless client has a condition in which the procedure would be contraindicated (e.g. cervical spinal injury or trauma). The nurse needs to assess the UAPs knowledge and experience of hair care for clients of other cultures, if appropriate EQUIPMENTS Clean brush and comb A wide-toothed comb is usually used for many black-skinned people because finer combs pull the hair into knots and may also break the hair Towel Hair oil preparation, if appropriate

1 2 3

Performance Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate Wash hands and observe other appropriate infection control procedures Provide client privacy by drawing the curtain around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Hygiene is a personal matter Position and prepare the client appropriately Assist the client who can sit to move to a chair. Hair is more easily brushed and combed when the client is in a sitting position. If health permits, assists a client confined to a bed to a sitting position by raising the head of the bed. Otherwise, assists the client to alternate side-lying positions, and do one side of the head at a time If the client remains in bed, place a client towel over the pillow and the clients shoulders. Place it over the sitting clients shoulder. The towel collects any removed hair, dirt, and scaly material Remove any mats or tangles gradually Mats can usually be pulled apart with fingers or worked out with repeated brushing If the hair is very tangled, rub alcohol or an oil, such as mineral oil, on the strands to help loosen the tangles Comb out tangles in a small section of hair toward the ends. Stabilize the

Yes

No

Remarks

hair with one hand and comb toward the ends of the hair with the other hand. This avoids scalp trauma Brush and comb the hair For short hair, brush and comb one side at a time. Divide long hair into two sections by parting it down the middle from the front to the back, if the hair is very thick, divide each section into front and back subsections or into several layers Arrange the hair as neatly and attractively as possible, according to the individuals desire Braiding long hair help prevent tangles Document assessments and special nursing interventions. Daily combing and brushing of the hair are not normally recorded VARIATION: HAIR CARE FOR AFRICAN AMERICAN CLIENTS Position and prepare the client Untangle the hair first, if appropriate Use fingers to reduce hair breakage and discomfort. Move fingers in a circular motion starting at the roots and gently moving up to the tip of the hair Comb the hair Apply hair oil preparation as the client indicates Using a large and open toothed comb, grasp a small section of hair and, holding the hair at the tip, start untangling at the tip and work down toward the scalp OIL SHAMPOO An oil shampoo is composed of one part alcohol and four parts mineral oil. The alcohol is an antiseptic and both the alcohol and mineral oil are cleansing agent Warm the mixture Pour it into the hair and gently massage Comb the hair Remove excess oil with a towel OILING THE HAIR If a water based shampoo was used it may be necessary to oil and massage the scalp. Part the hair in sections Place a small amount of hair oil on the scalp. The hair is so dense that oiling the top of the hair will not help a dry scalp Ask the client if he or she would like the hair braided. Braiding will decrease tangling, however, the choice is the clients . EVALUATION Conduct ongoing assessments for problems such as dandruff, alopecia, pediculosis, scalp lesions or excessive dryness or matting Evaluate effectiveness of medication (e.g. for treating pediculosisi), if appropriate

Shampooing the Hair of a Client Confined to Bed Purposes To stimulate blood circulation through massage To clean the hair and increase the clients sense of well-being

ASSESSMENT Determine routinely used shampoo products Assess Any scalp problems Activity tolerance if the client

PLANNING Delegation Brushing and combing hair, shampooing hair, shaving facial hair can be delegated to UAP unless client has a condition in which the procedure would be contraindicated (e.g. cervical spinal injury or trauma). The nurse needs to assess the UAPs knowledge and experience of hair care for clients of other cultures, if appropriate EQUIPMENT Comb and brush Plastic sheet or pad Two bath towels Shampoo basin Washcloth or pad Bath blanket Receptacle for the shampoo water Cotton balls (optional) Pitcher of water Bath thermometer Liquid or cream shampoo Hair dryer

PREPARATION Determine whether the physicians order is needed before a shampoo can be given. Some agencies require an order Determine the type of shampoo to be used (e.g. medicated shampoo). Discuss with the client. A person who must remain in bed may find the shampoo tiring. Choose a time when the client is rested and can rest after the procedure Performance Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate Wash hands and observe other appropriate infection control procedures Yes No Remarks

1 2

10.

Provide client privacy by drawing the curtain around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Hygiene is a personal matter Position and prepare the client appropriately Assist the client to the side of the bed which you will work Remove pins and ribbons from the hair, and brush and comb it to remove any tangles Arrange the equipment Put the plastic sheet or pad on the bed under the head. Plastic keeps the bedding dry Remove the pillow from under the clients head, and place it under the shoulders unless there is some underlying conditions 9e.g. neck surgery, arthritis of the neck). This hyperextends the neck Tuck a bath towel around the clients shoulders. This keeps the shoulders dry Place the shampoo basin under the head, putting a folded washcloth or pad where the clients neck rests on the edge of the basin, if the client is on a stretches, the neck can rest on the edge of the sink with the washcloth as padding. Padding supports the muscles of the neck and prevents undue muscle strain and discomfort Fanfold the top bedding down to the waist, and over the upper part of the client with the bath blanket. The folded bedding will stay dry, and the bath blanket, which can be discarded after the shampoo, will keep the client warm Place the receiving receptacle on a table or chair at the bedside. Out the spout of the shampoo basin over the receptacle Protect the clients eyes and ears. Place a damp washcloth over the clients eyes. The washcloth protects the eyes from soapy water. A damp washcloth will not slip Place cotton balls in the clients ear if indicated. These keep water from collecting in ear canals Shampoo the hair Wet the hair thoroughly with the water Apply shampoo to the scalp. Make a good lather with the shampoo while massaging the scalp with the pads of your fingertips. Massage all areas of the scalp systematically, for example, starting at the front and working toward the back of the head. Massaging stimulates the blood circulation in the scalp. The pads of the fingers are used so that the fingernails will not scratch the scalp. Rinse the hair briefly, and apply shampoo again Make a good lather and massage the scalp as before Rinse the hair thoroughly this time to remove all shampoo remaining in the hair may dry and irritate the hair and scalp. Squeeze as much water as possible out of the hair with your hands Dry the hair thoroughly Rub the client hair with the dryer. Set the temperature at warm Continually move the dryer to prevent burning the clients scalp Ensure client comfort Assists the person confined to bed to a comfortable position Arrange the hair using a clean brush and comb Document the shampoo and any assessments

EVALUATION Conduct ongoing assessment such as any scalp or intolerance to the procedure. Report any problems noted to the nurse in charge USING A SAFETY RAZOR TO SHAVE FACIAL HAIR Wear gloves in case facial nicks occur and you come in contact with blood Apply shaving cream or soap and water to soften the bristles and make the skin more pliable Hold the skin taut, particularly around creases, to prevent cutting of the skin Hold the razor so that the blade is at a 45 degree angle to the skin, and shave in short, firm strokes in the direction of hair growth After shaving the entire area, wipe the clients face with wet washcloth to remove any remaining shaving cream and hair Dry the face well, then apply aftershave lotion or powder at the client prefer To prevent irritating the skin, pat on the lotion with the fingers and avoid rubbing the face

Removing, Cleaning, and Inserting a Hearing Aid Purpose To maintain hearing aid function

ASSESSMENT Determine if the client has experienced any problems with the hearing aid and hearing aid practices. Assess for the presence of inflammation, excessive wax, drainage or discomfort in the external ear PLANNING Delegation A nurse can delegate the task for a hearing aid to the UAP. It is important, however, for the nurse to first determine that UAP knows the correct way to care for a hearing aid. Inform the UAP to report the presence of ear inflammation, discomfort, excess wax or drainage to the RN EQUIPMENT Clients hearing aid Soap, water, and towels or a damp cloth Pipe cleaner or toothpick (optional) New battery (if needed)

1 2 3

Performance Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate Wash hands and observe other appropriate infection control procedures Provide client privacy by drawing the curtain around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Hygiene is a personal matter Remove the hearing air Turn the hearing aid off and lower the volume. The on/off switch may be labelled O (off), M (microphone), T (telephone), TM (Telephone/Microphone). The batteries continue to run if the hearing aid is not turned off Remove the earmold by rotating it slightly forward and pulling it outward If the earing aid is not to be used for several days, remove the battery. Removal prevents corrosion of the earing aid from battery leakage. Store the earing aid in a safe place and label with clients name. Avoid exposure to heat and moisture. Proper storage prevents loss or damage Clean the earmold Detach the earmold if possible. Disconnect the earmild from the receiver of the body hearing aid or from the earing aid case of behind-the-ear and eyeglass hearing aids where the tubing meets the hook of the case. Do not remove the earmold if it is glued or secured by a small metal ring. Removal facilitates cleaning and prevents inadvertent damage to other parts

Yes

No

Remarks

If the earmold is detachable, soak it in a mild soapy solution. Rinse and dry it well. Do not use isopropyl alcohol. Alcohol can damage the hearing aid If the earmold is not detachable or is for an in-the-ear aid, wipe the earmold with a damp cloth Check the earmoild opening is patent. Blow any excess moisture through the opening or remove debris (e.g. earwax) with a pipe cleaner or toothpick Reattach the earmold if it was detached from the rest of the hearing aid Insert the hearing aid Determine form the client if the earmold is for the left or the right ear Check that battery is inserted in the hearing aid. Turn off the hearing aid and make sure the volume is turned all the way down. A volume that is too loud is distressing Inspect the earmold to identify the ear canal portion. Some earmolds are fitted for only the ear canal and concha; others are fitted for all the contours of the ear. The canal portion, common to all, can be used as a guide for correct insertion Line up the parts of the earmold with the corresponding parts of the clients ear Rotate the earmold slightly forward and insert the ear canal portion Gently press the earmold into the ear while rotating it backward Check that the earmlod fits snugly by asking the client if it feels secure and comfortable Adjust the other components of a behind the ear or body hearing aid Turn the earing aid on, and adjust the volume according to the clients need Correct problems associated with improper functioning If the sound is weak or there is no sound A. Ensure that the volume is turned high enough. B. Ensure that earmold opening is not clogged C. Check the battery by turning the hearing aid on, turning up the volume, cupping your hand over the earmold, and listening. A constant whistling sound indicates the battery is functioning. If necessary, replace the battery. Be sure that the negative (-) and positive (+) signs on the battery match those where indicated on the hearing aid D. Ensure that the ear canal is not blocked with wax, which can obstruct sound waves If the client reports a whistling sound or squeal after insertion: A. Turn the volume down B. Ensure that the earmold is properly attached to the receiver C. Reinsert the earmold Document pertinent data The removal and the insertion of hearing aid are not normally recorded Report and record any problems the client has with the hearing aid EVALUATION Speak to the client in a normal conversational tone and observe client behaviors Compare the clients hearing ability to previous assessments Report to the physician any deviations from normal for the client