ORAL CARE - Independent -Dependent

FOOT AND TOENAIL CARE

ORAL CARE FOR INDEPENDENT PATIENTS

 Oral Hygiene includes cleansing of the mouth, gums and teeth or dentures. This procedure should be done before breakfast, after all meals and at bedtime.

Purpose:
To improve appetite, communication and dental health. To give the patient a feeling of well-being. To decrease mouth odor.

Equipments:
Fresh Water Cup Straw, if necessary Toothbrush and toothpaste Emesis basin Face towel

ASSESSMENT

1. Check the chart for any information related to the patients ability to participate in the procedure being planned.

To know your limitations & to know the condition of the patient.

Assess the patient for specific symptoms related to diagnosis, for fatigue and for hygiene preferences. PLANNING

3. Wash your hands 4. Assemble the equipments

To break the cycle of infection.

IMPLEMENTATION

5. Identifies the patient and explains the procedure 6. Provides for privacy

An explanation facilitates cooperation

The patient may be embarrassed if cleansing involves removal of dentures. Promotes good body mechanics A sitting or side-lying position prevents aspiration of fluids into the lungs. The towel protects the patient from dampness. Raising the bed promotes efficient body mechanics.

7. Raises the bed to a working height 8. Assists the patient to sit up

9. Spreads the towel across the patients chest

10. Offers the client water to rinse his mouth

The nurse should encourage the patient to exercise as much independence as possible.

11. Moistens the toothbrush with water from the Water softens the bristles. glass. Spreads a small amount of toothpaste on the toothbrush.

12. Offers the toothbrush to the patient if he/she is able. If unable, brushes patients teeth using gentle motion starting above the gum line and going down the teeth. Repeats the stroke until to all the teeth.

Brushing facilitates the removal of plaque and tartar.

13. Offers water to rinse patients mouth. 14. Wipes the patients mouth and makes patient comfortable.

Vigorous swishing helps remove loosed debris

15. Returns bed to its comfortable position. Opens curtains or screens.

16. Cleans equipments and places them properly.

17. Washes hands

18. Documents pertinent observations.

ORAL FOR DEPENDENT PATIENTS

Purpose:
Due to high level of dependence, some patients may require special oral hygiene methods. Unconscious patients are prone to drying of salivary secretions due to their incapacity to eat or drink and rendering them unable to swallow salivary secretions. The adverse effect of certain procedures (i.e., chemotherapy, radiation and nasogastric tube intubation) may cause the patient to develop stomatitis. In cases like this, gentle brushing is recommended and use of commercial mouthwash should be avoided.

Equipments:
Gloves Paper Towels Suction (if necessary) Emesis basin Tongue depressor Toothbrush Toothpaste KY Jelly

ACTIONS 1. Wash hands. Wear gloves

RATIONALE Reduces transmission of microorganisms

2. Assess patient for the presence of gag reflex.

Gag reflex may cause aspiration

3. Examine patients oral cavity.

Determines frequency and extent of oral hygiene needed.

4. Assess patient for risk of oral hygiene Alterations in the oral cavity indicate frequency or problems. precautions in oral care. 5. Remove gloves and wash hands. Hand washing and gloving deters the spread of microorganisms.

6. Position the client to lie on side with head Prevents risk of aspiration turned toward dependent side.

7. Explain procedure to the patient. 8. Wash hands and don gloves.

Reduces anxiety and promotes cooperation Reduces transmission of microorganisms

9. Assemble equipment on over bed table the Organization facilitates task performance. Suction bedside table. Prepare suction if necessary. may be needed to prevent aspiration. 10. Raise bed to working height. Elevate head of bed, as high as possible

11. Lower side rail on working side and turn To facilitates drainage of fluid and secretions patients head toward you. (If patient can not lean during procedure forward, position head slightly forward.

12. Place a towel across the chest and an emesis A towel and kidney basin protect the patient from basin against patients chin. dampness

13. Gently open patients mouth and insert a A padded tongue depressor keeps the mouth padded tongue depressor between the back open for easier cleaning and prevents the patient morals. from biting down on the nurses hands or utensils

14. Moistens toothbrush very lightly and brush all An applicator or toothbrush provides friction to tooth surfaces. Dip applicator into water of clean areas accumulated by tartar and plaque. mouthwash and wipe gums, teeth, tongue and inside of mouth with applicator. (repeat if necessary)

15. Discards used applicators appropriately into To prevent spread of microorganisms plastic bag. 16. Rinses the patients mouth with small amounts of water, either allowing it to drain into the emesis basin or used an asepto-syringe to aspirate it. Rinsing helps to remove debris from the mouth.

17. If secretions accumulated, use suction. 18. Wipe the patients mouth.

Prevents aspiration. To prevent skin irritation.

19. Apply lubricant to tips. Uses a water soluble lubricant

Lubricants prevent drying and cracking of lips.

20. Leave the patient in a lateral position with Prevents aspiration. head toward the side for 30 60 minutes after oral hygiene. Removes towel and raises side rail.

21. Lowers height of bed. Return patient to a Restores patients comfort. comfortable position.

22. Clean equipments and put away.

To maintain medical asepsis.

23. Remove gloves and discard appropriately. Hand washing deters the spread of microorganisms. Washes hands. 24. Document observations. procedure and pertinent Documentation facilitates communication to other health personal and may also serve for legal purposes.

21. Lowers height of bed. Return patient to a comfortable position. 22. Clean equipment and put away. To maintain medical asepsis.

23. Remove gloves and discard appropriately. Hand washing deters the spread of microorganisms. Washes hands.
24. Document observations. procedure and pertinent Documentation facilitates communication to other health personal and may also serve for legal purposes.

PROVIDING FOOT AND TOENAIL CARE

Purposes: To cleanse the feet To stimulate circulation to the lower extremities. To prevent injury. To maintain the integrity of the integument. To promote comfort to the feet. To treat local infections by soaking the feet in a medicated solution.

Equipment:
Wash basin Soap Warm water in pitcher Hand towels, 2 Nail cutter or scissors Nail file Lotion (optional) Powder (optional) Paper lining (as the case may be) Working gloves Nail brush

ACTIONS

RATIONALE

1. Assess the condition of the feet and toenails.

An appropriate plan for foot care cannot be individualized.

2. Discuss any identifiable foot and nail problems with the client.

The client should be informed of potential and actual health problems.

3. Explain the procedure to the client.

An explanation allays tear and aid in acquiring the clients cooperation.

4. Wash your hands

Hand washing deters the spread of microorganisms.

5. Gather the equipment

Organization promotes efficient time management.

6. Provide privacy to the client

Providing privacy shows respect for the clients feeling

7. Do your working gloves

8. Protect the bed linen with towel beneath the clients feet.

- Dead cells and dirt trapped between the nail and the toe may require mechanical removal.

9. Soak each foot one at a time in warm (40C or Soaking softens nails and helps to loosen dry 104F) of water for approximately 3-5 minutes. skin and debris. Warm water dilates circulations and promotes comfort.

10. Wash each foot with liberal amount of lathered soap.

11. Brush the toenails.

12. Changes the water between the care of each foot. 13. Cut the nails straight across ensuring that they are even with the tip of the toes.

The water should be clean and maintained at a temperature that promotes comfort. Cutting straight across is less likely to result in injury to adjacent tissues or to potentiate the risk of ingrown nails.

14. Dry each foot thoroughly.

Moisture allows the growth of fungi and can also tend to lacerate skin if it cannot evaporate

15. Apply lotion or powder to the legs or feet if needed.

Powder absorbs perspiration.Lotion lubricates dry skin

16. Discard the water and do after care of Caring for soiled articles supports the principle of equipment. medical asepsis.

17. Remove gloves then wash hands.

Hand washing deters the spread of the microorganisms

18. Document the care given, the response of the client. And the necessary observations you made.

Written information is a permanent record of the care provided for the client.