NCM 101

FUNDAMENTALS OF
NURSING PRACTICE

CLINICAL INSTRUCTOR:
IVY M. MANCERA, RN, MSN
Basic Interventions to
Maintain Client Hygiene
 Hygienic Care
• Involves care of:
• Skin
• Hair
• Nails
• Teeth
• Oral and nasal cavities
• Eyes
• Ears
• Perineal-genital area
 Types of Hygienic Care
• Early morning-offer
urinal/bedpan, wash face &
hands, & give oral care.
• Morning – after breakfast,
bedpan/urinal, bath/shower,
perineal care, back massage &
oral, nail & hair care.
• Hours of sleep (HS) or PM-
bedpan/urinal, washing hands &
face, oral care, & backrub.
• As needed (prn)- care as
needed
 Factors Influencing Personal Hygiene
• Culture - some bath
daily, some weekly.
• Body odor accepted
in some cultures,
privacy vs communal
• Religion - ceremonial
washings
• Environment - financial
limitations
 Factors Influencing Personal Hygiene
• Developmental level-
children learn at their
ability
• Health and energy-
illness, motivation
• Personal preference-
shower vs bath, AM vs
PM
 Bed-Making
• Provide smooth, wrinkle-
free bed foundation
• Place the bedside
table/overbed table within
reach
• Leave the bed in the high
position if returning by
stretcher
• Leave in the low position if
returning to bed after being
up
 Bed-Making
• When turning the client to the
side while making an occupied
bed, raise the side rail nearest
the client
• To ensure continued safety of
the client after making an
occupied bed:
• Raise the side rails
• Place the bed in the low position
• Put items used by the client within
easy reach
• Attach the signal cord
 Abnormal Findings of the Skin

• Abrasion
• Excessive
dryness
• Ammonia Ammonia dermatitis Abrasion

dermatitis
• Acne
• Erythema
• Hirsutism
Acne Hirsutism
 Abnormal Findings of the Skin

Erythema Dry Skin

• Excessive dryness
• Areas of inflammation or
swelling
• Fissures
• Scaling and cracking of skin Fissures

• Plantar warts
• Swelling and pitting edema
• Weak or absent pulses
• Cool skin temperature in one
or both feet
Plantar warts
 Abnormal Findings of the Nails
• Spoon nails
• Excessive thickness or
clubbing
• Grooves or furrows Spoon nails
• Beau’s lines
• Discolored or detached
• Bluish or purplish tint or
pallor
• Hangnails or paronychia
• Delayed capillary refilling
Beau’s lines
time
Abnormal Findings of the Nails

Clubbing of nails Discolored or detached

Hangnails or paronychia
 Abnormal Findings of the Mouth
• Halitosis
• Glossitis
• Gingivitis
• Periodontal
disease
Glossitis
• Reddened or
excoriated
mucosa
• Excessive
dryness of the
buccal mucosa
 Abnormal Findings of the Mouth
• Cheilosis (cracked
lips)
• Dental caries
• Stomatitis
• Parotitis
Cheilosis (cracked lips)

Stomatitis
Dental caries
 Abnormal Findings of the Hair
• Dandruff Pediculosis

• Hair loss
• Ticks Scabies
• Pediculosis
• Scabies
• Hirsutism
 Abnormal Findings of Eyes
• Loss of hair, scaling,
flaky eyebrows
• Redness, swelling,
flaking, crusting,
discharge,
asymmetrical
Unequal pupils
closing, ptosis of
eyelids
• Jaundiced sclera
• Unequal pupils
• Pupils fail to dilate
or constrict Jaundiced sclera
• Inability to see
 Abnormal Findings of Ears

• Asymmetrical,
excessively red
Lesions, flaky,
or tender scaly skin over
auricles auricles

• Lesions, flaky,
scaly skin over
auricles
• Normal voice Tender auricles
tones not heard
 Abnormal Findings of the Nose
• Asymmetrical Lesions of
Asymmetrical the nose
• Discharge
• Localized
redness,
tenderness or
lesions
 Nursing Process: Assessment
• Nursing history to
determine:
• Self care practices
• Self-care abilities
• Past or current
problems
• Identification of
clients at risk for
developing
impairment
• Physical assessment
 Nursing Process: Nursing Diagnoses
• Deficient knowledge
• Situational low self-esteem
• Risk for impaired skin
integrity
• Impaired skin integrity
• Self-care deficit
• Risk for infection
• Impaired oral mucous
membrane
• Disturbed body image
• Risk for injury
 Nursing Process: Planning
• Nurse and, if
appropriate, the client
and/or family set
goals/desired outcomes
• Nurse identifies
interventions to assist
the client to achieve the
designated outcomes
 Nursing Process: Interventions
• Assisting dependent clients
with hygiene activities
• Educating clients and/or
family about appropriate
hygienic practices
• Demonstrating use of
assistive equipment and
adaptive activities
• Assessing and monitoring
physical and psychological
responses
 Purposes of Bathing
• Remove transient
microorganisms, body
secretions and
excretions, and dead skin
cells
• Stimulate circulation
• Produce a sense of well-
being
• Promote relaxation and
comfort
• Prevent or eliminate
unpleasant body odors
 Categories of Baths

Cleansing baths Therapeutic baths

• Complete bed
• Self-help
• Partial
• Bag
• Tub
• Sponge
• Shower
Bath Equipment
 Hospitalized Client
• Early morning care • Morning care
• Urinal or bedpan • Usually after breakfast
• Washing face and • Elimination
hands
• Bath or shower
• Oral care
• Perineal care
• Back massage
• Oral, nail, and hair care
 Hospitalized Client
• Hour of sleep (HS) or • As needed (prn)
P.M. • As required by client
• Elimination need
• Washing face and • More frequent bathing
hands • Changes of clothes
• Oral care
• Back massage
Bathing an Adult or Pediatric Client
Providing Perineal-Genital Care
Brushing and Flossing Teeth
Artificial Dentures
Oral Care for the Unconscious Client
Shampooing Hair of Client Confined to Bed
Removing Contact Lenses
Inserting and Removing Artificial Eye
Types of Hearing Aids
Parts of the Hearing Aid
Cleaning a
hearing aid
 Thank you!
This ends our topic on
Hygiene

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Basic Interventions to Maintain
Client Mobility and Exercise