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- Universal Body Substance Precautions
- BASIC PRINCIPLES OF MOUTH CARE
- SIGNIFICANT NURSING OBSERVATIONS DURING THE BATHING PROCEDURE
- PROVIDING FOR SELECTED PATIENT NEEDS WHILE BATHING A PATIENT SAFETY
- TIMING OF PATIENT HYGIENE PROCEDURES
- NURSING INTERVENTION TO PREVENT SKIN BREAKDOWN
| Universal Body Substance Precautions Posted: 02 Jan 2011 08:53 AM PST Universal Body Substance Precautions Only blood, semen, vaginal secretions, and possibly breast milk have been implicated in transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other blood-borne pathogens. Blood is the single most important source of transmission of blood-borne pathogens in health care settings. Infection control efforts must focus on preventing exposures to blood. Although the risk is unknown, universal precautions also apply to tissues and to cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, and amniotic fluid. Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood. Although universal precautions do not apply to these body substances, the wise nurse wears gloves for protection from other infections. Precautions are used for all patients. (Reason: It is impossible to know which patients are infected with such conditions as HIV, HBV, or other infectious agents.) Gloves are worn whenever the health care worker may come in contact with blood, body fluids containing blood, and other body fluids to which universal precautions apply. (Reason: Diseases can be carried in the body substances.) Wear gloves at all times if you have any break in the skin of your hands. If you have an exudative condition, such as weeping dermatitis, you must be evaluated before working with patients and patient care equipment. (Reason: You may be at great risk of contracting a disease; you might also spread disease.) Change gloves after each contact with a client. (Reason: The gloves may be contaminated.) Wash your hands and skin surfaces immediately and thoroughly if they are contaminated with blood or body fluids. (Reason: Proper washing will help to stop the spread of infection.) Wear a gown or apron when clothing could become soiled. (Reason: To prevent spread of infection to yourself or others.) Wear a mask and eye protection if splashing is possible. Hospital protocol will determine what type of eye protection is required for each specific case. (Reason: Infection could enter your body through the mucous membranes of your mouth or nose or through your eyes.) Dispose of sharp objects carefully. Do not recap or break needles. Needles and sharp objects are placed in a special container after use. (Reason: There is a possibility of accidental finger stick. It is important to protect yourself and housekeeping personnel.) If you have an on-the-job accident that causes a break in the skin, notify your nursing supervisor immediately. (Reason: Immediate precautions must be taken to protect you.) Special care is taken of a deceased patient’s body. (Reason: To prevent leakage of body substances. It is safer to assume that all patients are infectious.) All health care workers who perform or assist in vaginal or cesarean delivery should wear gloves and gowns when handling the placenta or the infant until blood and amniotic fluid have been removed from the infant’s skin. Gloves should be worn until after postdelivery care of the umbilical cord. Pregnant health care workers are not known to be at greater risk of contracting HIV infection than health care workers who are not pregnant; however, if a health care worker develops HIV infection during pregnancy, the infant is at risk. Because of this risk, pregnant health care workers should be especially familiar with and strictly adhere to precautions to minimize the risk of HIV transmission. (Adapted from Centers for Disease Control: Recommendations for prevention of HIV transmission in health care settings. MMWR 36: Suppl. 25: 1987. Centers for Disease Control: Update: Universal precautions for prevention or transmission of human immunodeficiency virus, hepatitis B virus, and other blood-borne pathogens in health-care settings. MMWR 37: 24, 1988)
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| BASIC PRINCIPLES OF MOUTH CARE Posted: 02 Jan 2011 08:47 AM PST Purposes. 1.Provide oral care of the teeth, gums, and mouth. 2.Remove offensive odors and food debris. 3.Promote patient comfort and a feeling of well-being. 4.Preserve the integrity and hydration of the oral mucosa and lips. 5.Alleviate pain and discomfort, thereby enhancing oral intake. General Guidelines. 1.Oral hygiene should be performed before breakfast, after each meal, and at bedtime. 2.Oral hygiene is especially important for patients receiving oxygen therapy, patients who have nasogastric tubes, and patients who are NPO. Their oral mucosa dries out much faster than normal due to their mouth-breathing. 3.You should provide for patient privacy during the procedure, as this is an extremely personal procedure for most patients. 4.Oral care for the unconscious patient should be performed at least every four hours. 5.Lipstick, chap stick, or vaseline may be applied to the lips to keep them from drying out. Nursing Records. Nursing observations for the patient’s mouth should be recorded in the clinical record, noting such factors as: 1.Bleeding. 2.Swelling of gums. 3.Unusual mouth odor. 4.Effect of brushing the teeth. Note if there is bleeding when you brush the patient’s gums and teeth. Conscious Patients with Dentures. 1.General considerations. *Many patients are sensitive or embarrassed about wearing dentures; therefore, the patient’s privacy should be respected when the dentures are cleaned. *Dentures must be handled carefully; they are fragile and expensive, and the patient is handicapped without them. *If the dentures are left out of the mouth for any period of time, place them in a covered opaque container with the patient’s name on the container. *Dentures must be kept in water to preserve their fit and general quality; the color may change if they become dry. *You may avoid breaking the dentures while cleaning them by holding them over a basin of water with a washcloth folded in the bottom.2. Dentures are brushed in the same way as natural teeth; be sure to rinse them well. 3.The denture cup should be labeled with the patient’s name and room number. 4.Never use hot water to rinse the dentures as it could warp them; use cool or lukewarm water. 5.The patient’s gums and soft tissues should be cared for at least twice per day while the dentures are out of the mouth; a soft-bristled toothbrush, swab, or gauze-covered tongue blade dipped in mouthwash should be used to cleanse the gums, tongue, and soft tissues. Patients With Mouth Complications. The following problems are common in patients receiving chemotherapy and radiation therapy: 1.Bleeding. *Observe the patient’s mouth frequently for the amount of bleeding present and the specific areas. *Do not floss the patient’s teeth; use a Water-pik®. *Brush the teeth and clean the mouth using one of the following methods: o1 Brush the teeth carefully with a very soft toothbrush. o2 Wrap a tongue blade with a gauze sponge saturated with a prescribed solution; carefully swab the teeth and mouth. Do not use lemon/glycerine swabs or commercial mouthwash because they contain alcohol, which causes burning. 2.Infection. *Observe the patient’s mouth for appearance, integrity, and general condition. *Wear clean gloves during the procedure. *Obtain a culture, if ordered. *Do not floss the teeth if the mouth is irritated or painful. *Assist the patient with brushing the teeth and cleaning the mouth, using a soft toothbrush or a gauze-padded tongue blade. *Rinse the mouth with water and the prescribed solution, if ordered. 3.Ulcerations, to include stomatitis. *Basic procedure for the patient with an infection should be followed. *If the patient’s mouth is extremely painful, rinsing the mouth with a local anesthetic, as prescribed by a physician, may be necessary. *Mouthwash and other solutions which contain alcohol should not be used for the patient with ulcerations as they are frequently very painful. Unconscious Patients. 1.Oral care should be performed at least every four hours. 2.Oral suctioning may be required for the unconscious patient to prevent aspiration. 3.A soft toothbrush or gauze-padded tongue blade may be used to clean the teeth and mouth. 4.The patient should be positioned in the lateral position with the head turned toward the side to provide for drainage and to prevent aspiration. source http://www.brooksidepress.org/Products/Nursing_Fundamentals_1/lesson_3_Section_1.htm
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| SIGNIFICANT NURSING OBSERVATIONS DURING THE BATHING PROCEDURE Posted: 02 Jan 2011 08:43 AM PST Physical Observations. 1.Observe the skin under good, natural light. 2.Any abnormal skin condition should be described as to its location, color, and size and how it feels to the patient. 3.The following skin observations should be checked upon admission and daily thereafter: *Cleanliness. *Odor. May be caused by sweat secreted by the sweat glands; by abnormal conditions, such as infection or kidney disease; or by bodily discharges (urine, feces) that need to be cleaned. *Texture. Smooth and elastic or dry and rough; nutritional deficiencies can influence skin texture. *Color. Reddened areas that could indicate pressure, cyanosis (bluish tinge) or jaundice (yellowish tinge). *Temperature. Hot skin could mean fever; cold skin could mean poor circulation. *Sensitivity. Pain, tenderness, itching, or burning. *Swelling (edema). Stretched or tight appearing; usually begins in the ankles or legs or any other dependent part; may be associated with injury. *Skin lesions. Rashes, growths, or breaks in the skin. 4.Observations may begin at the head (scalp) and proceed to the feet in a systematic manner. Psychosocial Observations. 1.Problems in this area may be related to the patient’s present problems. 2.The time of the patient’s bath may be a good time to find out more about the patient’s psychosocial needs. 3.Remember that the patient’s nonverbal communication may tell you much about the way he/she is feeling. source :http://www.brooksidepress.org/Products/Nursing_Fundamentals_1/lesson_3_Section_1.htm
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| PROVIDING FOR SELECTED PATIENT NEEDS WHILE BATHING A PATIENT SAFETY Posted: 02 Jan 2011 08:39 AM PST 1. The bed may be in the high position during the patient’s bed bath, but should be placed in the low position upon completion. The side rails should be up after the patient’s bath for the patient who is confined to the bed. Side rails help to prevent falls for the elderly patient or the patient who is confused or has a decreased level of consciousness. The legal aspect requires diligence on the part of nursing personnel. 3. The patient’s call light should be within easy reach to prevent the need to reach for it and risk falling out of bed and to provide easy access in case of pain or distress. Fire safety in the patient care area calls for the following rules: No smoking in bed. No smoking if oxygen is in use. 5. Always wash your hands before entering and upon leaving the patient’s room. Privacy. 1. Respect for the patient’s privacy decreases the patient’s emotional discomfort during personal care. Keep the door to the patient’s room closed. Pull the curtains around the unit and drape the patient’s body during care. Allow the patient to complete as much personal care as possible; self-care is appropriate and provides additional privacy. Comfort. 1. Ensure a comfortable temperature in the patient’s room. Close any windows and the door to the patient’s room to prevent drafts and chilling. Drape the patient appropriately during the bath. For a bedside bath, maintain bath water between 110oF and 115oF; change the water as it cools and/or gets soapy.
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| TIMING OF PATIENT HYGIENE PROCEDURES Posted: 02 Jan 2011 08:38 AM PST TIMING OF PATIENT HYGIENE PROCEDURES A patient’s bath may be given at any time, according to the patient’s needs, but certain routines are generally followed on a ward. Morning Care. 1.The procedure followed in the morning affects the patient’s comfort throughout the day. 2.Each morning before breakfast, the patient should be assisted to the bathroom, or a bedpan or urinal should be provided, according to the patient’s activity level. 3.The patient is then given the opportunity to wash his/her hands and face and brush his/her teeth. The bed linen is straightened, and the overbed table is cleaned in preparation for the breakfast tray. 4.After breakfast, the patient has a complete bath (type is dependent upon the patient’s condition and mobility), mouth care, a change of clothing, and a back massage. 5.Bed linens are changed; and the unit is cleaned and straightened to provide a comfortable and safe environment for the patient. Evening Care. 1.The care the patient receives at the end of the day greatly influences the patient’s level of relaxation and ability to sleep. 2.An opportunity is provided for elimination; the patient’s hands and face are washed; the teeth are brushed; a back rub is given. 3.Bed linens are straightened; the patient’s unit is straightened to ensure comfort and safety. It is important that there are no items, which the patient could slip on, or fall over, such as chairs or linens, on the floor. source http://www.brooksidepress.org/Products/Nursing_Fundamentals_1/lesson_3_Section_1.htm
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| NURSING INTERVENTION TO PREVENT SKIN BREAKDOWN Posted: 02 Jan 2011 08:33 AM PST NURSING INTERVENTION TO PREVENT SKIN BREAKDOWN
source http://www.brooksidepress.org/Products/Nursing_Fundamentals_1/lesson_3_Section_1.htm
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