HYGIENE AND CLIENT SAFETY
Personal hygiene is the basic concept of cleaning, grooming and caring for our bodies. While it is an important part of our daily lives at home, personal hygiene isnt just about combed shiny hair and brushed teeth; its important for worker health and safety in the workplace. Workers who pay attention to personal hygiene can prevent the spread of germs and disease, reduce their exposures to chemicals and contaminants, and avoid developing skin allergies, skin conditions, and chemical sensitivities.
The first principle of good hygiene is to avoid an exposure by forming a barrier over the skin with personal protective equipment (PPE) such as gloves, coveralls, and boots. It is important to check the PPE often for excessive contamination, wear, tears, cuts, or pinholes. Workers should clean, decontaminate or replace protective equipment frequently to make sure it doesnt collect or absorb irritants. If protective equipment becomes too soiled during the job, the worker should stop and replace it with clean equipment.
Basic hand washing and skin care can prevent work exposures and disease. Good washing and scrubbing with water and soap helps to remove germs, contaminants, and chemicals. It can also prevent exposure by ingestion and cross-contamination of the surfaces and objects we touch.
Workers should periodically wash their hands on the during the day. In some jobs, regular hand washing is required by law. Hand washing is important before and after using the restroom and before or after certain activities. Workers should wash their hands before, during, and after preparing food and before they take breaks at work to eat, drink or smoke. To control the spread of germs that can cause the flu or common cold, workers should wash their hands whenever they cough, sneeze, or blow their noses, and whenever they are around someone that is sick.
Hand washing involves more than a quick rinse under a faucet. To wash hands properly, workers should first wet them under the faucet and then use liquid or bar soap. Hands should be held out of the water until all skin surfaces are scrubbed and lathered for at least twenty seconds. Workers can then rinse with clean water and dry their hands with a disposable towel. To wash hands with a hand sanitizer, workers should apply the appropriate amount of sanitizer into the palm of the hand, and then rub hands together until they are dry, being careful to cover all surfaces of the hands. For some job activities, hand sanitizers are not an acceptable means of hand cleaning. Showering and face-washing after work is also a good idea. Proper personal hygiene and hand protection can help keep workers productive and on the job. Be safely clean with good hygiene.
BATHING A CLIENT IN BED
Bathing of clients is an essential component of nursing care. Whether the nurse performs the bath or delegates the activity to another health care provider, the nurse retains the responsibility for ensuring that the hygienic needs of the client are met. The type of bath provided will depend on the purpose of the bath and the client’s self-care ability. The two categories of baths are cleaning and therapeutic. Cleaning baths are provided as routine client care. The purpose of a cleaning bath is personal hygiene. Following are the five types of cleaning baths:
1. Shower
2. Tub
3. Self-help, or assisted bed bath
4. Complete bed bath
5. Partial bath
For clients who are confined to bed, the bed bath is used to provide hygienic care. There are several variations of bed bath depending on the client’s ability to assist with care. The complete bed bath is provided to dependent clients confined to bed. The nurse washes the client’s entire body during a complete bed bath. A partial bed bath and a self-help bed bath are variations of the complete bed bath.
ASSESSMENT
1. Assess the client’s level of ability to assist with the bath. Determine if the client is able to follow directions. Check the client’s ability to assist with cleaning any portion of the body.
2. Assess the client’s level of comfort with the procedure. Check into potential cultural, sexual, or generational issues. Determine whether the client is uncomfortable, tense, or nervous about being bathed by someone else.
3. Assess the environment. Verify that the equipment needed is available. Check whether clean, warm water is available. Determine whether the need for modesty and privacy can be met. The environment should be conducive to a clean and comfortable procedure.
PLANNING
Expected Outcomes:
1. Clients will be cleaned without damage to their skin.
2. Clients’ privacy will be maintained throughout the procedure.
3. Clients will participate in their own hygiene as much as possible.
4. Clients will not become overly tired or experience increased pain, cold, or discomfort as a result of the bath.
EQUIPMENT NEEDED:
1.
2. Washcloths
3.
4. Washbasin
5. Soap
6. Soap dish
7. Lotion
8. Deodorant
9. Powder
10. Clean gown
11. Clean linen
12. Disposable gloves
EVALUATION
• The client was cleaned adequately without skin damage.
• The client’s modesty was maintained throughout the procedure.
• The client participated in the procedure as much as possible.
• The client remained comfortable during the procedure.
ORAL CARE
The oral cavity functions in mastication, secretion of mucus to moisten and lubricate the digestive system, secretion of digestive enzymes, and absorption of essential nutrients. Common problems occurring in the oral cavity include the following:
• Bad breath (halitosis)
• Dental cavities (caries)
• Plaque
• Periodontal disease
• Inflammation of the gums (gingivitis)
• Inflammation of the oral mucosa (stomatitis)
Poor oral hygiene and loss of teeth may affect a client’s social interaction and body image as well as nutritional intake. Daily oral care is essential to maintain the integrity of the mucous membranes, teeth, gums, and lips. Through preventive measures, the oral cavity and teeth can be preserved. Preventive oral care consists of fluoride rinsing, flossing, and brushing.
ASSESSMENT
1. Assess whether the client is able to assist with oral care and to what extent. Promotes independence where possible.
2. Evaluate whether the client has an understanding of proper oral hygiene. Promotes self-care and teaching.
3. Check whether the client has dentures. Determines how oral care will be performed.
4. Assess the condition of the client’s mouth. Determines how oral care will be performed.
5. Assess whether inflammation, bleeding, infection, or ulceration is present. Determines how oral care will be performed. Determines the need for additional assessment and intervention.
6. Assess what cultural practices must be taken into consideration. Determines how oral care will be performed.
7. Assess whether there are any appliances or devices present in the client’s mouth such as braces, endotracheal tube, or bridgework. Determines how oral care will be performed.
8. Check that the proper equipment is available to perform oral care. Ensures a smooth procedure.
EQUIPMENT NEEDED (see Figure 4-8-2):
Brushing and Flossing
• Toothbrush
• Toothpaste with fluoride
• Emesis basin
•Towel
• Cup of water
• Nonsterile gloves
• Dental floss
• Mirror
• Lip moisturizer
DENTURE CARE
• Denture brush
• Denture cleaner
• Emesis basin
•Towel
• Cup of water
• Nonsterile gloves
• Tissue
• Denture cup
PERINEAL AND GENITAL CARE
The perineum is the external structure of the pelvic floor. It is composed of the skin and muscle surrounding the genitalia; it is the area between the scrotum and anus in the male and between the vulva and anus in the female. Care of the perineum and genitalia is directed toward maintaining a hygienic perineal environment.
Perineal and genital care is usually self-care; however, alterations in the client’s ability to perform self-care or alterations in the perineum and genitalia are reasons for nurses or other care providers to perform this skill.
Perineal and genital care is an emotionally and culturally difficult subject. Many cultures have specific beliefs and taboos regarding the perineal/genital area. Many people are embarrassed by the idea of anyone else seeing or touching their genitals, particularly a stranger.
The nurse must be aware of these possibilities when approaching genital/perineal care. In general, a professional, nonjudgmental approach will put the client more at ease with the procedure. Ask the client or the client’s caregiver if possible about any preferences the client may have in this area. During labor, amniotic fluid, urine, and feces may be expelled.While the client is ambulatory, encourage frequent peri-care with urination. If the client is anesthetized, perform frequent peri-care to prevent infection and before any invasive procedure such as vaginal examination, internal monitoring, or rupture of membranes.
Obstetrics presents special perineal care needs. In the postpartum period for vaginal birth: If the client is ambulatory, perform peri-care at the toilet. Use a peri-bottle with water at a temperature comfortable to the mother. Teach her to use the entire contents of the bottle and spray from the front to the back, across the perineum (not into the vagina) to remove urine and fecal material. If there is an episiotomy or laceration, she will want to blot with tissue or a washcloth until the perineum is no longer sore. Also, if perineal medications are to be used (witch hazel, topical anesthetics, and so on), teach the client to do this with each urination and to use a clean sanitary pad.
Ice should be considered to help alleviate pain and edema.
In the postpartum period for Cesarean birth: Until the mother is ambulatory, peri-care must be performed in the bed. Assist the mother to a bedpan, which has been padded underneath with waterproof pads. Use the water bottle to spray vaginal secretions from the perineum from the front to the back, across the perineum (not into the vagina). If an episiotomy is present, apply perineal medications as required and consider ice compresses for the first 12 hours to alleviate pain and edema. Once the mother is ambulatory, this care may be performed at the toilet and the client instructed in the technique.
ASSESSMENT
1. Evaluate client status: level of consciousness, ability to ambulate, ability to perform self-care, frequency of urination and defecation, skin condition. This allows the nurse to decide who, where, how, and when to perform perineal care.
2. Identify cultural preferences for perineal care. Perineal care is strongly associated with cultural practices, who may touch the perineal area and how as well as the proper way to “wipe.” To the extent possible, these preferences should be identified and incorporated into the client’s care.
3. Assess the client’s perineal health. Ask the client if he has any perineal/genital itching or discomfort. Ask the client if she has any urethral, vaginal, or anal discharge. Determines the presence of signs and symptoms that may need additional assessment and intervention.
4. Determine if the client is incontinent of urine or stool. Affects how the procedure will be done and what additional procedures may be necessary.
5. Assess whether the client has recently had perineal/genital surgery. Affects how the procedure will be done and what additional procedures may be necessary.
EQUIPMENT NEEDED:
1. Personal protective equipment (gloves, gown)
2. Toilet paper/washcloths
3. Waterproof pads
4. Cleansing solution if needed
5. Perineal wash bottle (fill with plain, warm water).
6. Water receptacle (bedpan or toilet if client is ambulatory)
7. Dry towels
8. Perineal treatment (i.e., ointment or lotions) if necessary
9. Linen receptacle
10. Room deodorizer
EYE CARE
Generally, the eye needs little daily care. Normally, eyes are continually cleansed by the production of tears and movement of eyelids over the eyes. Some clients, however, do have special eye care needs.
ASSESSMENT
1. Determine if the client is wearing contact lenses or has an ocular prosthesis. If the client is unable to answer questions, you will need to find out another way. Does it indicate in the client’s chart if the client wears contact lenses or has a prosthesis?
Are there family members present to ask? This will affect how eye care is given.
2. Are the eye care supplies needed available? If the client can tell you what kind of eye care products he normally uses, ask or have a family member bring his products from home. This will affect how eye care is given.
3. Assess whether the client can do his own eye care.
EQUIPMENT NEEDED:
Artificial Eye
• Storage container
• Mild soap
•3 3 3 Gauze sponges
• Cotton balls
•Towel
• Emesis basins
• Eye irrigation syringe (optional)
• Running water
• Sterile gloves
• Biohazard bag
• Saline solution
Contact Lenses
• Lens container
• Soaking solution—type used by client
•Towel
HAIR AND SCALP CARE
Healthy hair is dependent on maintaining a healthy scalp. Combing, brushing, and shampooing stimulates circulation; removes dead cells, dirt, and debris; and distributes hair oils, preventing skin irritation and producing a healthy sheen. These procedures, and styling the hair, relax clients and improve their appearance and self-esteem.
ASSESSMENT
1. Assess client need for hair and scalp care to determine what procedures need to be done.
2. Assess structure and functional integrity of the hair and scalp, identifying possible need for medicated shampoo, conditioners, or treatments.
3. Assess client preferences for frequency of care and care products to determine possible allergies to products and client preferences for personal hygiene.
4. Confirm client is not allergic to latex or any ingredients/products to be used during the procedure to prevent adverse reactions to the procedures.
5. Assess client’s medical condition and health status such as contraindications to head manipulation and ability to tolerate sitting, prone, or side-lying positions to prevent adverse reactions to the procedures.
6. Assess client’s knowledge of the procedure to determine possible teaching needed.
7. Assess client’s ability to perform/assist with the procedure to determine and plan how the procedure will be performed.
Equipment Needed (see Figure 4-11-2):
• Bedside/chair-side table
• Clean comb (with dull teeth) and hairbrush (soft but firm bristles)
• Washcloth
• 2 or 3 bath towels
• Shampoo tray
• Washbasin, plastic trash can, or pail
• Water pitchers/container: 1–2 large (1–2 gal.) and
1 small (2–3 cup)
• Linen saver or plastic trash bag
• Nonsterile gloves
• Liquid shampoo
• Other: bath thermometer, conditioner, detangler (spray is convenient)
• Hair dryer (safety approved)
HAND AND FOOT CARE
Daily hand and foot care maintains the structure and function of two major body areas vital to mobility and to the ability to carry out activities of daily living.
It promotes cleanliness, controls odor, prevents infection, and stimulates circulation.
ASSESSMENT
1. Assess skin integrity to identify early intervention for abnormalities.
2. Assess nail integrity to identify present or potential disease or harm to skin.
3. Assess structural integrity of hands and feet to identify special needs of hands or feet.
4. Assess functional status of hands and feet to identify special needs of hands or feet.
5. Identify allergies prior to the procedure to avoid inadvertent client exposure.
6. Assess client’s knowledge and performance ability of basic hand and foot care to identify baselines for client education.
7. Assess client’s preferences for cleansing agents, moisturizing agents, protective devices (socks, shoes, slippers), and equipment to be used in the procedure, and evaluate them in light of function and safety.
EQUIPMENT NEEDED :
• Gloves
• Bath/washbasin (plastic dishpan, bucket, or wastebasket will work as well)
• Warm water
• Towels (1–2)
• Washcloth (soft but textured)
• Soap (liquid preferable) or Cetaphil
• Nail brush (soft)
• Cotton-tip applicators
• Nail clippers: one for fingernails, plier-type for toenails
• Nail scissors (for cutting hangnails)
• Emery board
• Talcum powder (water absorbent without cornstarch)
• Body cream, petrolatum, or oil
• Optional/bath blanket
• Optional/linen-saver pad
• Optional/pillow
• Optional/cotton or lamb’s wool pieces
• Optional/2 3 2 gauze pads
• Optional/bath thermometer
SHAVING A CLIENT
Shaving the male client is done to remove facial hair if the client is unable to complete this selfcare. It is usually done after a bath or shower and as often as required to remove unwanted facial hair. Most men shave every day, although the facial hair of older clients does not grow as rapidly. If a beard or mustache is present, it should be groomed daily and trimmed as appropriate. Do not shave off beards or mustaches without the client’s permission.
ASSESSMENT
1. Assess whether the client is able to perform selfcare. Promote independence when possible.
2. Assess the client’s skin for areas of redness, skin breakdown, moles, or skin lesions. Shaving could irritate the skin further.
3. Assess whether the client has a bleeding tendency or is on anticoagulants. If there is an increased risk of bleeding, an electric razor should be used.
4. If the client prefers to shave himself, assess the client’s ability to manipulate the razor. The client must be able to shave safely.
5. Assess the client’s preference for the type of shaving, type of equipment, and type of lotion (if there are options). This promotes independence.
SHOWER
Most ambulatory clients are capable of taking a shower. Clients with limited physical ability can be accommodated by placing a waterproof chair in the shower (Figure 31-28). The nurse provides minimal assistance with a shower. The Nursing Checklist discusses guidelines for helping clients with tub or shower baths.
TUB
Clients frequently prefer and enjoy tub baths. A tub bath permits washing and rinsing in the tub. Tub baths can also be therapeutic. Clients with limited physical ability should be assisted with entering and exiting the tub.
SELF-HELP
A self-help, or assisted, bed bath is used to provide hygienic care for clients who are confined to bed. In the self-help (assisted) bed bath, the nurse prepares bath equipment but provides minimal assistance. This assistance is usually limited to washing difficult-to-reach body areas such as the feet and back.
COMPLETE BED
A complete bed bath is provided to dependent clients confined to bed. The nurse washes the client’s entire body during a complete bed bath. Procedure 31-9 outlines the actions involved in giving a complete bed bath.
PARTIAL
A partial (or abbreviated) bath consists of cleaning only body areas that would cause discomfort or odor if not washed thoroughly. These areas are the face, axillae, hands, and perineal area. The nurse or client may perform a partial bath depending on the client’s self-care ability. Partial baths may be performed with the client lying in bed or standing at the sink.
RISK FOR INFECTION
Risk for infection is the state in which an individual is at increased risk for being invaded by pathogenic organisms (NANDA, 2001). The risk factors that increase the client’s vulnerability to infections are:
• Inadequate primary defenses (broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH of secretions, and altered peristalsis)
• Inadequate secondary defenses, acquired immunity, and immunosuppression
• Tissue destruction and increased environmental exposure
• Chronic diseases and malnutrition.
PREVENT FALLS
Falls occur among clients who are weak, fatigued, uncoordinated, paralyzed, confused, or disoriented. The data obtained from the client’s fall risk appraisal will identify which clients require special nursing measures to prevent falls. The risk for falls can be reduced by:
1. Good supervision
2. Orienting clients to the environment and call system
3. Providing ambulatory aids (wheelchairs or walkers)
4. Placing personal belongings on tables near the bed
5. Keeping hospital beds in lowest position with side rails up
6. Using nonslip mats and rugs
7. Illuminating the environment
Although falls do not necessarily constitute malpractice, they are a major reason why nurses are involved in lawsuits (Ignatavicius, 2000). Sullivan and Badros (1999) and Ignatavicius (2000) identify the need for registered nurses to assess patients’ risk of falls and implement evidence-based interventions. The concept of evidencebased practice (EBP) refers to health care based on research findings, expert consensus, or both (Davis & Madigan, 1999).
APPLY RESTRAINTS
Restraints are protective devices used to limit the physical activity of a client or to immobilize a client or extremity. Restraints are used to protect the client, allow for treatment in a safe environment, and reduce the risk of injury to others.
The use of restraints has become very controversial because of client injuries from restraints. The Omnibus Budget Reconciliation Act (OBRA) of 1987 and the Health Care Financing Administration regulations of 1999 governing client’s rights are forcing a reexamination of how clients are cared for in acute and critical care settings (Bower & McCullough, 2000). In response to more individualized care regarding the use of restraints, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revised their standards for restraint use with nonpsychiatric clients; see the accompanying display for JCAHO-revised standards.
Restraints used to either limit physical activity or immobilize a client can be physical or chemical. Physical restraints reduce the client’s movement through the application of a device.
Most states require a physician’s order for the application of physical restraints. Chemical restraints are medications used to control the client’s behavior.
Commonly used chemical restraints are anxiolytics and sedatives. This chapter limits discussion to the common types of physical restraints:
• Jacket (body restraint): A sleeveless vest with straps that cross in front or back of the client and are tied to the bed frame or chair legs (Figure 31-6A).
• Belt: Straps or belts applied across the client to secure him or her to the stretcher, bed, or wheelchair (Figure 31-6B).
• Mitten or hand: Enclosed cloth material applied over the client’s hand to prevent injury from scratching (Figure 31-
• Elbow: A combination of fabric and plastic or wooden tongue blades that immobilize the elbow to prevent flexion (Figure 31-6D).
• Limb or extremity: Cloth devices that immobilize one or all limbs by securely tying the restraint to the bed frame or chair (Figure 31-6E).
• Mummy: A blanket or sheet that is folded around the child to limit movement. Mummy restraints are used to perform procedures on children (Figure 31-
The nursing plan of care should include safety measures to reduce the potential for injury from restraints (Procedure 31-1). Additional safety measures to observe
when using restraint devices are:
• Restraints can be changed and released easily, using only a clove hitch knot, as shown in Procedure 31-1.
• Restraints should not interfere with any treatments (e.g., intravenous therapy) or aggravate the client’s health problem.
• There should be enough slack on the straps so that the client can move both arms and legs and for range-of-motion exercises.
• At least once every 2 hours, the nurse must perform circulation and neurological exams, assessing the color, sensation, temperature, motion, and capillary refill in the area distal to the restraint.
• There should be a provision for psychological support of client and significant others.
nonslip pads to rugs, cleaning up spills immediately, and removing objects that could fall from the tops of appliances.
REDUCE BATHROOM HAZARDS
Bathrooms pose a threat to the client in the home because of the presence of water and storage of medication. Common bathroom accidents are falls, scalds or burns, and poisonings. Bathroom accidents can be reduced by the use of grab bars near the tub, shower, and toilet; nonslip mats in the tub and shower; and a secured bathroom rug near the tub or shower. Other safety measures include checking the temperature of the water before entering tub or shower; checking the thermostat setting on the water heater; and storing medications in a locked cabinet, out of reach of children or disoriented or confused adults.
PREVENT FIRE
Fire is a potential danger to all people in an institutional or home environment. Immobilized or incapacitated clients are at increased risk during a fire. Common causes of fire are smoking in bed, discarding cigarette butts in trash cans, and faulty electrical equipment. Fire occurs with the interaction of three elements: sufficient heat to ignite the fire, combustible material, and oxygen to support the fire.
Nursing goals are fire prevention and protection of clients during a fire. Nursing interventions aimed at preventing or reducing the risk of fire include:
• Clearly marking fire exits
• Knowing locations of fire extinguishers and their operation
• Practicing fire evacuation procedures
• Posting emergency phone numbers by all telephones
• Keeping open spaces and hallways clear of clutter
• Checking electrical cords and outlets for exposed or damaged wires
• Reporting identified electrical hazards
• Educating clients about fire hazards
In the event of a fire, follow institutional policy and procedures for fire containment and evacuation. Nursing interventions during a fire are directed at protecting the client from injury and containing the fire. Nurses should be familiar with the location of fire alarm pull boxes. If a fire occurs, the nurse should utilize the nearest fire box for notification and move clients to safety.
Nurses should be familiar with the use of fire extinguishers and their locations. The fire extinguisher should be directed toward the base of the fire. The four types of fire extinguishers used are water, carbon dioxide, regular dry chemical, and multipurpose dry chemical. Each type of fire extinguisher is used for a specific class of fire, as discussed in Table 31-5.
MEDICAL ASEPSIS
Medical asepsis uses practices to reduce the number, growth, and spread of microorganisms. Medical asepsis is also referred to as “clean technique.” Objects are generally referred to as “clean” or “dirty” in medical asepsis.
Clean objects are considered to have the presence of some microorganisms that are usually not pathogenic. Dirty (soiled) objects are considered to have a high number of microorganisms, with some that are potentially pathogenic. Common medical aseptic measures used for clean or dirty objects are handwashing, gloves, changing linens daily, and cleaning floors and hospital furniture daily. Refer to Appendix D for Your Guide to Gloves, based on the CDC’s standard precautions.
HANDWASHING
Handwashing is the rubbing together of all surfaces and crevices of the hands using a soap or chemical and water. Handwashing is a component of all types of isolation precautions and is the most basic and effective infection control measure that prevents and controls the transmission of infectious agents. The CDC (2000) recommends vigorous scrubbing with warm, soapy water for at least 15 seconds to prevent the transfer of germs.
The three essential elements of handwashing are soap or chemical, water, and friction (see Procedure 31-2 for the proper steps of handwashing). Soaps that contain antimicrobial agents are frequently used in high-risk areas such as emergency departments and nurseries.
Friction is the most important element of the three because it physically removes soil and transient flora. Handwashing should be performed after arriving at
work, before leaving work, between client contacts, after removing gloves, when hands are visibly soiled, before eating, after excretion of body waste (urination and defecation), after contact with body fluids, before and after performing invasive procedures, and after handling contaminated equipment. The exact duration of time required for handwashing is not known. A washing time of 10 to 15 seconds is recommended to remove transient flora from the hands. High-risk areas, such as nurseries, usually require about a 2-minute handwash. Soiled hands usually require more time (CDC, 2000).
