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COMFORT AND SAFETY MEASURES

PROVIDING PERSONAL HYGIENE

PERSONAL HYGIENE

● Measure for personal cleanliness and grooming that promotes physical and
psychological well-being.

PROVIDING SCHEDULED HYGIENE CARE

1. Early Morning Care

● Nursing personnel on the night shift provides basic hygiene to patients
getting ready for breakfast, scheduled test or early morning surgery.
● It includes offering a bedpan or urinal to the patient; providing oral care, hair
care and washing client’s hands and face.

2. Morning Care (AM Care)

● Is performed after breakfast, the nurse assists a bedpan or a urinal to
patients confined to bed; providing a bath or shower, providing oral, foot, nail
and hair care; giving a back rub, changing patient’s gown or pajamas; changing
bed linens; fixing the patient’s bedside unit and room.
● This is often referred to as “complete AM care”

3. Afternoon Care (PM Care)

● Care is given after lunch and preparing the patient to receive visitors.
● Nursing measures includes washing the hands and face, assisting with the
oral care, offering a bedpan or urinal and straightening bed linens.

4. Hour of Sleep Care (HS Care)

● Care given before the patient retires, that helps the patient relax to promotes
sleep.
● The nurse offers assistance with toileting, washing of face and hands;
providing oral care, changing soiled linen, gowns or pajamas; giving a back
massage; offering a bedpan or urinal to non-ambulatory and positioning for
comfort.

5. As Needed Care (PRN Care)

● The nurse offers individual hygienic measures as needed such as oral care
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every 2 hours or changing bed linens if soiled and changing position as needed.

Factors Influencing Individual Hygienic Practices

1. Culture
2. Religion
3. Environment
4. Developmental level
5. Health and energy
6. Personal preferences

Common Skin Problems

Problem and Appearance Nursing Implications

1. ABRASION
● Superficial layers 1. Prone to infection; therefore, wound
of the skin are scraped should be kept clean and dry.
or rubbed away. Area 2. Do not wear rings or jewelry when
is reddened and may providing care to avoid causing abrasions to
have localized clients.
bleeding or serous 3. Lift, do not pull, a client across a bed.
weeping. 4. Use two or more people for assistance.

2. EXCESSIVE DRYNESS
● Skin can appear
1. Prone to infection if the skin cracks; therefore,
flaky and rough.
provide alcohol-free lotions to moisturize the skin
and prevent cracking.

2. Bathe client less frequently; use no soap, or use

nonirritating soap and limit its use. Rinse skin
thoroughly because soap can be irritating and
drying.

3. Encourage increased fluid intake if health permits

to prevent dehydration.

3. AMMONIA DERMATITIS
(DIAPER RASH)
● Caused by skin 1. Keep skin dry and clean by applying
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bacteria reacting with protective ointments containing zinc oxide to

urea in the urine. The areas at risk (e.g., buttocks and perineum).
skin becomes 2. Boil an infant’s diapers or wash them
reddened and is sore. with an antibacterial detergent to prevent
infection. Rinse diapers well because detergent
is irritating to an infant’s skin.

6. HIRSUTISM
● Excessive hair on 1. Remove unwanted hair by using
a person’s body and depilatories, shaving, electrolysis, or tweezing.
face, particularly in 2. Enhance client’s self-concept.
women.

ETIOLOGIES OF SELF-CARE DEFICITS

● Decreased or lack of motivation
● Weakness or tiredness
● Pain or discomfort
● Perceptual or cognitive impairment
● Inability to perceive body part or spatial relationship
● Neuromuscular or musculoskeletal impairment
● Medically imposed restriction
● Therapeutic procedure restraining mobility (e.g., intravenous infusion, cast)
● Severe anxiety
● Environmental barriers

General Guidelines for Skin Care

1. Intact, healthy skin is the body’s first line of defense.
2. The degree to which the skin protects the underlying tissues from injury
depends on the general health of the cells, the amount of subcutaneous tissue,
and the dryness of the skin.
3. Moisture in contact with the skin for more than a short time can result in
increased bacterial growth and irritation.
4. Body odors are caused by resident skin bacteria acting on body secretions.
5. Skin sensitivity to irritation and injury varies among individuals and in
accordance with their health.
6. Agents used for skin care have selective actions and purposes.

BATHING
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Definition:
● Removes accumulated oil, perspiration, dead skin cells and some bacteria. It
also stimulate circulation.
● Excess bathing can interfere with the intended lubricating effect of the
sebum, causing dryness of the skin.

AGENTS COMMONLY USED ON THE SKIN

1. Soap ● Lowers surface tension and thus helps
in cleaning. Some soaps contain
antibacterial agents, which can change the
natural flora of the skin.

2. Chlorhexidine ● A disposable cloth saturated with 2%

gluconate (CHG) CHG and skin-moisturizing substances. An
advantage is continued antimicrobial
activity after application. These cloths are
often used in critical-care settings.

3. Bath oil ● Used in bathwater; provides an oily

film on the skin that softens and prevents
chapping. Oils can make the tub surface
slippery, and clients should be instructed
about safety measures (e.g., using nonskid
tub surface or mat).

4. Skin cream, lotion ● Provides a film on the skin that

prevents evaporation and therefore
chapping.

5. Powder ● Can be used to absorb water and

prevent friction. For example, powder under
the breasts can prevent skin irritation. Some
powders are antibacterial.

6. Deodorant ● Masks or diminishes body odors.

7. Antiperspirant ● Reduces the amount of perspiration.

CATEGORIES:
A. Cleaning bath
B. Therapeutic bath
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Cleansing Bath: are given to clients chiefly for hygiene purposes.

Types:
1. Complete bed bath - The nurse washes the entire body of a dependent client in
bed.
2. Self-help bed bath - Clients confined to bed but are able to bathe themselves
with the help from the nurse for washing the back and perhaps the feet.

3. Partial bath (abbreviated bath)

● Only the parts of the client’s body that may cause discomfort or odor, if
neglected, are washed: Ex. The face, the hands, axillae, perineal area and
back.
● Omitted are the arms, chest, abdomen, legs and feet.
● Some ambulance client prefers to take a partial bath at the sink.

4. Bag Bath
● This bag is a commercial prepared product that contains 10 to 12 presoaked
disposable washcloths that contains no-rinse cleanser solution. Each area of the
body is cleaned with a different cloth and then air dried.
● Because the body is not rubbed dry, the emollient in the solution remains on the
skin.

5. Towel Bath
● This bath is similar to a bag bath but uses regular towels.
● It is useful for clients who are bedridden and clients with dementia. The
client is covered and kept warm throughout the bathing process by a bath
blanket.
● The nurse gradually replaces the bath blanket with a large towel that has
been soaked with warm water and no-rinse soap.
● The client is then gently massaged with the warm, wet, soapy towel. The
wet towel is replaced with a large dry towel for drying the client’s skin.

6. Tub Bath
● Tub baths are often preferred to bed baths because it is easier to wash and rinse
in a tub.
● The amount of assistance, the nurse offers depends on the ability of the clients.
There are specially designed tubs for dependent clients. These tubs greatly
reduce the work of the nurse in lifting a client in and out of the tub and offer
greater benefits than a sponge bath in bed.
7. Shower
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● Many ambulatory clients are able to use shower facilities and require only
minimal assistance from the nurse.
● The wheels on the shower chair allow clients to be transported from their room
to the shower. The shower chair also has a commode seat to facilitate cleansing
of the client’s perineal area during the shower process

2. THERAPEUTIC BATHS
● Are given for physical effects, such as to soothe irritated skin or to treat an area.
● Medications may be placed in the water. A therapeutic bath is generally taken in
a tub one- third or one-half full. The client remains in the bath for a designated
time, often 20-30 minutes. The area to be treated needs to be immersed in the
solution.
Ex. Sitz bath
Tepid sponge bath

BATHING AN ADULT CLIENT

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Purposes:
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● To remove transient microorganisms, body secretions and excretions, and

dead skin cells
● To stimulate circulation to the skin
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● To promote a sense of well-being

● To produce relaxation and comfort
● To prevent and eliminate unpleasant body odors

ASSESSMENT
Assess
● Physical or emotional factors (e.g., fatigue, sensitivity to cold, need for control,
anxiety or fear)
● Condition of the skin (color, texture and turgor, presence of pigmented spots,
temperature, lesions, excoriations, abrasions, and bruises). Areas of erythema
(redness) on the sacrum, bony prominences, and heels should be assessed for
possible pressure sores
● 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 client’s bathing process (e.g.,
mobility, strength, cognition)
● Need for use of clean gloves during the bath
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EQUIPMENT
● Washbasin and warm water
● Personal hygiene supplies (deodorant, lotion, and others)
● Soap and soap dish
● Emollient and skin barrier, as indicated
● Towels (2)
● Washcloths (2)
● Bath blanket
● Gown or pajamas
● Additional bed linens and towels, if required
● Bedpan or urinal
● Laundry bag
● Clean gloves, if appropriate (e.g., presence of body fluids or open lesions)
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PROCEDURE:

STEPS RATIONALE

1. Check the doctor’s order for any To prevent further injury while doing the
precautionary measures pertaining bathing activities.
to patient’s movement.

2. Identify and discuss the procedure This promotes reassurance and provides
with the client. Assess the client’s knowledge about the procedure.
ability to assist in bathing as well as Dialogue also encourages client
with personal hygiene preference. participation and allows for individual
nursing care.
3. Bring the necessary equipment to This conserves time and energy.
the bedside stand or over bed table. Arranging items nears the client makes it
Wash hands. convenient and helps prevent stretching
and twisting the nerve/muscles.
4. Close curtains around bed and This ensures the patient’s privacy and
close the door to the room, if lessens the risk for loss of body heat
possible. Adjust the room during the bath.
temperature, if necessary.

5. Don gloves. Offer the bedpan or Voiding or defecating before a bath

urinal. lessens the likelihood that the bath with
be interrupted since the warm bath may
stimulate the urge to void.

6. Remove gloves and perform hand Hand hygiene deters the spread of
hygiene microorganisms.

7. Raises the bed to working height. Having the bed in a high position
prevents strain on the nurse’s back.

8. Put on gloves. Lower side rail Gloves prevent transmission of

nearer to you and assist patient to microorganisms. Having the patient
side of bed where you will work. positioned near the nurse and lowering
Have patient lie on his or her back. the side rail prevent unnecessary
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9. Loosen top covers and remove all stretching and twisting of muscles on
except the top sheet. Place bath the part of the nurse.
blanket over patient and then
remove top sheet while patient holds
bath blanket in place. If linen is to be
reused, fold it over a chair. Place
soiled linen in laundry bag. Take
care to prevent linen from coming in
contact with your clothing.

10. Put on gloves, if necessary. Fold Gloves are necessary if there is potential
the washcloth like a mitt on your
contact with blood or body fluids.
hand so that there are no loose ends
(Figure 1, Figure 2, Figure 3). Having loose ends of cloth drag across
the patient’s skin is uncomfortable.
Loose ends cool quickly and feel cold to
the patient.

11. Lay a towel across patient’s chest This prevents chilling and keeps the bath
and on top of bath blanket. blanket dry.

12. With no cleanser on the Soap is irritating to the eyes. Moving

washcloth, wipe one eye from the from the inner to the outer aspect of the
inner part of the eye, near the nose, eye prevents carrying debris toward the
to the outer part (Figure 4). Rinse or nasolacrimal duct. Rinsing or turning the
turn the cloth before washing the washcloth prevents spreading
other eye organisms from one eye to the other.

13. Bathe patient’s face, neck, and Use of emollients is recommended to

ears. Apply appropriate emollient. restore and maintain skin integrity
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(Voegeli, 2008a; Watkins, 2008; Brown &

Butcher, 2005).

14. Expose patient’s far arm and place The towel helps to keep the bed dry.
towel lengthwise under it. Using firm Washing the far side first eliminates
strokes, wash hand, arm, and axilla, contaminating a clean area once it is
lifting the arm as necessary to washed. Gentle friction stimulates
access axillary region (Figure 5). circulation and muscles and helps
Rinse, if necessary, and dry. Apply remove dirt, oil, and organisms. Long,
appropriate emollient. firm strokes are relaxing and more
comfortable than short, uneven strokes.
Rinsing is necessary when using some
cleansing products. Use of emollients is
recommended to restore and maintain
skin integrity (Voegeli, 2008a; Watkins,
2008; Brown & Butcher, 2005).

15. Place a folded towel on the bed Placing the hand in the basin of water is
next to the patient’s hand and put an additional comfort measure for the
basin on it. Soak the patient’s hand patient. It facilitates thorough washing
in basin (Figure 6). Wash, rinse if of the hands and between the fingers
necessary, and dry hand. Apply and aids in removing debris from under
appropriate emollient. the skin. Use of emollients is
recommended to restore and maintain
skin integrity (Voegeli, 2008a; Watkins,
2008; Brown & Butcher, 2005).

16. Repeat Actions 15 and 16 for the

arm nearer you. An option for the
shorter nurse or one susceptible to
back strain might be to bathe one
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side of the patient and move to the

other side of the bed to complete the
bath.

17. Spread a towel across patient’s Exposing, washing, rinsing, and drying
chest. Lower bath blanket to one part of the body at a time avoids
patient’s umbilical area. Wash, rinse, unnecessary exposure and chilling.
if necessary, and dry chest. Keep Areas of folds of skin may be sources of
chest covered with towel between odor and skin breakdown if not cleaned
the wash and rinse. Pay special and dried properly.
attention to the folds of skin under
the breasts.

18. Lower bath blanket to the perineal Keeping the bath blanket and towel in
area. Place a towel over patient’s place avoids exposure and chilling.
chest.

19. Wash, rinse, if necessary, and dry Skin-fold areas may be sources of odor
abdomen (Figure 7). Carefully and skin breakdown if not cleaned and
inspect and clean umbilical area dried properly.
and any abdominal folds or creases.

20. Return bath blanket to original The towel protects linens and prevents
position and expose far leg. Place the patient from feeling uncomfortable
towel under far leg. Using firm from a damp or wet bed. Washing from
strokes, wash, rinse, if necessary, ankle to groin with firm strokes promotes
and dry leg from ankle to knee and venous return. Use of emollients is
knee to groin (Figure 8). Apply recommended to restore and maintain
appropriate emollient. skin integrity (Voegeli, 2008a; Watkins,
2008; Brown & Butcher, 2005).

21. Wash, rinse if necessary, and dry Drying of the feet is important to prevent
the foot. Pay particular attention to irritation, possible skin breakdown, and
the areas between toes. Apply infections (National Institute on Aging
appropriate emollient. [NIA], 2009). Use of emollients is
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recommended to restore and maintain

skin integrity (Voegeli, 2008a; Watkins,
2008; Brown & Butcher, 2005).

22. Repeat Actions 21 and 22 for the

other leg and foot.

23. Make sure patient is covered with The bath blanket maintains warmth and
bath blanket. Change water and privacy. Clean, warm water prevents
washcloth at this point or earlier, if chilling and maintains patient comfort.
necessary.

24. Assist patient to prone or side- Positioning the towel and bath blanket
lying position. Put on gloves, if not protects the patient’s privacy and
applied earlier. Position bath blanket provides warmth. Gloves prevent contact
and towel to expose only the back with body fluids.
and buttocks.

25. Wash, rinse, if necessary, and dry Fecal material near the anus may be a
back and buttocks area (Figure 9). source of microorganisms. Prolonged
Pay particular attention to cleansing pressure on the sacral area or other bony
between gluteal folds, and observe prominences may compromise
for any redness or skin break- down circulation and lead to development of
in the sacral area. decubitus ulcer.

26. If not contraindicated, give patient A backrub improves circulation to the

a backrub. Back massage may be tissues and is an aid to relaxation. A
given also after perineal care. Apply backrub may be contraindicated in
appropriate emollient and/or skin patients with cardiovascular disease or
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barrier product. musculoskeletal injuries. Use of

emollients is recommended to restore
and maintain skin integrity (Voegeli,
2008a; Watkins, 2008; Brown & Butcher,
2005). Skin barriers protect the skin from
damage caused by excessive exposure
to water and irritants, such as urine and
feces (Voegeli, 2008a).

27. Raise the side rail. Refill basin with The washcloth, towel, and water are
clean water. Discard washcloth and contaminated after washing the
towel. Remove gloves and put on patient’s gluteal area. Changing to clean
clean gloves. supplies decreases the spread of
organisms from the anal area to the
genitals.

28. Clean perineal area or set patient Providing perineal self-care may
up so that he or she can complete decrease embarrassment for the patient.
perineal self-care. If the patient is Effective perineal care reduces odor and
unable, lower the side rail and decreases the risk for infection through
complete perineal care, following contamination. Skin barriers protect the
guidelines in the accompanying Skill skin from damage caused by excessive
Variation. Apply skin barrier, as exposure to water and irritants, such as
indicated. Raise side rail, remove urine and feces (Voegeli, 2008a).
gloves, and perform hand hygiene.

29. Help patient put on a clean gown This provides for the patient’s warmth
and assist with the use of other and comfort.
personal toiletries, such as
deodorant or cosmetics.

30. Protect pillow with towel and

groom patient’s hair.

31. When finished, make sure the Proper positioning with raised side rails
patient is comfortable, with the side and proper bed height provides for
rails up and the bed in the lowest patient comfort and safety.
position.

32. Change bed linens. Dispose of Removing PPE properly reduces the risk
soiled linens according to agency for infection transmission and
policy. Remove gloves and any other contamination of other items. Hand
PPE, if used. Perform hand hygiene. hygiene prevents the spread of
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microorganisms.

33. Record any significant A careful recording is important for

observations. Share to attending planning and individualizing the client’s
physician (AP) and nurse in charge. care.

PERFORMING PERINEAL CLEANSING

PROCEDURE:

STEPS

1. Assemble supplies and provide for privacy.

2. Explain the procedure to the patient, perform hand hygiene, and put on
disposable gloves.

3. Wash and rinse the groin area (both male and female patients).
For a female patient
● Spread the labia and move the washcloth from the pubic area toward
the anal area to prevent carrying organisms from the anal area back over
the genital area (Figure A).
● Always proceed from the least contaminated area to the most
contaminated area.
● Use a clean portion of the washcloth for each stroke. Rinse the washed
areas well with plain water.

For a male patient

● Clean the tip of the penis first, moving the washcloth in a circular motion
from the meatus out- ward.
● Wash the shaft of the penis using downward strokes toward the pubic
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area (Figure B). Always proceed from the least contaminated area to the most
contaminated area.
● Rinse the washed areas well with plain water. In an uncircumcised male
patient (teenage or older), retract the foreskin (prepuce) while washing the
penis.
● Pull the uncircumcised male patient’s foreskin back into place over the
glans penis to prevent constriction of the penis, which may result in
edema and tissue injury.
● It is not recommended to retract the foreskin for cleaning during infancy
and childhood, because injury and scarring could occur (MedlinePlus,
2007b).
● Wash and rinse the male patient’s scrotum. Handle the scrotum, which
houses the testicles, with care because the area is sensitive.

CARE OF HAIR
● The appearance of the hair often reflects a person’s feelings of self-concept
and socio-cultural well-being. Becoming familiar with hair care needs and
practices that may be different from our own is an important aspect of
providing nursing care to all clients.
● People who feel ill may not groom their hair as before.
● A dirty scalp and hair are itchy and uncomfortable and can have an odor.
● The hair may reflect state of health.

NURSING MANAGEMENT

Assessing: Assessment of the client’s hair, hair care practices and potential problems
includes a nursing history and physical assessment.

Nursing History:
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During the nursing history the nurse elicits data about usual hair care, self-care abilities,
history of hair or scalp problems and conditions known to affect the hair.

Chemotherapeutic agents and radiation of the head may cause alopecia (hair loss).
Hypothyroidism may cause hair to be thin, dry and brittle.

Physical Assessment:
Include problems on:
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1. Dandruff - often accompanied by itching. Appears as a diffuse scaling

of the scalp.
2. Hair loss - hair loss and growth are continual process. Some permanent
thinning of hair normally occurs with aging. Baldness, common in men, is
thought to be a hereditary problem.
3. Ticks - small grey-brown parasites that bite into tissue and suck blood.
● it transmits several diseases to people, in particular Rocky mountain
spotted fever, lyme disease and tularemia.
4. Pediculosis- Pediculosis (lice) are parasitic insects that infest mammals.
Three Common Kinds of Lice that Infest Humans:
a. Pediculosis capitis - the head louse usually found in the scalp.
b. Pediculosis corporis - the body louse. Tends to cling to clothing.
c. Pediculosis pubis - the crab louse. Stays in the pubic hair.
5. Hirsutism- the growth of excessive body hair is called hirsutism.
● The acceptance of the body hair in the axillae and the legs is largely
dictated by culture.

BRUSHING AND COMBING HAIR

To be healthy, hair needs to be brushed daily. Brushing has three major functions:
1.It stimulates the circulation of blood in the scalp.
2.It distributes the oil along the hair shaft.
3.It helps to arrange the hair.

● Hair must be combed and brushed at least once or twice a day for a confined
client to prevent from becoming matted.
● A brush with stiff bristles provides best stimulation to blood circulation in the
scalp. The bristles should not be so sharp that injure the client’s scalp.
● A comb with dull, even teeth is advisable; a comb with sharp teeth might injure
the scalp. Combs that are too fine can pull and break the hair.

SHAMPOO IN BED
●Hair accumulates the same dirt and oil as the skin. It should be washed as often as
necessary to keep it clean. A weekly shampoo may be sufficient for some
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persons whereas others may prefer to perform this aspect of personal hygiene daily.
The nurse may need to shampoo the hair of those clients who cannot get out of
bed for bathing and showering or who lack the strength or ability to
independently care for their hair.

Definition: Washing of the hair with the use of shampoo or bath soap as often as
necessary to keep it clean.

Purposes:
1. To cleanse the hair and scalp.
2. To maintain or improve self-esteem.
3. To treat conditions of the scalp with topical applications of medications.
4. To remove substances, such as blood, body secretions or electrode jelly (used
when an electroencephalogram or other such study is done.)
5. To stimulate the blood circulation to the scalp through massage.

ASSESSMENT
● Assess the patient’s hygiene preferences: frequency, time of day, and
type of hygiene products. Assess for any physical activity limitations.
● Assess the patient’s ability to get out of bed to have his or her hair
washed. If the physician’s orders allow it and patient is physically able to
wash his or her hair in the shower, the patient may prefer to do so.
● If the patient cannot tolerate being out of bed or is not allowed to do so,
perform a bed shampoo. Assess for any activity or positioning limitations.
Inspect the patient’s scalp for any cuts, lesions, or bumps. Note any
flaking, drying, or excessive oiliness.
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EQUIPMENT
● Water pitcher
● Warm water

● Shampoo trough

● Shampoo
● Conditioner (optional)
● Disposable gloves
● Additional PPE, as indicated
● Protective pad for bed
● Shampoo board
● Bucket
● Towels
● Gown
● Comb or brush
●Blow dryer (optional)
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PROCEDURE:

STEPS RATIONALE

1. Check for order and assess need Some hospital agencies require an order
for shampoo. for this procedure. Prevent further injury
to patient.

2. Determine the type of shampoo Some physician will order for a

to be used. medicated shampoo.

3. Identify and explain the An explanation facilitates understanding

procedure to the client. and cooperation.

4. Wash your hands. Handwashing deters the spread of

microorganisms.

5. Assemble the equipment near the Organization is a form of appropriate

client. time-management and prevents fatigue
and frustration of the client.

6. Close the curtain or windows and Prevent chilling and hygiene is a personal
door. matter in which privacy needs to be
observed.

7. Raise the bed to a height Adjusting the bed helps to prevent

convenient for you and lower the muscle strain or fatigue.
nearer side rail.

8. Position the client with head and A supine position facilitates drainage
shoulder near the edge of the bed away from the face, eyes and head. CB
(near the nurse). Place dry CB in prevents entrance of water inside the ears.
both external ear canal.

9. Lay the waterproof pad under the

patient’s head covering the pillow.
Lay a towel on a water proof pad.

10. Place a shampoo trough under Using a shampoo trough provides a

the client’s head. method for collecting and draining the
water away from the client and the bed.

11. Place a folded bath towel under Layered material absorbs water and
the client’s neck, shoulders and prevents the client from feeling wet and
back. chilled. It also avoids saturating the bed
linen.
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12. Comb or brush the client’s hair. Removing tangles before washing will
prevent breaking strands of hair.

13. Cover client’s eye with face towel and

wet hair thoroughly with warm water.
Apply shampoo.
Wet hair dilutes the
shampoo and helps to form suds.

14. Work the shampoo into a lather. Lathering helps distribute the shampoo
throughout the entire hair for uniform
cleansing.

15. Rinse the hair with clean water. Rinsing prevents leaving shampoo in the
hair, which gives hair a dull appearance;
if left on the scalp, shampoo could cause
irritation for some people.

16. Remove shampoo trough.

17. Remove dry CBs from the external

ears. Reposition the pillow under the
head.

18. Wrap the client’s head with dry towel. Towel absorbs water.

19. Remove the equipment used for Discarding the water and equipment will
shampooing. prevent accidental spilling of water in the
floor.

20. Fluff the hair with towel and comb Loosening and combing the hair prepare
the hair. it for styling.

21. Raise the side rail and lower the bed Precautionary measures; prevent falls
when leaving the client. and injury to the client.

22. Wash your hands. Handwashing deters the spread of

microorganisms.

23. Document care provided the client’s Careful recording is important for
ability to participate and his/her planning and individualizing the client’s
response. care.

MOUTH
● Each tooth has three parts: the crown, the root, and the pulp cavity.
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● The crown is the exposed part of the tooth which is outside the gum.
● It is covered with a hard substances called enamel.
● The ivory colored internal part of the crown below the enamel is the dentin. The
root of a tooth is embedded in the jaw and covered by a bony tissue called
cementum.
● The pulp cavity in the center of the tooth contains the blood vessels and nerves.

ASSESSMENT
Assessment of the client's mouth and hygiene practices includes:
a.Nursing health history
b.Physical assessment of the mouth
c.Identification of client at risk for developing oral problems

Nursing History - Nursing health history, the nurse obtains data about the client's oral
hygiene practices, including dental visits, self-care abilities, and past or current mouth
problems. Data about the client's oral hygiene help the nurse determine learning needs
and incorporate the client's needs and preferences in the plan of care.

Physical Assessment
Dental caries (cavities) and periodontal disease are the two problems that most
frequently affect the teeth. Both problems are commonly associated with plaque and
tartar deposits.
Plaque - it is an invisible soft film that adheres to the enamel surface of the teeth; it
consist of bacteria, molecules of saliva, and remnants of epithelial cells and leukocytes.
Tartar - is a visible, hard deposit of plaque and dead bacteria that forms at the gum
lines.
Gingivitis - red, swollen gingiva.
Pyorrhea - the teeth are loose and pus is evident.

Identifying Clients at Risk

Certain clients are prone to oral problems because of lack of knowledge or the inability
to maintain oral hygiene, such as:
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1. Seriously ill
2. Confused
3. Comatose
4. Depressed
5. Dehydrated clients
6. Client with nasogastric tubes
7. Client receiving oxygen therapy
8. Post-oral or jaw surgery client
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COMMON PROBLEMS OF THE MOUTH

PROBLEM DESCRIPTION NURSING INDICATION

Halitosis Bad Breath Teach or provide regular oral

hygiene.

Glossitis Inflammation of the As above

tongue

Gingivitis Inflammation of the As above

gums

Periodontal disease Gums appears spongy As above

and bleeding

Reddened or Reddened gums Check for ill fitting dentures

excoriated mucosa

Excessive dryness of Buccal mucosa appears Increase fluid intake as health

the buccal mucosa dry permits.

Cheilosis Cracking of lips Lubricate lips, use antimicrobial

ointment to prevent infection.

Dental caries Teeth have darkened Advise client to see a dentist.

areas, may be painful.

Sordes Accumulation of foul Teach or provide regular cleansing

(food, micro- cleansing.
organism and epithelial
elements) on the teeth
and on the lips

Stomatitis Inflammation of the oral Teach or provide regular cleaning.

mucosa.

Parotitis Inflammation of the Teach or provide regular oral

parotid salivary gland hygiene
oral hygiene

ASSISTING THE CLIENT IN ORAL CARE

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(Independent Client)

Definition: It is the brushing and flossing of the teeth including the Inspection of the
mouth for dental carries, gum problems, soft plaque deposits etc.
Purposes:
1.To cleanse the teeth of food residue and microorganisms.
2.To prevent dental caries.
3.To refresh the mouth.
4.To improve the pleasure of eating,
5.To maintain or improve self-concept.
1

Equipment:
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2.Toothbrush
3.Toothpaste
4.Emesis basin
5.Class of water
6.Towel
7.Mouthwash (optional)
8.Dental floss (optional)
9.Petroleum jelly (optional)
10.Working gloves
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PROCEDURE:

STEPS RATIONALE

1. Wash your hands and don gloves. Handwashing deters the spread of
microorganisms.

2. Identify and explain procedure to the An explanation facilitates cooperation

client.

3. Assemble equipment on overbed table To save time and energy.

within patient’s reach.
4. Close the room door or curtains. Place Closing the door or curtains provides
the bed at an appropriate and privacy. Proper bed height helps reduce
comfortable working height; usually back strain while performing the
elbow height of the caregiver (VISN 8 procedure.
Patient Safety Center, 2009).
5. Lower side rail and assist The sitting or side-lying position
patient to sitting position, if prevents aspiration of fluids into the
permitted, or turn patient onto side. lungs. The towel protects the patient
Place towel across patient’s chest. from dampness.
Raise bed to a comfortable
working position.
6. Encourages the client to brush his The nurse should encourage the client
to exercise as much independence as
own teeth or assist if necessary possible.
7. Moisten the toothbrush and Water softens the bristles.
apply toothpaste.
8. Place brush at a 45-degree Brushing facilitates the removal of
angle to gum line (Figure 1) and plaque and tartar.
brush from gum line to crown of
each tooth (Figure 2). Brush outer
and inner surfaces. Brush back
and forth across biting surface of
each tooth.
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9. Brush tongue gently with the Removes coating on the tongue. Gentle
toothbrush (Figure 3). motion does not stimulate gag reflex.

10. Have patient rinse vigorously The vigorous swishing motion helps to
with water and spit into emesis remove debris. Suction is appropriate if
basin (Figure 4). Repeat until clear. patient is unable to expectorate well.
Suction may be used as an
alternative for removal of fluid and
secretions from mouth.

11. Assist patient to floss teeth, if Flossing aids in removal of plaque and
appropriate promotes healthy gum tissue.
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12. Remove approximately 6 The floss must be held taut to get

inches of dental floss from between the teeth.
container or use a plastic floss
holder. Wrap the floss around the
index fingers, keeping about 1 to
1.5 inches of floss taut between
the fingers.

13. Insert floss gently between Trauma to the gums can occur if floss is
teeth, moving it back and forth forced between teeth.
downward to the gums.
14. Move the floss up and down, This ensures that the sides of both teeth
first on one side of a tooth and are cleaned.
then on the side of the other tooth,
until the surfaces are clean (Figure
5). Repeat in the spaces between
all teeth.

15. Instruct patient to rinse mouth Vigorous rinsing helps to remove food
well with water after flossing. particles and plaque that have been
loosened by flossing.
16. Offer mouthwash if patient Mouthwash leaves a pleasant taste in
prefers. the mouth.
17. Offer lip balm or petroleum Lip balm lubricates lips and prevents
jelly. drying.
18. Remove equipment. Remove Removing gloves properly reduces the
gloves and discard. Raise side rail risk for infection transmission and
and lower bed. Assist patient to a contamination of other items. These
position of comfort. actions promote patient comfort and
safety.
19. Remove any other PPE, if Removing PPE properly reduces the risk
used. Perform hand hygiene. for infection transmission and
contamination of other items. Hand
1

hygiene prevents the spread of

microorganisms.

20. Records the procedure done and the Charting provides accurate
client's responses. documentation of client's care.

EVALUATION
● The expected outcomes are met when the patient receives oral care,
experiences little to no discomfort, states mouth feels refreshed, and
demonstrates understanding of reasons for proper oral care.

DOCUMENTATION
● Record oral assessment, significant observations and unusual findings,
such as bleeding or inflammation. Document any teaching done.
Document procedure and patient response.

Sample Documentation
9/20/24 0930 Patient performed oral care with minimal assistance. Oral cavity
mucosa pink and moist. No evidence of bleeding or ulceration. Lips slightly dry;
lip moisturizer applied. Reinforcement provided related to importance of
flossing teeth every day. Patient demonstrates appropriate flossing technique.
1

PROVIDING ORAL CARE FOR DEPENDENT CLIENT

Purposes:
1. To cleanse the teeth and mouth.
2. To maintain oral moisture and integrity of the tissue.
3. To prevent oral infection.
4. To relieve discomfort from inflamed lesions.

Equipment:
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1. Toothbrush

2. Toothpaste

3. Emesis basin

4. Glass with cool water

5. Disposable gloves

6. Additional PPE, as indicated

7. Towel

8. Mouthwash (optional)

9. Dental floss (optional)

10. Denture-cleaning equipment (if necessary)

11. Denture cup

12. Denture cleaner

13. 44gauze

14. Washcloth or paper towel

15. Lip lubricant (optional)

16. Sponge toothette

17. Irrigating syringe with rubber tip (optional)

18. Suction catheter with suction apparatus (optional)

1

ASSESSMENT
● Inspect lips, gums, oral mucosa, and tongue for deviations from normal.
● Identify presence of oral problems such as tooth caries, halitosis,
gingivitis, and loose or broken teeth.
● Assess for gag reflex, when appropriate.

PROCEDURE

STEPS RATIONALE

1. Wash your hands and don gloves. Handwashing deters the spread of
microorganisms.

2. Identify and explain procedure to the An explanation facilitates cooperation

client.

3. Assemble equipment on overbed table To save time and energy.

within patient’s reach.
4. Close the room door or Cleaning another person’s mouth is
curtains. Place the bed at an invasive and may be embarrassing
appropriate and comfortable (Holman, et al., 2005). Closing the door
working height, usually elbow or curtains pro- vides privacy. Proper
height of the caregiver. Lower one bed height helps reduce back strain
side rail and position patient on the while performing the procedure. The
side, with head tilted forward. side-lying position with head forward
Place towel across patient’s chest prevents aspiration of fluid into lungs.
and emesis basin in position under Towel and emesis basin protects
chin. Put on gloves. patient from dampness. Gloves prevent
the spread of microorganisms.
5. Gently open the patient’s Toothbrush provides friction necessary
mouth by applying pressure to to clean areas where plaque and tartar
lower jaw at the front of the mouth. accumulate.
Remove dentures, if present. Brush
the teeth and gums carefully with
toothbrush and paste (Figure 1).
Lightly brush the tongue.
6. Use toothette dipped in water Rinsing helps clean debris from the
to rinse the oral cavity. If desired, mouth. Forceful irrigation may cause
insert the rubber tip of the irrigating aspiration.
syringe into patient’s mouth and
1

7. Clean the dentures before Cleaning maintains dentures and oral

replacing. hygiene. Plaque can accumulate on
dentures and promote oropharyngeal
colonization of pathogens (Yoon &
Steele, 2007).
8. Apply lubricant to patient’s This prevents drying and cracking of
lips. lips.
9. Remove equipment and return Promotes patient comfort and safety.
patient to a position of comfort. Removing gloves properly reduces the
Remove your gloves. Raise side rail risk for infection transmission and
and lower bed. contamination of other items.
10. Remove additional PPE, if Removing PPE properly reduces the risk
used. Perform hand hygiene. for infection transmission and
contamination of other items. Hand
hygiene prevents the spread of
microorganisms.
11. Document the procedure done Written information documents the
and any unusual observations individualized care given to the patient
including bleeding, inflammation,
tartar, etc.

EVALUATION
● The expected outcomes are met when the patient’s oral cavity is
clean and free from complications, and the patient states or demonstrates
improved body image. In addition, if the patient is able, he or she
verbalizes a basic understanding of the need for oral care.
1

DOCUMENTATION
Record oral assessment, significant observations, and unusual findings, such as
bleeding or inflammation. Document any teaching done. Document procedure
and patient response.

SAMPLE DOCUMENTATION
7/10/24 0945 Oral care performed. Oral cavity mucosa pink and moist. Small
amount of bleeding noted from gums after using soft-bristled toothbrush.
Resolved spontaneously when brushing completed. No evidence of ulceration.
Lips slightly dry; lip moisturizer applied.

PROVIDING DENTURE CARE

● Plaque can accumulate on dentures and can promote oropharyngeal
colonization of pathogens.
● Diligent oral hygiene care can improve oral health and limit the
growth of pathogens in the oropharyngeal secretions, decreasing the
incidence of aspiration pneumonia and other systemic diseases.
● Dentures should be cleaned at least daily, to prevent irritation and
infection. They may be cleaned more often, based on need and the
patient’s personal

EQUIPMENT
● Soft toothbrush or denture brush
● Toothpaste
● Denture cleaner (optional)
● Denture adhesive (optional)
● Glass of cool water
● Emesis basin
● Denture cup (optional)
● Nonsterile gloves
● Additional PPE, as indicated
● Towel
● Mouthwash (optional)
● Washcloth or paper towel
● Lip lubricant (optional)
● Gauze
1

ASSESSMENT
● Assess the patient’s oral hygiene preferences: frequency, time of day, and
type of hygiene products.
● Assess for any physical activity limitations.
● Assess for difficulty chewing, pain, tenderness, and discomfort.
● Assess patient’s oral cavity. Look for inflammation, edema, lesions, bleeding,
or yellow/ white patches.
● The patches may indicate a fungal infection called thrush.
● Assess patient’s ability to perform own care.

NURSING DIAGNOSIS
● Determine the related factors for the nursing diagnosis based on the patient’s
current status. Possible nursing diagnoses may include:
1. Ineffective Health Maintenance
2. Impaired Oral Mucous Membrane
3. Disturbed Body Image
4. Deficient Knowledge

OUTCOME IDENTIFICATION AND PLANNING

● The expected outcome to achieve is that the patient’s mouth and dentures
will be clean; the patient will exhibit a positive body image; and the patient
will verbalize the importance of oral care.

IMPLEMENTATION
PROCEDURE

STEPS RATIONALE

1. Perform Hand hygiene and PPE prevent the

hand hygiene spread of microorganisms. PPE is
and put on required based on transmission
PPE, if precautions.
indicated.
1. Identify patient. Explain Identifying the patient ensures the right
procedure to patient. patient receives the intervention and
helps prevent errors. Explanation
facilitates cooperation.
1

2. Assemble equipment on overbed Organization facilitates performance of

table within reach. task.
3. Provide privacy for patient. Cleaning another person’s mouth is
invasive and may be embarrassing.
Patient may be embarrassed by removal
of dentures.
4. Lower side rail and assist patient Lower side rail and assist patient to
to sitting position, if permitted, sitting position, if permit- ted, or turn
or turn patient onto side. Place patient onto side. Place towel across
towel across patient’s chest. patient’s chest. Raise bed to a
Raise bed to a comfortable comfortable working position, usually
working position, usually elbow elbow height of the caregiver. Put on
height of the caregiver. Put on gloves.
gloves.
5. Apply gentle pressure with 4x4 Apply gentle pressure with 4x4 gauze to
gauze to grasp upper denture grasp upper denture plate and remove it
plate and remove it (Figure 1). (Figure 1). Place it immediately in
Place it immediately in denture denture cup. Lift lower dentures with
cup. Lift lower dentures with gauze, using slight rocking motion.
gauze, using slight rocking Remove, and place in denture cup.
motion. Remove, and place in
denture cup.

6. Place paper towels or washcloth Place paper towels or washcloth in sink

in sink while brushing. Using the while brushing. Using the toothbrush
toothbrush and paste, brush all and paste, brush all surfaces gently but
surfaces gently but thoroughly thoroughly (Figure 2). If patient prefers,
(Figure 2). If patient prefers, add add denture cleaner to cup with water
denture cleaner to cup with and follow directions on preparation.
water and follow directions on
preparation.
1

7. Rinse thoroughly with water. Rinse thoroughly with water. Apply

Apply denture adhesive, if denture adhesive, if appropriate.
appropriate.
8. Use a toothbrush and paste to Cleaning removes food particles and
gently clean gums, mucous plaque, permitting proper fit and
membranes, and tongue. Offer preventing infection. Mouthwash leaves
water and/or mouthwash so a pleasant taste in the mouth.
patient can rinse mouth before
replacing dentures.
9. Insert upper denture in mouth This ensures patient comfort.
and press firmly. Insert lower
denture. Check that the dentures
are securely in place and
comfortable.
10. If the patient desires, dentures Storing in water prevents warping of
can be stored in the denture cup dentures. Proper storage prevents loss
in cold water, instead of and damage.
returning to the mouth. Label
the cup and place in the
patient’s bedside table.
11. Remove equipment and return Promotes patient comfort and safety.
patient to a position of comfort. Removing gloves properly reduces the
Remove your gloves. Raise side risk for infection transmission and
rail and lower bed. contamination of other items.

12. Remove additional PPE, if used. Removing PPE properly reduces the risk
Perform hand hygiene. for infection transmission and
contamination of other items. Hand
hygiene prevents transmission of
microorganisms.

EVALUATION
● The expected outcomes are met when the patient’s oral cavity and
dentures are clean, free from complications, and patient states or
demonstrates improved body image. In addition, the patient verbalizes a
basic understanding of the need for oral care.

DOCUMENTATION
1

● Record oral assessment, significant observations and unusual

findings, such as bleeding or inflammation. Document any teaching done.
Document procedure and patient response.

SAMPLE DOCUMENTATION
7/10/24 0945 Oral care performed. Oral cavity mucosa pink and moist.
Denture and oral care given. No evidence of bleeding, ulceration, or
inflammation.

CARE OF FEET

Feet are essential for ambulation and merit attention even when are confined to bed.
Each foot contains 26 bones, 107 ligaments and muscles. These structures function
together for both standing and walking.

Nursing Management:
Assessment of the client's feet includes a nursing health history, physical assessment
of the feet, and identifying clients at risk for foot problems.
1

Nursing Health Assessment: The nurse determines the client's history of

1

b) Normal nail and foot care practices,

c) Type of footwear worn
d) Self-care abilities
e) Presence of risk factors for foot problems
f) Any foot discomfort
g) Any perceived problems with foot mobility
1

Physical Assessment:
Each foot and toe is inspected for shape, size and presence of lesions and is palpated
to assess areas of tenderness, edema, and circulatory status. Normally, the toes are
straight and flat.
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Common foot problems include the following:

1

2. Fungal infections (athlete's foot)

3. Fissures between the toes
4. Unpleasant odors
5. Calluses
6. Corns
7. Plantar warts
1

Callus - is a thickened portion of epidermis, a mass of keratotic materials.

Corn - is a keratosis caused by friction and pressure from a shoe.
Unpleasant Odors - occurs as a result of perspiration and its interaction with
microorganisms.
Plantar Warts - appear on the sole of the foot. These warts are caused by the virus
papovavirus hominis.
Fissures - or deep grooves, frequently occur between the toes as a result o dryness and
crackling of the skin.
Tines Pedis - athlete’s foot (ringworm of the foot is caused by a fungus.
The symptoms are scaling and cracking of the skin, particular between
the toes.
Ingrown Toenails - the growing inward of the nail into the soft tissue around it. Most
often results from improper nail trimming.

Identifying Clients at Risk

Because of the reduced peripheral circulation to the feet, clients with diabetes or
peripheral vascular disease are particularly prone to infection if skin breakage occurs.
Many foot problems can be prevented by teaching client simple foot care guidelines.
1

PROVIDING FOOT AND TOENAIL CARE

1

Purposes:
1

1. To cleanse and promote the comfort of the feet.

1. To maintain the skin integrity of the feet.
2. To stimulate circulation to the lower extremities.
3. To prevent infection and injury.
4. To treat local infections by soaking the feet in a medicated solution.
5. To prevent odors.

Equipment:
1

2. Paper lining (as the case may be)

3. Warm water in a pitcher
4. Nail cutter or scissors
5. Powder (optional)
6. Lotion (optional)
7. Hand towel , 2
8. Working gloves
9. Wash basin
10. Nail brush
11. Nail file
12. Soap
1

PROCEDURE:

STEPS RATIONALE

1. Assess the An appropriate plan for foot care cannot

condition of be individualized without pertinent data.
the feet and
toenails.
1. Discuss any identifiable foot and The client should be informed of
nail problems with the client. potential and actual health problems.
2. Explain the procedure. An explanation allays fear and aids in
acquiring the client's cooperation.
3. Wash your hands. Handwashing deters the spread of
microorganisms.
4. Assemble the equipment. Organization promotes efficient time
management.
5. Provide privacy. Providing privacy demonstrate respects
for the client's feelings.
6. Don your working gloves.
7. Lay the water proof under pad A towel absorbs water and prevents
protects the bed with towel wetting the linen.
beneath the client's feet.
8. Soak each foot one at a time in Soaking softens the nails and helps to
warm (40° C or 104° F) water for loosen dry skin and debris. Warm water
approximately 3-5 minutes. dilates blood vessels, which improves
circulation and promotes comfort it
9. Wash each foot with liberal Soap removes bodily oil, surf dirt and
amount of lathered soap. microorganisms
10. Brush the toenails. Dead cells and dirt trapped between the
nail and toe may require mechanical
removal.
1

11. Change the water between the The water should be clean and
care of each foot. maintained at a temperature that
promotes comfort.
12. Dry each foot thoroughly. Make Moisture supports the growth of fungi
sure to dry between each toe. and can also tend to lacerate skin if
cannot evaporate.
13. Cut the nails straight across, Cutting straight across is less likely to
seeing to it that they are even result in injury to adjacent tissue or to
with the tip of the toes. potentiate the risk for ingrown nails.
14. Apply lotion or powder to the Lotion lubricates dry skin. Powder
legs or feet if needed. absorbs perspiration.
15. Dispose used water and do after Caring for soiled articles supports the
care of equipment. principles of asepsis.
16. Make patient comfortable.
17. Remove gloves then wash your Handwashing deters the spread of
hand. microorganisms.
18. Chart the care given, the Written information is a permanent
response of the client, and the record of the care provided for the client.
necessary observations you
made.