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**Major functions of the skin: (Skin -Largest organ of the body)**

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-Protects underlying tissues from injury. The skin and mucous membranes are considered the body's first line of defense. -Regulates the body temperature. -Secretes sebum, an oily substance that softens and lubricates the hair and skin. -Transmits sensations through nerve receptors, which are sensitive to pain, temperature, touch, and pressure. -Produces and absorbs vitamin D in conjunction with ultraviolet rays from the sun.

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**Nursing Process - diagnoses**

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-Self care deficit - bathing R/T...... -Impaired skin integrity R/T (specify the cause immobility, nutrition, circulation, irritants trauma, surgery -Impaired health maintenance - oral R/T poor oral hygiene -Knowledge deficit - (specify what)

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**Nursing Process - Assessing**

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-History (any skin problems - what kind of care -Examine skin for any breakdown or abnormalities -Identify high risk

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**Personal Hygiene**

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...

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Well- being

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-Physical -Psychological

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Physical Assessment

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-Physical Assessment of the skin, which involves inspection and palpation.

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Diagnosing

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-Self- care Deficit diagnoses are used for patients who have problems performing hygiene care. --Self- care Deficit: Bathing / Hygiene --Self- care Deficit: Dressing/Grooming --Self- care Deficit: Toileting

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Etiologies of self-care deficit:

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-Decreased or lack of motivation -Weakness or tiredness -Pain or discomfort -Perceptual or cognitive impairment -Inability to perceive body part -Neuromuscular or musculoskeletal impairments -Medically imposed restriction -Therapeutic procedure restraining mobility -Severe anxiety -Environmental barriers

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Planning

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-The nurse and, if appropriate, the patient and /or family set outcomes for each nursing diagnosis.

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Implementation

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The nurse applies the general guidelines for skin care while providing one of the various types of baths available to patients.

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**General guidelines for skin care**

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-An intact, healthy skin is the body's first line of defense. Nurses need to ensure that all skin care measures prevent injury and irritation. -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. -Body odors are caused by resident skin bacteria acting on body secretions -Skin sensitivity to irritation and injury varies among individuals and in accordance with their health. -Agents used for skin care have selective actions and purposes. -Moisture in contact with the skin for more than a short time can result in increased bacterial growth and irritation.

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**Bathing**

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-Bathing removes accumulated oil, perspiration, dead skin cells and some bacteria. -Two categories of baths are given to patients: cleaning and therapeutic. Cleaning baths are given chiefly for hygiene purposes and include these types: --Complete bed bath --Self-help bed bath --Partial bath --Bag bath --Tub bath --Shower

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Therapeutic bath

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-baths are given for physical effects, such as to soothe irritated skin or to treat an area such as perineum. Medication may be placed in the water.

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Perineal-Genital Care

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-Perineal-genital care is also referred to as perineal care or pericare.

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Feet

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The feet are essential for ambulation and merit attention even when people are confined to bed.

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**Nursing Management Assessing it includes the following**

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...

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Nursing Health History

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-The nurse determines the patient's history of (a) normal nail and foot practices, (b) type of foot wear worn, (c) self-care abilities, (d) presence of risk factors for foot problems, (e) any foot discomfort, and (f) any perceived problems with foot mobility.

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Physical Assessment

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-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. Common foot problems include:-

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callus

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-is a thickened portion of epidermis, a mass of keratotic material. Most calluses are painless and flat and are found on the bottom or side of the foot over a bony prominence, usually caused by pressure from shoes.

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Unpleasant odors

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-occur as a result of perspiration and its interaction of microorganisms.

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Planter warts

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-appear on the sole of the foot.

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Fissures

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-or deep grooves frequently occur between the toes as a result of dryness and cracking of the skin.

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Ingrown toenail

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-the growing inward of the nail into the soft tissues around it, most often results from improper nail trimming.

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Identifying Patients at Risk

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-Because of reduced peripheral circulation to the feet, patients with diabetes or peripheral vascular disease are particularly prone to infection if skin breakage occurs.

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Diagnosing

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The most common diagnostic labels with possible related factors are as follows: *Self care deficit: Hygiene (foot care) R/T - Visual impairment - Impaired hand coordination * Risk for impaired skin integrity R/T - Poorly fitting shoes * Risk for infection R/T - Impaired skin integrity (trauma, corn) - Deficient nail or foot care * Deficient knowledge (diabetic foot care) R/T - Lack of teaching/learning activities about diabetic foot care - Newly established medical diagnosis (diabetes)

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Planning

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Planning involves (a) identifying nursing interventions that will help the patient maintain or restore healthy foot care practices and (b) establishing desired outcomes for each patient.

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Implementation

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In Skill lab we explain how to provide foot care.

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Nails Nursing Management

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...

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Assessing

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During the nursing health history, the nurse explores the patient's usual nail care practices, self - care abilities, and any problems associated with them. Physical assessment involves inspection of the nails (shape and texture, nail bed color, and tissues surrounding the nails).

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Diagnosing

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Nursing diagnosing related to nail care and nail problems include:- *Self care Deficit: Grooming related to impaired vision *Risk for infection around the nail bed related to - Impaired skin integrity of cuticles - Altered peripheral circulation

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Planning

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The nurse identifies measures that will assist the patient to develop or maintain healthy nail care practices.

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Implementation

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In Skill lab we explain how to provide foot care.

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Evaluation

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the client being able to: --Demonstrate healthy nail care practices as shown by: ---Clean, short nails with smooth edges ---Intact cuticles and hydrated surrounding skin ---Describe factors contributing to the nail problems

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**Administering Oral Hygiene**

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-Moistening the mouth -Cleaning the mouth -Caring for dentures -Tooth brushing and flossing -Using mouthwashes

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Mouth

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...

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Nursing Management

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...

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Assessing

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Assessment of the patient's mouth and hygiene practices includes:-

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Nursing history

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The nurse obtains data about the patient's oral hygiene practices, including dental visits, self care abilities, and past or current mouth problems.

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Physical assessment

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...

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Most common problems affect the teeth.

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tarter, gingivitis, pyorrhea

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Tarter

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is a visible, hard deposit of plaque and dead bacteria that forms at the gum lines.

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Gingivitis

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"red, swollen gingival", bleeding, receding gum lines, and the formation of pockets between the teeth and gums.

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Pyorrhea

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the teeth are loose and pus is evident when the gums are pressed.

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Identifying Patients at Risk

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-Certain patients are prone to oral problems because of lack of knowledge or the inability to maintain oral hygiene. --e.g. Seriously ill, confused, comatose, depressed, and dehydrated clients. --Also, people with nasogastric tubes or receiving oxygen are likely to develop dry oral mucous membranes. Patients who have had oral or jaw surgery must have meticulous oral hygiene care to prevent the development of infections. -Patients in long-term care settings are at high risk for oral health problems. -A dry mouth can be aggravated by poor fluid intake, heavy smoking, alcohol use, high salt intake, anxiety, and many medications. -Patients who are receiving or having radiation treatments to the head and neck may have permanent damage to salivary glands

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Diagnosing

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Nursing diagnosing related to problems with oral hygiene and the oral cavity are: *Self -care deficit: oral hygiene will be used for patients unable to perform oral care independently. *Impaired oral mucous membrane related to - Ineffective oral hygiene - Physical injury or drying effect (mouth breathing, oxygen therapy)

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Planning

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Specific detailed nursing activities taken by the nurse may include the following: -Monitor every shift for dryness of the oral mucosa -Monitor for signs and symptoms of glossitis" inflammation of the tongue" and stomatitis" inflammation of the mouth". -Assist dependent patients with oral care. -Provide special oral hygiene for patients who are debilitated, unconscious, or have lesions of the mucous membrane or other oral tissues. -Teach patients about good oral hygiene practices and other measures to prevent tooth decay. -Reinforce oral hygiene regimen as part of discharge teaching.

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Implementation

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Good oral hygiene includes daily stimulation of the gums, brushing, flushing of the mouth.

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Promoting Oral Health through the Life Span: Infant and Toddler

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-The nurse should give parents the following instructions to promote and maintain dental health: --Beginning at about 18 months of age, brush the child's teeth with a soft toothbrush

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Infants and Toddlers

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-Fluoride supplement daily or as recommended -First visit 2-3 years old -Seek professional dental attention for any problem such as discoloring of the teeth. -Bottle, sippy cup

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Hair Developmental Variations

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-Newborn may have lanugo" fine hair on the body of the fetus''. -In older adults the hair is generally thinner, grows more slowly and loses its color as a result of aging.

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Nursing Management Assessing

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...

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Nursing history

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The nurse collect data about usual hair care, self care abilities, history of hair or scalp problems.

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Physical assessment

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...

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Problems include

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scabies, hirsutism, dandruff, pediculous, hairloss

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Scabies

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is a contagious skin infestation by the itch mite. Treatment involves through cleansing of the body with soap and water to remove scales and debris from crusts, and then an application of the scabicide lotion. All bed linens and clothing should be washed in very hot or boiling water.

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Hirsutism

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the growth of excessive body hair. The cause is not always known.

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Dandruff

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Often accompanied by itching.

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Pediculosis (Lice)

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...

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Hair loss

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...

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Diagnosing

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Nursing diagnosing related to hair hygiene and hair and scalp problems include: * Self - care deficit: Grooming related to - Activity intolerance - Immobility - Pain in upper extremities - Altered level of consciousness - Lack of motivation associated with depression * Impaired skin integrity related to - Scalp laceration - Insect bite * Risk for infection related to - Scalp laceration - Insect bite *Disturbed body image related to alopecia

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Implementing

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-Brushing and Combing Hair -Shampooing the hair. -Beard and mustache care

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**EYES**

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...

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Nursing Management

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...

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Assessing

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Assessment of the patient's eyes includes: - Nursing health history --Eyeglasses or contact lenses --Examination by an ophthalmologist --History of eye problems - Physical assessment --Inspection of the external eye structures

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Diagnosing

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Nursing diagnosing related to eye problems may include: *Self - care deficit (insertion and removal contact lens, cleaning) related to - Deficient Knowledge - Impaired vision associated with cataracts * Risk for infection related to - Improper contact lens hygiene - Accumulation of secretions on eyelids *Risk for injury related to -Prolonged wearing of contact lenses - Absence of blink reflex associated with unconsciousness

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Implementing

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Nursing activities may include:- --Eye Care; dried secretions that have accumulated on the lashes need to be softened and wiped away. --Eyeglass Care --Removing Contact Lenses --Inserting Contact Lenses

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General Eye Care - Teach patients

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-Avoid home remedies for eye problems. -If dirt or dust gets into the eyes, clean them copiously with clean, tepid water as an emergency treatment. -Take measures to guard against eyestrain and to protect exertion. -Schedule regular eye examinations, particularly after age 40 to detect problems such as cataracts.

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Evaluation

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The desired outcomes to evaluate the effectiveness of nursing interventions follow: -Conjunctiva and sclera free of inflammation -Eyelids free of secretions -No tearing -No eye discomfort -Demonstrate appropriate methods of caring for contact lenses -Describe interventions to prevent eye injury and infection

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**EARS**

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-Normal ears require minimal hygiene. -Patients who have excessive earwax and dependent patients who have hearing aids may require assistance from the nurse. --Cleaning the Ears --Care of Hearing Aids

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**NOSE**

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Supporting A Hygienic Environment Age, severity of illness, activity Room Temperature Ventilation. Noise

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NOSE

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-Nurses usually need not provide special care for the nose, because clients can ordinarily clear nasal secretions by blowing gently into a soft tissue. -Supporting A Hygienic Environment --When providing a comfortable environment it is important to consider the client's age, severity of illness, and level of activity ---Room Temperature ---Ventilation. ---Noise

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Hospital Beds

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Commonly used bed positions - Flat - Fowler's position (semisitting position in which head of bed is raised to angle of at least 45.) - Semi- Fowler's position (head of bed is raised only to 30 angle.) - Trendelenburg's position (head of bed is lowered and the foot raised in a straight) - Reverse Trendelenburg's position (head of bed raised and the foot lowered)

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Ant embolism (TED) stockings

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-Purpose: prevent venous stasis and clotting of the venous blood in deep veins -Type and how to measure -How to put them on -When on and off -Laundry -Intermittent or sequential pneumatic compression stockings

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Guidelines for Applying Ant embolism Stockings

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-Measure patient's leg for size of stocking -Apply stocking in morning before patient is out of bed and while patient is supine -Do not massage the legs -Check legs regularly for redness, blistering, swelling, and pain -Launder the stockings as necessary

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