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Chapter 30
Hygiene- measure of personal cleanliness
Factors affecting it: culture, economic class, spiritual practice, health state
Assessing the Skin
• Head-to-toe sequence
• Compare bilateral for symmetry
• What to consider?
• Cleanliness, color, temperature, turgor, moisture, sensation, vascularity,Â
evidence of lesions (ABCDE)
Assessment of Oral Cavity
• Lips- color/moisture
• Buccal mucosa- color/nodules/bleeding
• Color and surface of gums
• Teeth- loose/missing/dentures (if they fit well)
• Hard & soft palate- intact/patches
• Oropharynx- movement of uvula (grading of tonsils)
• Halitosis/bad taste in mouth
• BOHSE- brief oral health status exam
• Observe for oral problems- dental caries (cavities), gingivitis, periodontal disease
• Mouth breathers/comatose patients
Oral Hygiene
• Moistening/cleaning the mouth
• Caring for dentures- remove when sleeping; wear gloves when cleaning
• Using mouthwashes- for children must contain fluoride
Early Morning Care
• Assist patient with toileting
• Provide comfort measures
• Wash face and hands
• Provide mouth care
Morning Care (AM care) *after breakfast unless patient wants it done first
• Toileting
• Oral care
• Bathing
• Back massage/ special skin measures
• Hair care/cosmetics/dressing
• Position for comfort
• Refresh or change bed linens/tidying up bedside
Afternoon Care (PM care) *ensure patients comfort after lunch
• Offer assistance with toileting, hand washing, oral care
• Straighten bed linens
• Help patient with mobility to reposition self
Hours of Sleep Care (HS care) *before patient goes to bed
• Offer assistance with toileting, washing and oral care
• Offer back massage
• Change any soiled linens
• Position patient comfortably
• Ensure call light or any other objects are in reach
As Needed Care (PRN care)
• Offer individual hygiene as needed
• Change clothing and bed linens to diaphoretic patients
• Provide oral care every 2 hours as needed
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