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    Mastery of content in this chapter will enable the student to: Describe factors that influence personal hygiene practices. Discuss the role critical thinking plays in providing hygiene. Conduct a comprehensive assessment of a client’s total hygiene needs.

     Discuss conditions that place clients at risk for impaired skin integrity. Discuss factors that influence the condition of the nails and feet. Explain the importance of foot care for the diabetic client. Discuss conditions that place clients at risk for impaired oral mucous membranes.

     List common hair and scalp problems and their related interventions. Describe how hygiene care for the older adult client differs from that for the younger client.

     Discuss the different approaches used in maintaining a client’s comfort during hygiene care.

     Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.


     Companion CD

    ? NCLEX-Style Review Questions

     Audio Glossary

     Interactive Learning Activities

     English/Spanish Glossary


    ? NCLEX-Style Review Questions

     Audio Glossary

     English/Spanish Glossary

     Interactive Learning Activities


     Audio Summaries

     Video Clips


    Acne, p. 858

    Alopecia, p. 856

    Apocrine, p. 858

    Buccal glands, p. 851

Caries, p. 859

    Cerumen, p. 857

    Complete bed bath, p. 867

    Cuticle, p. 851

    Dermis, p. 851

    Eccrine, p. 858

    Edentulous, p. 859

    Effleurage, p. 868

    Enucleation, p. 894

    Epidermis, p. 850

    Gingivitis, p. 851

    Halitosis, p. 856

    Lunula, p. 851

    Mastication, p. 851

    Neuropathy, p. 856

    Ophthalmologist, p. 894

    Optometrist, p. 894

    Partial bed bath, p. 867

    Perineal care, p. 868

     Stomatitis, p. 885

    ersonal hygiene affects client’s comfort, safety, and well-being. Well people are capable of meeting their own hygiene needs. Ill P

    or physically challenged people often require various levels of assistance. A variety of personal, social, and cultural factors influence hygiene practices. In agency or home care settings, determine a client’s ability to perform self-care and provide hygienic care ac-cording to the client’s needs and preferences. In addition in the home setting, help the client and family adapt hygiene techniques and


    Because hygienic care requires close contact with the client, use communication skills (see Chapter 24) to promote a caring

    therapeutic relationship and to use the time with the client for teaching and counseling. You can integrate other nursing activities

    during hygiene care, including client assessment and interventions such as range-of-motion (ROM) exercises, application of

    dressings, or inspection and care of intravenous sites. During hygiene care, try to preserve as much of the client’s independence as

    possible, assess client’s ability to perform hygiene care, ensure privacy, convey respect, and foster the client’s physical comfort.

    Scientific Knowledge Base

    Proper hygienic care requires an understanding of the anatomy and physiology of the integument, oral cavity, and the eyes, ears, and

    nose. The skin and mucosa cells exchange oxygen, nutrients, and fluids with underlying blood vessels. The cells require adequate

    nutrition, hydration, and circulation to resist injury and disease. Good hygiene techniques promote the normal structure and function

    of body tissues.

    In addition, apply knowledge of pathophysiology to provide good preventive hygienic care. Learn to recognize those disease

    states that create changes in the integument, oral cavity, and sensory organs. For example, diabetes mellitus results in chronic

    vascular changes that impair healing of the skin and mucosa. In the early stages of acquired immunodeficiency syndrome (AIDS),

    fungal infections of the oral cavity are common. As a result of a stroke, paralysis of the trigeminal nerve (cranial nerve V) eli-

minates the blink reflex, causing risk of corneal drying. In the presence of conditions such as these, adapt hygiene practices to

    anticipate client needs and minimize any injurious effects. Integrate knowledge of anatomy, physiology, and pathophysiology during hygiene care; take this time to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive


    The Skin

    The skin is an active organ with the functions of protection, secretion, excretion, temperature regulation, and sensation (Table

    39-1). The skin has three primary layers: epidermis, dermis, and subcutaneous. The (outer layer) is composed of epidermis

    several thin layers of cells undergoing different stages of maturation. It shields underlying tissue against water loss and injury and

    prevents entry of disease-producing microorganisms. The innermost layer of the epidermis generates new cells to replace the dead cells that the skin’s outer surface continuously sheds. Bacteria commonly reside on the outer epidermis. These resident

    bacteria are normal flora (see Chapter 34) that do not cause disease but instead inhibit the multiplication of disease-causing


    The is a thicker skin layer containing bundles of collagen and elastic fibers to support the epidermis. Nerve fibers, blood dermis

    vessels, sweat glands, sebaceous glands, and hair follicles course through the dermal layers. Sebaceous glands secrete sebum, an oily,

    odorous fluid, into the hair follicles.

    The subcutaneous tissue layer contains blood vessels, nerves, lymph, and loose connective tissue filled with fat cells. The fatty tissue

    is a heat insulator for the body. Subcutaneous tissue also supports upper skin layers to withstand stresses and pressure without injury.

    Very little subcutaneous tissue underlies the oral mucosa.

    The skin often reflects a change in physical condition by alterations in color, thickness, texture, turgor, temperature, and hydra-

    tion (see Chapter 33). As long as the skin remains intact and healthy, its physiological function remains optimal. The Feet, Hands, and Nails

    The feet, hands, and nails often require special attention to prevent infection. Any injury or deformity to the foot, including any

    growths or injuries to the overlying skin, are painful and thus interfere with a client’s normal ability to walk and bear weight. The

    hand, in contrast to the foot, is constructed largely for manipulation rather than support. A wide range of dexterity exists in the hand because of the wide range of movement between the thumb and fingers. Any con-dition that interferes with movement of the hand (e.g., superficial or deep pain or joint inflammation) impairs a client’s self-help


    The nails are epithelial tissues that grow from the root of the nail bed, located in the skin at the nail groove, hidden by the fold of

    skin called the The visible part of the nail is the nail body. It has a crescent-shaped white area known as the Under cuticle.lunula.

    the nail lies a layer of epithelium called the nail bed (Figure 39-1). A normal healthy nail is transparent, smooth, and convex, with a

    pink nail bed and translucent white tip. Disease causes changes in the shape, thickness, and curvature of the nail (see Chapter 33).

    The Oral Cavity

    The oral cavity is lined with mucous membranes continuous with the skin. The oral or buccal cavity consists of the lips surrounding

    the opening of the mouth, the cheeks running along the sidewalls of the cavity, the tongue and its muscles, and the hard and soft

    palate. The oral mucosa is normally light pink and moist. The floor of the mouth and the undersurface of the tongue are richly

    supplied with blood vessels. Any type of ulceration or trauma results in significant bleeding. There are three pairs of salivary glands

    that secrete about 1 L of saliva a day. The found in the mucosa lining the cheeks and mouth maintain the hygiene and buccal glands

    comfort of oral tissues. The effects of medications, exposure to radiation, and mouth breathing impair salivary secretion in the


    The teeth are the organs of chewing, or They are designed to cut, tear, and grind ingested food so it can be mixed mastication.

    with saliva and swallowed. A normal tooth consists of the crown, neck, and root (Figure 39-2). The periodontal membrane lies just

    below the gum margins, surrounds a tooth, and holds it firmly in place. Healthy teeth appear white, smooth, shiny, and properly


    Difficulty in chewing develops when surrounding gum tissues become inflamed or infected or when teeth are lost or become loo-

    sened. Regular oral hygiene is necessary to maintain the integrity of tooth surfaces and to prevent or gum inflammation. gingivitis,

    The Hair

    Hair growth, distribution, and pattern indicate a person’s general health status. Hormonal changes, emotional and physical stress,

    aging, infection, and certain illnesses affect hair characteristics. The hair shaft itself is lifeless, and physiological factors do not di-

    rectly affect it. However, hormonal and nutrient deficiencies of the hair follicle cause changes in its color or condition (Figure 39-3).

    The Eyes, Ears, and Nose

    When nurses provide hygienic care, the eyes, ears, and nose require careful attention. Chapter 33 describes the structure and function of

    these organs. Clean the sensitive sensory tissues in a way that prevents injury and discomfort for the client, such as using care not to get

    soap in the client’s eyes. In addition, the time you spend with your client during hygiene provides an excellent opportunity to ask if

    there are any changes in vision, hearing, or sense of smell.

    Nursing Knowledge Base

    A number of factors influence a client’s personal preferences for hygiene. No two individuals perform hygiene in the same manner,

    and it is important to individualize the client’s care based on knowing about the client’s unique hygiene practices and preferences.

    Hygiene care is never routine; the care requires intimate contact with the client and communication skills to promote the thera-

    peutic relationship. In addition, during hygiene take time to learn about the client’s health promotion practices and needs, emotional needs, and health care education needs.

    Social Practices

    Social groups influence hygiene preferences and practices, including the type of hygienic products used and the nature and fre-

    quency of personal care. During childhood, family customs influence hygiene. This includes, for example, the frequency of bathing,

    the time of day bathing is performed, and the type of oral hygiene practiced. As children enter their adolescent years, peer group

    behavior often influences personal hygiene. Some young girls, for example, become more interested in their personal appearance

    and begin to wear makeup. During the adult years, involvement with friends and work groups shape the expectations people have

    about their personal appearance. Some older adults’ hygiene practices change because of living conditions and available resources.

    Personal Preferences

    Each client has individual desires and preferences about when to bathe, shave, and perform hair care. Clients select different

    products according to personal preferences, needs, and financial resources. Knowing clients’ personal preferences assists in pro-

    viding individualized care for the client. In addition, assist the client in developing new hygiene practices when indicated by an

    illness or condition. For example, you will need to teach a client with diabetes proper foot hygiene. Body Image

    Body image affects the way in which an individual maintains hygiene. If a client is neatly groomed, consider the details of grooming

    when planning care and consult the client before making decisions about how to provide hygienic care. Clients who appear unkempt

    or uninterested in hygiene often require education about the importance of hygiene or further assessment regarding their ability to

    participate with daily hygiene.

    A client’s general appearance reflects the importance hygiene holds for that person. Body image is a person’s subjective concept

    of his or her body, including physical appearance, structure, or function (see Chapter 27). These images change frequently. When

    clients undergo surgery, illness, or a change in functional status, body image changes dramatically. For this reason, take extra effort

to promote the client’s hygienic comfort and appearance.

    Socioeconomic Status

    A person’s economic resources influence the type and extent of hygiene practices used. Be sensitive in considering that the client’s

    economic status influences his or her ability to regularly maintain hygiene. When clients have the added problem of a lack of

    socioeconomic resources, it becomes difficult to participate and take a responsible role in health promotion activities such as basic


    When basic care items are not affordable, work to find alternatives. It is also important to learn if use of these products is a part of

    the social habits practiced by the client’s social group. For example, not all clients choose to use deodorant or cosmetics.

    Health Beliefs and Motivation

    Knowledge about the importance of hygiene and its implications for a person’s well-being influences hygiene practices. However,

    knowledge alone is not enough. Motivation is a key factor in the importance of hygiene. An internal barrier that may affect the

    success of hygiene practices is lack of motivation because of insufficient knowledge. Overcome this barrier by assessing the client’s needs and providing appropriate information. Provide materials that discuss the health-related issues relevant to the target behavior,

    including the short- and long-term consequences for the client. Individuals play a critical role in the determination of their own

    health status, because self-care represents the dominant mode of health care in our society. Many personal decisions are made daily

    that shape lifestyle and the social and physical environments (Pender, Murdaugh, and Parsons, 2002). It is important to know if a client perceives being at risk. For example, does the client perceive being at risk for dental disease, that

    dental disease is serious, and that brushing and flossing are effective in reducing risk? When clients recognize there is a risk and that

    they can take reasonable action with no negative consequence, they are more likely to be receptive to the nurse’s counseling and

    teaching efforts.

    Cultural Variables

    A client’s cultural beliefs and personal values influence hygiene care (Box 39-1). People from diverse cultural backgrounds follow different self-care practices (see Chapter 9). Culturally, maintaining cleanliness does not hold the same importance for some ethnic

    groups as it does for others (Galanti, 2004). Do not express disapproval when caring for clients whose hygienic practices are dif-

    ferent from yours. In North America it is common to bathe or shower daily, whereas in some other cultures it is customary to

    completely bathe only once a week.

    Physical Condition

    Clients with certain types of physical limitations or disabilities often lack the physical energy and dexterity to perform hygienic care.

    A client in traction or a cast or who has an intravenous line or other device connected to the body needs assistance with hygiene.

    Illnesses causing pain limit the dexterity and range of motion needed to perform certain measures. Clients still under the effects of

    sedation will not have the mental clarity or coordination to perform self-care. Chronic illnesses, such as cardiac disease, cancer,

    neurological disorders, and certain psychiatric conditions often exhaust or incapacitate a client. A weakened grasp resulting from

    arthritis, stroke, or muscular disorders prevents a client from using a toothbrush, washcloth, or comb. Critical Thinking

    Successful critical thinking requires synthesis of knowledge, experience, information gathered from clients, critical thinking atti-

    tudes, and intellectual and professional standards. Clinical judgments require you to anticipate the information necessary to analyze

    data and make decisions regarding client care. A client’s condition is always changing, requiring ongoing critical thinking. During

    assessment, consider all elements that build toward making appropriate nursing diagnoses (Figure 39-4). Because hygienic care is so important for a client to feel comfortable, refreshed, and renewed, avoid making hygiene care a

simple routine. Instead, integrate knowledge from nursing and other disciplines, previous experiences in providing hygiene, and

    information gathered from clients. The use of critical thinking attitudes, such as curiosity and humility, is necessary to design a plan

    of care to meet the client’s hygiene needs. Use professional standards, such as those from the American Diabetes Association and

    skin care practices supported by the Agency for Healthcare Research and Quality (AHRQ) when planning care to meet the client’s

    hygiene needs.

    Nursing Process

    Assessment ;;

    As you prepare to provide hygiene care, conduct a brief history to determine important areas for hygiene care (Box 39-2). This helps

    to focus additional areas for assessment. Nursing assessment is an ongoing process. All body regions are not completely assessed

    before administering hygiene; however, routinely assess the client’s condition whenever giving care. For example, during oral care inspect the condition of the teeth and oral mucosa. When a client has a repeated problem (e.g., dry skin or inflamed oral mucosa),

    conduct an assessment before care is administered because variations in technique are often necessary. Hygiene care is an oppor-

    tunity to assess and identify findings for a variety of health care problems.

    While assisting a client with personal hygiene, carefully assess the integument, oral cavity structures, Physical Examination.

    and the eyes, ears, and nose (see Chapter 33). Using the skills of inspection and palpation, look for alterations in the integrity and

    function of tissues. The assessment also reveals the type and extent of hygienic care required. Give special attention to the charac-

    teristics most influenced by hygiene measures. Is the skin intact, especially over bony prominences? Is the skin dry from too much

    bathing? Are there calluses of the feet that will benefit from soaking? Is there a coating of the tongue that requires frequent brushing

    and hydration? Over time, this assessment provides the baseline for determining whether hygienic measures maintain or improve the

    client’s condition.

    While inspecting the skin, thoroughly examine color, texture, thickness, turgor, temperature, and hydration. The skin Skin.

    needs to be smooth, warm, and supple with good turgor. Pay special attention to the presence and condition of any lesions (see

    Chapter 33). In addition, it is important to assess for dryness indicated by flaking, redness, scaling, and cracking. This is more

    prevalent in the winter months when the humidity is lower. Certain common skin problems affect how you administer hygiene

    (Table 39-2). Also give special care to assess less obvious or difficult-to-reach skin surfaces, such as under the female client’s breasts, under the male client’s scrotum, or around the female’s perineal tissues. When you observe skin problems, explain proper

    skin care with the client and use the time to instruct in specific hygiene techniques. Certain conditions place clients at risk for impaired skin integrity (Box 39-3). Be particularly alert when assessing clients with

    reduced sensation, vascular insufficiency, and immobility. Be sure to assess both extremities and assist in turning a client so that you

    can fully view a skin surface. The development of pressure ulcers is a common complication that can extend hospital stays and

    threaten the well-being of the long-term care client. Identifying changes in skin color and determining if these changes are normal

    reactive hyperemia or abnormal reactive hyperemia is important in evaluating clients’ risks for pressure ulcers (see Chapter

    48).When client’s natural skin contains more melanin, it becomes more difficult to determine abnormal reactive hyperemia or

    cyanosis. When caring for clients with darkly pigmented skin, be aware of assessment techniques and skin characteristics unique to

    highly pigmented skin (Box 39-4).

    Assessment of the feet involves a thorough examination of all skin surfaces, including areas between the toes Feet and Nails.

    and over the soles of the feet. The heels, soles, and sides of the feet are prone to irritation from poorly fitting shoes. In addition,

    inspect the shape and size of toes and shape of the foot. The toes are normally straight and flat. The feet are in straight alignment with

    the ankle and tibia. Inspection of the feet for lesions includes noting areas of dryness, inflammation, or cracking.

    Observe the client’s gait. Painful foot disorders or decreased sensation cause limping or an unnatural gait. Ask whether the client has foot discomfort, and determine factors that aggravate the pain. Foot problems sometimes result from bone or muscular altera-tions or wearing poorly fitting footwear rather than skin disorders. Assess clients with peripheral vascular disease, such as those with diabetes mellitus and other diseases that affect peripheral circulation and sensation for the adequacy of circulation to the feet (see Chapter 33). Foot ulceration is the most common single precursor to lower extremity amputations among persons with diabetes (Frykberg and others, 2006). Daily inspection and following preventive foot care are important to maintaining ulcer-free feet. Palpation of the dorsalis pedis and posterior tibial pulses indicates whether adequate blood flow is reaching peripheral tissues. Edema and changes in skin color, texture, and temperature indicate if the client requires special hygienic care. Also check persons with diabetes mellitus for degeneration of the peripheral neuropathy,

    nerves characterized by a loss of sensation. Assess the client’s sensation to light touch, pinprick, and temperature (see Chapter 33). Inspect the condition of the fingernails and toenails, looking for lesions, dryness, inflammation, or cracking (Table 39-3). The nail is surrounded by a cuticle, which slowly grows over the nail. The skin around the nail beds and cuticles remain smooth and without inflammation. Ask women whether they frequently polish their nails and use polish remover, because chemicals in these

    products cause excessive nail dryness. Disease changes the shape and curvature of the nails (see Chapter 33). Inflammatory lesions and fungus of the nail bed cause thickened, horny nails, which separate from the nail bed.

    Inspect all areas carefully for color, hydration, texture, and lesions (see Chapter 33). Clients who do not follow Oral Cavity.

    regular oral hygiene practices sometimes have receding gum tissue, inflamed gums, a coated tongue, discolored teeth (particularly along gum margins), dental caries, missing teeth, and (bad breath). Localized pain and infection are common symptoms of halitosis

    a gum disease and certain tooth disorders.

    Clients in acute care settings require complete oral assessment. Identification of risks for infection and other conditions identifies the type and frequency of oral care. Proper oral care reduces pneumonia in nursing home residents because it reduces the bacterial count in oral secretions, which are aspirated, causing a bacterial infection (Research update, 2002). It is especially important to examine the oral cavity of clients receiving radiation or chemotherapy. Both treatments cause reduction in the amount of saliva, and, as a result, there is drying and inflammation of the oral mucosal tissues. The nurse’s assessment serves as a basis for preventive care for clients as they undergo treatment.

    Before performing hair care, assess the condition of the hair and scalp. Normally the hair is clean, shiny, and untangled, Hair.

    and the scalp is clear of lesions. The hair of dark-skinned clients is usually thicker, drier, and curlier than that of lighter-skinned clients. Table 39-4 summarizes hair and scalp problems. In the community health and home care settings it is particularly important to inspect the hair for lice so that you can provide appropriate hygienic treatment. If you suspect pediculosis capitis (head lice), guard against self-infestations by hand washing and using gloves or tongue blades to inspect the client’s hair. The loss of hair (alopecia)results from the effects of chemotherapy medications, hormonal changes, or improper hair care practices. Clients at risk for scalp problems are those who have experienced head trauma and those who practice poor hygiene.

    Examine the condition and function of the eyes, ears, and nose (see Chapter 33). Normally the eyes Eyes, Ears, and Nose.

    are free of infection and irritation. The sclerae are visible anteriorly as the white portion of the eye. The conjunctivae (the lining of the eyelids) are clear, pink, and without inflammation. The eyelid margins are in close approximation with the eyeball, and the lashes are turned outward. The lid margins are without inflammation, drainage, or lesions. The eyebrows are usually symmetrical. Another important aspect of an eye examination is to determine if the client wears contact lenses. This is especially significant for clients who enter hospitals or other agencies unresponsive or in a confused state. To determine if a contact lens is present, stand to the side of the client’s eye and observe the cornea for the presence of a soft or rigid lens. It is also important to observe the sclera to

    detect the presence of a contact lens that has shifted off the client’s cornea. An undetected lens causes severe corneal injury when left in place too long.

    Assessment of the external ear structures includes inspection of the auricle, external ear canal, and tympanic membrane. Use of an otoscope is necessary (see Chapter 33). While performing hygienic measures, look for the presence of accumulated or cerumendrainage in the ear canal, local inflammation, or tenderness on palpation or the client’s report of pain (see Chapter 33).

    Inspect the nares for signs of inflammation, discharge, lesions, edema, and deformity (see Chapter 33). The nasal mucosa is normally pink and clear and has little or no discharge. A clear, watery discharge is the result of allergies. If clients have any form of

    tubing exiting the nose (e.g., nasogastric), look at the nares surfaces that come in contact with the tubing for tissue sloughing,

    pressure areas, localized tenderness, inflammation, and bleeding.

    The normal process of aging influences the condition of body tissues and structures and thus the Developmental Changes.

    manner in which the client performs hygienic measures. Chapter 49 addresses the changes in hearing, vision, and olfaction across

    the life span as a result of growth and development.

    The neonate’s skin is relatively immature at birth. The epidermis and dermis are loosely bound together, and the skin is Skin.

    very thin. Friction against the skin layers causes bruising. Handle the neonate carefully during bathing. Any break in the skin can

    easily result in an infection.

    A toddler’s skin layers are more tightly bound together. Thus the child has a greater resistance to infection and skin irritation.

    However, because of the child’s more active play and the absence of established hygienic habits, parents and caregivers need to provide thorough hygiene and to begin teaching good hygiene habits.

    During adolescence the growth and maturation of the integument increases. In girls, estrogen secretion causes the skin to become

    soft, smooth, and thicker, with increased vascularity. In boys, male hormones produce an increased thickness of the skin with some

    darkening in color. Sebaceous glands become more active, predisposing adolescents to and sweat glands acne.Eccrineapocrine

    become fully functional during puberty. Adolescents usually begin to use antiperspirants. More frequent bathing and shampooing also

    become necessary to reduce body odors and eliminate oily hair. Sweating is usually more pronounced in boys. The condition of the adult’s skin depends on hygienic practices and exposure to environmental irritants. Normally the skin is

    elastic, well hydrated, firm, and smooth. When an adult practices frequent bathing or is exposed to an environment with low hu-midity, the skin becomes very dry and flaky.

    As we age, the skin loses its resiliency and moisture, and sebaceous and sweat glands become less active. The epithelium thins,

    and elastic collagen fibers shrink, making the skin fragile and subject to bruising and breaking. These changes warrant caution when

    turning and repositioning older adults (Meiner and Lueckenotte, 2006). Typically the older person’s skin is dry and wrinkled. Daily

    bathing as well as bathing with water that is too hot or soap that is harsh causes the skin to become excessively dry.

    During standing, the foot provides body support and absorbs shock. With aging, the feet begin to show signs of Feet and Nails.

    wear and tear. This occurs earlier if a person has failed to wear comfortable, supportive footwear. The cushioning layer of fat on the

    soles of the feet becomes thin.

    Chronic foot problems are a common part of poor foot care, improper fit of footwear, aging, or systemic disease. Older adults often have dry feet because of a decrease in sebaceous gland secretion, dehydration of epidermal cells, and poor condition of footwear. Fissures that result in itching frequently develop (Bryant and Beinlich, 1999). One of the most common problems for older

    adults is foot pain (Meiner and Lueckenotte, 2006). Painful feet are the result of congenital deformities, weak structure, injuries, and

    diseases such as diabetes, rheumatoid arthritis, or osteoarthritis. Arthritis is generally the cause for changes in the feet after age 55.

    Additional common problems of the feet include hammer and claw toes (flexion contractures); bunions, corns, and calluses; loss of

    sensation; and pathological nail conditions (Boyer, 2001).

    Fungal infections occur under toenails, causing dirty yellow streaks or total discoloration. The nails also become opaque, scaly,

    and hypertrophied. If foot or nail problems stay unresolved, the client can easily become disabled. Apply knowledge about typical

    changes in the feet and nails when anticipating the client’s hygiene needs.

     At approximately 6 to 8 months of age, infants begin teething. The first permanent (secondary) teeth erupt at about The Mouth.

    6 years of age (Hockenberry and Wilson, 2007). From adolescence, when all of the permanent teeth are in place, through middle adulthood, the teeth and gums remain healthy if a person follows good eating patterns and good dental care. Avoidance of fer-mentable carbohydrates and sticky sweets are central to keeping the teeth free of Regular brushing and flossing help to caries.

    prevent caries and periodontal disease.

    As a person ages, there are numerous factors that result in poor oral care. These include age-related changes of the mouth, chronic

disease such as diabetes, physical disabilities involving hand grasp or strength affecting the ability to perform oral care, lack of

    attention to oral care, and prescribed medications that have oral side effects. Aging teeth become brittle, drier, and darker in color.

    Teeth become uneven, jagged, and fractured; gums lose vascularity and tissue elasticity, which causes dentures to fit poorly. Often

    older adults are and wear complete or partial dentures. It is important to learn if older adults wear dentures and the edentulous

    condition of underlying supportive gum tissue.

    Throughout life, changes in the growth, distribution, and condition of the hair influence hair hygiene. As males reach Hair.

    adolescence, shaving becomes a part of routine grooming. Young girls who reach puberty often begin to shave their legs and axillae.

    With aging, as scalp hair becomes thinner and drier, shampooing is usually performed less frequently.

    Although much of hygiene care focuses on preventing infection and injury and maintaining The Eyes, Ears and Nose.

    function, be aware of developmental changes and risks to these special sensory organs. Although the structure of the eyes does not

    have marked developmental changes, altered visual acuity occurs at several points during the aging process; for example, when

    children start school or when clients reach middle age, there are sometimes changes in visual acuity. In addition, as clients age, they

    are at risk for changes in visual clarity, such as those that occur with glaucoma, and visual field losses, such as those that occur with

    macular degeneration or glaucoma.

    Structures of the ears do not change as the client ages; however, changes in hearing acuity or balance often occur with aging. In

    the young child changes in hearing acuity result from foreign objects being placed in the ear; this is usually temporary and is re-

    solved once the object is removed. Changes also result from repeated ear infections or exposure to loud music, especially when the

    child listens to loud music while wearing ear pods.

    Older adults have changes in the structure and function of the small bones in the inner ear that affect changes in hearing acuity.

    Aging results in increased cerumen production, which impedes hearing acuity. In addition, there are age-related changes in the

    movement of fluid through the semicircular canals, and the client sometimes experiences positional dizziness or some balance

    problem. Although changes in the sense of smell occur at any time, they seem to be more frequent in the older adult population. It is

    important to remember that changes in the sense of smell also affect taste and the client’s appetite.

    You need to fully assess and evaluate new and acute changes in the structure and function of the eyes, ears, and nose. Timely

    evaluation of these changes helps to identify other illnesses or verify that they are age related.

    For clients who wear eyeglasses, contact lenses, artificial eyes, or hearing aids, assess client’s know- Use of Sensory Aids.

    ledge and methods used for care and have the client describe his or her typical approach used in routine care (Box 39-5). Compare

    information gathered from the client with the proper care technique for these devices. Any difference between client practice and

    standard practice is an opportunity for client education.

    Clients with physical or cognitive impairments need assistance with all or some aspects of personal hygiene. Self-Care Ability.

    Assessment of the client’s physical and cognitive status determines specifically what aspects of hygiene care can be performed

    independently, those that require some assistance, and those that require total assistance. The nurse’s assessment includes measurement of a client’s muscle strength, flexibility and dexterity, balance, coordination, and activity tolerance necessary in performing activities such as bathing, brushing teeth, and bending over to inspect the feet (Figure

    39-5). The degree of assistance needed by a client during hygienic care also depends on vision, the ability to sit without support,

    hand grasp strength, the range of motion in the client’s extremities, or the presence of equipment, such as an intravenous (IV) line,

    dressings, or traction. Painful conditions of the upper extremities pose special problems. Assess self-care ability by observing clients

    performing activities, such as toothbrushing or combing the hair. Observe the client carefully, and note not only if the client is

    performing the activity correctly, but also if he or she is able to be thorough and complete the task. When clients have self-care limitations, part of the assessment determines if family or friends are available to assist. Assess how

    the family will assist the client, how often they will provide this assistance, and what their feelings are about being caregivers. In

    addition, assess the home environment and its influence on the client’s hygiene practices. Are there barriers in the home that affect

    the client’s self-care abilities? Water faucets that are too tight to easily adjust, bathtubs with high sides, and a bathroom too small to

    fit a chair in front of a sink are a few examples.

    Assessment of hygiene practices reveals the client’s preferences for grooming. For example, a client Hygiene Practices.

    chooses to groom the hair in a certain style or chooses to trim nails in a certain way. When a client has a physical disability, special precautions are necessary to perform grooming without injury. For example, special techniques are used when trimming toenails

    when the client has diabetes. Asking the client to assist or show how to perform preferred grooming practices gives the client a greater sense of independence and helps to avoid causing the client any discomfort or injury.

    A client’s cultural background influences hygiene needs. Culture plays a role not only in hygiene practices Cultural Factors.

    and preferences but also in sensitivity to personal space (see Box 39-1, p. 853 and Chapter 9). For example, some Chi-

    nese-Americans may view tasks associated with closeness and touch as being offensive or impolite, and Vietnamese-Americans feel very uneasy during a back rub. Ask a client what will make him or her feel most comfortable during a bath (Galanti, 2004). Perhaps the client prefers only a partial instead of a full bath from the nurse, with a family member completing the bathing of more private body parts. Some clients will also defer part of hygiene. If you believe hygiene is critical to prevent developing or worsening problems, such as skin breakdown, take the time to understand the client’s concerns and then offer an explanation that will help the

    client accept your intervention.

    There are clients who present risks that require more attentive and rigorous hy- Clients at Risk for Hygiene Problems.

    gienic care (Table 39-5). These risks result from side effects of medications, a lack of knowledge, an inability to perform hygiene, or a physical condition that potentially injures the skin, integument, or other structures. For example, an immobilized client with a fever requires more frequent bathing to minimize perspiration on the skin and more frequent turning and positioning to reduce the chance of skin breakdown.

    Anticipate whether a client is predisposed to any risks, and follow through with a complete assessment. For example, if a client is receiving cancer chemotherapy, there is the risk of the medication destroying normal flora in the mouth, allowing for the overgrowth of opportunistic bacteria. Therefore be more thorough and detailed during the oral examination, checking all surfaces of the tongue and mucosa. If a client is diaphoretic, provide special attention to body areas, such as beneath the woman’s breasts and perineal area, to check where moisture collects and irritates skin surfaces. Anticipate problems created by these risks to provide preventive care. Assessment includes a review of the client’s medical and surgical history, medications, and the specific risk factors the client is likely to have.

    Depending on the type of hygiene needed, there are focused as- Special Considerations in Hygiene Assessment.sessments that are important to conduct. For example, before giving foot care, assess the type of footwear a client wears. Children or young adults who frequently fail to wear socks have excess perspiration that promotes fungal growth. Tight or poorly fitting shoes, socks, garters, or knee-high nylon stockings cause skin irritation and interfere with circulation to the feet. Also determine whether clients wear clean footwear daily because repeated use of soiled footwear leads to infection. If the client has diabetes mellitus or other peripheral vascular disease, it is extremely important to wear the correct footwear. People with evidence of increased plantar pressure (e.g., erythema, warmth, callus, or measured pressure) use footwear that cushions and redistributes the pressure. People with bony deformities (e.g., hammertoes, prominent metatarsal heads, and bunions) may need extrawide or extradeep shoes. People with extreme bony deformities (e.g., Charcot’s foot) who cannot be accommodated with commercial therapeutic footwear may need

    custom-molded shoes (American Diabetes Association, [ADA], 2007). A client’s eating patterns are important to assess before oral care. The presence of any problems helps to locate abnormalities. Ask

    clients if any problems are noted with chewing, denture fit, or swallowing. A client may have changed the type of food in the diet as a result of chewing difficulties. The presence of an ulcer or irritation sometimes impairs chewing and causes a client to avoid eating. This is common in an older adult with poorly fitting dentures.

    As is the case in any nursing assessment, it is important to know what a client expects from nursing care. Client Expectations.

    In regard to hygienic care, some clients simply expect to have hygiene preferences and practices applied in the health care setting. Ask questions such as “To make you most comfortable and feel at home, how can I best perform your bath and personal care?” or “How can we help you care for your teeth, nails, and hair, now that you are back home?”

    Learning a client’s expectations and applying them in practice is important in establishing a caring relationship. Truly indivi-

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