Skin and Perineal
3 layers of the skin
Common problems of the feet affecting older adults
corns, calluses, bunions, hammertoes and fungal infections
Lips surrounding the opening of the mouth, cheeks, tongue and its muscles, hard and soft palate, mucous membrane
Planning involves... (3 things)
Goals and outcomes
Set priorities based on assistance required, extent of problems, nature of nursing diagnoses
Teamwork and collaboration
Hair and scalp care includes...
Brushing and combing
Shampooing
Shaving
Mustache and beard care
Why is perineal care important?
Maintains skin integrity, relieve discomfort, and prevents transmission of micro-organisms
These problems may be overlooked and contribute to comfort, mobility, and quality of life.
Looking at this specifically in the oral cavity (not anatomical regions)
color, hydration, texture and lesions
Common diagnoses associated with hygiene
Activity Intolerance
Impaired Dressing and Grooming
Impaired Mobility
Impaired Health Maintenance
Impaired Skin Integrity
Ineffective health maintenance
Risk for infection
Bathe clients to...
cleanse the body, stimulate circulation, provide relaxation, and enhance healing.
Perineal care in males vs. females
For females, a downward motion should be used to clean the area, while it is best to use a circular motion and go from the top to the bottom for males. Foreskin should be retracted, and then replaced after care.
Conditions of the hands/feet influence patient's ability to...
receding gum tissue, inflamed tongue (glossitis), discolored, broken or missing teeth
Assess nose for...
inspect nares for inflammation, discharge, lesions, deformity. Nasal mucosa is normally pink, white and clear, with little to no discharge
Health promotion includes...
Make any instruction relevant based on your assessment of the patient’s knowledge, motivation, preferences, and health beliefs.
Teach patients ways to avoid injury.
Reinforce infection control practices.
2 components of skin assessment
Assessment of self-care ability
Physical assessment of the skin
Problems of the feet, hands, and nails may be the result of...
nail-biting, trimming nails too short, exposure to harsh chemicals, wearing poorly fitted shoes
loss of hair. Often appears as brittle and broken hair in the hair line, that progresses to bald patches.
What is alopecia?
Assess ears for...
Observe for accumulated earwax or drainage and any pain or localized inflammation
Hygiene considerations for older adults (5)
Skin is drier, thinner and will not tolerate as much bathing
Higher incidence of infection and periodontal disease
Dentures must fit correctly, or they can cause digestive issues, pain and discomfort. Dentures are pt’s private property. Never leave them on meal tray or where they could be damaged or lost
Dry mouth is common in older adults due to decreased saliva production, and use of certain medications
Poor nutritional status is often due to dental problems, socioeconomic status, or a limited ability to prepare healthy foods
What do you look for in an assessment of the skin?
Color, texture, thickness, turgor, temperature
Lesions? Wounds? Redness?
Excessive moisture, soiling or debris
Separate skin folds and look all areas (under breasts, groin)
4 assessment components for feet and nails
Examine all skin surfaces including areas between fingers and toes and over the entire sole of the foot
Inspect for lesions, excess dryness, inflammation, edema or cracking
Observe patient’s gait
Determine factors that aggregates pain
Hair care practices focus on...
scalp, axilla and PUBES
Assess eyes for...
redness, inflammation, ask if patient wears contact lenses
3 types of bath
Complete Bed Bath: patients who can tolerate it and whos hygiene warrants it
Partial Bed Bath: useful when clients cannot tolerate a complete bath, need partial cleansing of odorous or uncomfortable areas, or can perform part of the bath independently.
Theraputic Baths: To promote comfort and/or provide treatment, such as soothe itchy skin.