INFECTION

IS AN INVASION OF BODY TISSUE BY MICROORGANISMS AND

THEIR PROLIFERATION THERE.
MICROORGANISM IS CALLED INFECTIOUS AGENT.
IF MICROORGANISM PRODUCES NO CLINICAL EVIDENCE OF
DISEASE, IT IS CALLED ASYMPTOMATIC OR SUBCLINICAL.

DISEASE
DETECTABLE ALTERATION IN NORMAL TISSUE FUNCTION.
COMMUNICABLE DISEASE – AIRBORNE INFECTION.

PATHOGENICITY
ability to produce disease.
PATHOGEN – microorganism that causes diseases.
OPPORTUNISTIC PATHOGEN – causes disease only in a susceptible individual.

ASEPSIS

freedom from disease-causing microorganism.

Used to decrease the possibility on transferring microorganism from one place to another.
MEDICAL ASEPSIS – includes all practices intended to confine a speciic microorganism to a
specific area, limiting the number, growth and transmission of microorganism.
SURGICAL ASEPSIS or STERILE TECHNIQUE – practices that keep an area or object free of all
microorganism. It includes practices that destroy all microorganism and spores. It is used for all
procedures involving the sterile areas of the body.
SEPSIS – state of infection.

TYPES OF MICROORGANISM CAUSING INFECTION

1. BACTERIA – most common infection-causing microorganisms. It transported through air, water,

food, soil, body tissues and fluids and inanimate objects.
 2. VIRUSES – consists primarily of nucleic acid and therefore must enter living cells in order to
reproduce.

3. FUNGI – A fungus is a member of a large group of eukaryotic organisms that includes

microorganisms such as yeasts and molds, as well as the more familiar mushrooms. The fungi
are classified as a kingdom that is separate from plants, animals and bacteria.

4. PARASITES – live on other living organisms. It includes protozoa such as the one that causes
malaria, helminthes (worms), anthropods (mites, fleas, ticks).

TYPES OF INFECTION

COLONIZATION – process by which strains of microorganism become resident flora. Microorganism may
grow and multiply but do not cause disease.

1. LOCAL INFECTION – limited to the specific part of the body where the organisms remain.
2. SYSTEMIC INFECTION – if microorganism spread and damage different parts of the body.
BACTEREMIA – when a culture of a person’s blood reveals microorganisms.
SEPTICEMIA – when bacteria results in systemic infection.
3. ACUTE AND CHRONIC INFECTION
ACUTE – generally appear suddenly and may last for a short time.
CHRONIC – may occur slowly, over a long period and may last months or year.
4. NOSOCOMIAL INFECTION – associated with the delivery of health care services in a health care
facility. It can either develop during a client’s stay in a facility or manifest after discharge.
ENDOGENOUS SOURCE – microorganism that causes nosocomial infection can originate
from the client themselves.
EXOGENOUS SOURCE – microorganism that causes nosocomial infection can originate from
the hospital environment and personnels.
5. IATROGENIC INFECTION – direct result of diagnostic or therapeutic procedures.
 CHAIN OF INFECTION

INFECTIOUS AGENT
A microbial organism with the ability to cause disease. The greater the organism's virulence
(ability to grow and multiply), invasiveness (ability to enter tissue) and pathogenicity (ability to
cause disease), the greater the possibility that the organism will cause an infection. Infectious
agents are bacteria, virus, fungi, and parasites.

II. RESERVOIR
A place within which microorganisms can thrive and reproduce. For example, microorganisms
thrive in human beings, animals, and inanimate objects such as water, table tops, and
doorknobs.

III. PORTAL OF EXIT

A place of exit providing a way for a microorganism to leave the reservoir. For example, the
microorganism may leave the reservoir through the nose or mouth when someone sneezes or
coughs. Microorganisms, carried away from the body by feces, may also leave the reservoir of
an infected bowel.

IV. MODE OF TRANSMISSION

Method of transfer by which the organism moves or is carried from one place to another. The
hands of the health care worker may carry bacteria from one person to another.

a. DIRECT TRANSMISSION – involves immediate and direct transfer of microorganisms from

person to person through touching, biting, kissing or sexual intercourse.

b. INDIRECT TRANSMISSION – it can be either vehicle-borne or vector-borne.

1. VEHICLE-BORNE TRANSMISSION – A vehicle is any substance that serves as an

intermediate means to transport and introduce an infectious agent into a
susceptible host through a suitable portal of entry.
 2. VECTOR-BORNE TRANSMISSION – A vector is an animal or flying or crawling
insects that serves as an intermediate means of transporting the infectious agent.

c. AIRBORNE TRANSMISSION – it may involve droplets or dust. Droplets nuclei, the residue
of evaporated droplets emitted by an infected host such as someone with tuberculosis, can
remain in the air for long periods.

V. PORTAL OF ENTRY
An opening allowing the microorganism to enter the host. Portals include body orifices, mucus
membranes, or breaks in the skin. Portals also result from tubes placed in body cavities, such as
urinary catheters, or from punctures produced by invasive procedures such as intravenous fluid
replacement.

VI. SUSCEPTIBLE HOST

A person who cannot resist a microorganism invading the body, multiplying, and resulting in
infection. The host is susceptible to the disease, lacking immunity or physical resistance to
overcome the invasion by the pathogenic microorganism.

BODY DEFENSES AGAINST INFECTION

Individual normally have defenses that protect the body from infection. These defenses can be
categorized as non-specific and specific.

NONSPECIFIC DEFENSES
protect the person against all microorganisms regardless of prior exposure.

a. ANATOMIC and PHYSIOLOGIC BARRIERS

Intact skin and mucous membranes are the body’s first line of defense against microorganisms.

The nasal passages have a defensive function.

Each body orifice also has protective mechanisms.

The eye is protected from infection by tears, which continually wash microorganisms away and
contain inhibiting lysozyme.

The gastrointestinal tract also has defenses against infection.

The vagina also has natural defenses against infection.

b. INFLAMMATORY RESPONSE

Inflammation is a local and nonspecific defensive responses o the tissues to an injurious or

infectious agent. It is an adaptive mechanism that destroys or dilutes the injurious agent,
prevents further spread of the injury and promotes the repair of damaged tissue. It is
characterized by five signs: a) pain, b) swelling, c) redness, d) heat and e) impaired function of
the part, if injury is severe. Commonly, words with the suffix –itis described an inflammatory
process.

A series of dynamic events is commonly referred to as the three stages of the

inflammatory response.

a. VASCULAR AND CELLULAR RESPONSE – At the start of the first stage of

inflammation, constrictions of the blood vessels occurs at the site of injury., lasting
only a few moments. This initial constriction is rapidly followed by the dilation of
small blood vessels. Thus, more blood flows to the injured area. Vascular
permeability increases at the injured site with the dilation of the vessels in response
to all death, the release of chemical mediators and the release of histamine.

b. EXUDATE PRODUCTION – In the second stage of inflammation, the inflammatory

exudates is produced, consisting of fluid that escaped from the blood vessels, dead
phagocytic cells, and dead tissue cells and the product they released. During the
second stage, the injurious agent is overcome and the exudates is cleared away by
lymphatic drainage. The nature and amount of exudates vary according to the tissue
involved and the intensity and duration of inflammation.

c. REPARATIVE PHASE – The third stage of the inflammatory response involve the
repair of injured tissue by regenerationor replacement with fibrous tissue (scar)
formation. Regeneration is the replacement of destroyed tissue cells by cells that
are identical or similar in structure and function.

SPECIFIC DEFENSES
Involves the immune system

An antigen , substance that indicates a state of sensitivity of immune responsiveness

(immunity). If the proteins originated in person’s own body, the antigen is called an
autoantigen.

The immune response has two components: antibody-mediated defense and cell-
mediated defenses.

a. ANTIBODY-MEDIATED DEFENSES – also called as HUMORAL (or

CIRCULATING) IMMUNITY because these defenses reside ultimately in the B
lymphocytes and are mediated by antibodies produced by B cells. Antibodies
also called as immunoglobulins, are part of the body’s plasma proteins. The
 antibody-mediated responses defend primarily against the extracellular
phases of bacterial and viral infections.

b. CELL-MEDIATED DEFENSES – The cell-mediated defenses, or cellular

immunity occur the T-cell system. On exposure to an antigen, the lymphoid
tissues release large numbers of activated T-cells into the lymph system.
There are three main groups of T-cells, a) helper T-cells, which helps in the
function of the immune system, b) cytotoxic cells, which attack and kill
microorganism and sometimes the body’s own cell, and c) suppressor T-cells,
which can suppress the functions of the helper T-cells and the cytotoxic cells.

TYPES OF IMMUNITY
Immunity is the ability of the body to resist becoming infected upon exposure to a
microorganism or parasite. The body's various modes of resistance to attack give rise to
different terminology to describe the types of immunity.

Term Definition Example

ACTIVE DPT immunization

IMMUNITY
immunity acquired actively, as when exposure to a exposure to an upper respiratory virus
vaccine induces formation of antibodies that mark
foreign substances for destruction

PASSIVE gamma-globulin injections for

IMMUNITY immunodeficient patients
immunity transferred to the patient
"passively,"rather than formed by the patient maternal immunity to infections
himself; usually in the form of antibody protein transferred via the bloodstream prior to
substances delivery or in breast milk

FACTORS INCREASING THE SUSCEPTIBILITY TO

INFECTION
1. AGE. Newborns and older adults have reduced defenses against infection.
2. HEREDITY. Heredity influences the development of infection in that some people have a genetic
susceptibility to certain infections.

3. NATURE, NUMBER, and DURATION OF PHYSICAL and EMOTIONAL STRESSORS.

4. RESISTANCE. Depends on adequate nutritional status.

5. MEDICAL THERAPIES.

6. MEDICATIONS

7.DISEASES THAT LESSENS THE BODY’S DEFENSE.

SUPPORTING DEFENSES OF A SUSCEPTIBLE

HOST
1. HYGIENE

2. NUTRITION

3. FLUID

4. REST AND SLEEP

5. STRESS

6. IMMUNIZATIONS
 ASEPSIS
Is the absence of microorganisms. Providing nursing care using aseptic technique
decreases the risk and spread of nasocomial infections.

Aseptic technique

Is the infection control practice used to prevent the transmission of pathogens.

2 types of asepsis:
Medical Asepsis
 Includes all practices intended to confine a specific microorganism to a specific
area, limiting the number, growth, and transmission of most all microorganisms.
In medical asepsis, objects are referred to as clean, which means the absence of
almost all microorganisms, or dirty (soiled, contaminated), which means likely to
have microorganisms; some of which may be capable of causing infection.
 Uses practices to reduce the number, growth, and spread of microorganisms.
Medical asepsis is also referred to as “clean technique.” Objects are generally
referred to as “clean” or “dirty” in medical asepsis. Clean objects are considered
to have the presence of some microorganisms that are usually not pathogenic.
Dirty (soiled) objects are considered to have a high number of microorganisms,
with some that are potentially pathogenic. Common medical aseptic measures
used for clean or dirty objects are hand washing, gloving, changing linens daily,
and cleaning floors and hospital furniture daily.
 HAND WASHING
Is important in every setting, including hospitals. It is considered one of the most
effective infection control measures. Any client may harbor microorganisms that are
currently harmless to the client if they find a portal of entry. It is important that both
nurses’ and the clients’ hands be washed at the following times to prevent the spread of
microorganisms: before eating, after using the bedpan or toilet, and after the hands
have come in contact with any body substances, such as sputum or drainage from a
wound. In addition, health care workers should wash their hands before and after giving
care of any kind.
For routine client care, the CDC recommends antimicrobial foam, hand gel, or vigorous
hand washing under a stream of water for at least 10 seconds using granule soap are
usually provided in high-risk areas, such as the newborn nursery, and are frequently
supplied in dispensers at the sink. Studies have shown that the convenience of
antimicrobial foams and gels, which do not require soap and water, may increase health
care worker’s adherence to hand cleansing. The CDC recommends antimicrobial hand
washing agents in the following situations:

• When there are known multiple resistant bacteria

• Before invasive procedures
• In special care units, such as nurseries and ICUs
• Before caring for severely immunocompromised clients.

It is important to recognize that hand washing with either plain soap or antimicrobial
soap can damage the skin through the drying effect of the detergents or chemicals. If
the nurse develops dermatitis, the client may be at higher risk because hand washing
does not decrease bacterial counts on skin with dermatitis. The nurse is also at higher
risk because the normal skin barrier has been broken. Although lotions, moisturizers,
and emollients have been tried, no research has yet confirmed their effectiveness in
decreasing the problem.

• Surgical Asepsis

An object is sterile only when it is free of all microorganisms. It is well known that sterile
technique is practiced in operating rooms, labor and delivery rooms, and special
diagnostic areas. Less known perhaps is that sterile technique is also employed for many
procedures in general care areas (such as administering injections, changing wound
dressings, performing catheterizations, and administering intravenous therapy). In these
situations, all of the principles of surgical asepsis are applied as in the operating or
delivery room; however, not all of the sterile techniques that follow are always
required. For example, before an operating room procedure, the “scrub” nurse
generally puts on a mask and cap, performs a surgical hand scrub, and then dons a
 sterile gown and gloves. In a general care area, the nurse may only perform a hand wash
and don sterile gloves.

Sterile field

Is a microorganism-free area. Nurses often establish a sterile field by using the

innermost side of a sterile wrapper or by using a sterile drape. When the field is
established, sterile supplies and sterile solutions can be placed on it. Sterile forceps are
used in many instances to handle and transfer the sterile supplies.
So that their sterility can be maintained, supplies may be wrapped in a variety of
materials. Commercially prepared items are frequently wrapped in plastic, paper, or
glass. In the past, it was not usual for sterile liquids e.g. sterile water for irrigations to be
supplied in large containers and used many times. This practice is considered
undesirable today because once a container has been opened, there can be no
assurance that it is sterile. Liquids are preferably packaged in amounts adequate for one
use only. Any leftover liquids discarded.

Sterile Gloves

May be donned by the open method or the closed method. The open method is most
frequently used outside the operating room because the closed method requires that
the nurse wear a sterile gown. Gloves are worn during many procedures to maintain the
sterility of equipment and to protect a client’s wound.
Sterile gloves are packaged with a cuff of about 5 cm [2 in] and with the palms facing
upward when the package is opened. The package usually indicates the size of the glove
[e.g., size 6 or 7 ½ ].
Latex, nitrile, and vinyl sterile gloves are available to protect the nurse from contact with
blood and body fluids. Latex and nitrile are more flexible than vinyl, mold to the
wearer’s hands, allow freedom of movement, and have the added feature of resealing
tiny punctures automatically. Therefore, wear latex or nitrile gloves when performing
tasks [a] that demand flexibility, [b] that place stress on the material [e.g., turning
stopcocks, handling sharp instruments or tape], and [c] that involve a high risk of
exposure to pathogens. Vinyl gloves should be chosen tasks unlikely to stress the glove
material, requiring minimal precision, and with minimal risk of exposure to pathogens.

Sterile Gowns

Sterile gowning and closed gloving are chiefly carried out in operating or delivery rooms,
where surgical asepsis is necessary. The closed method of gloving can be used only
when a sterile gown is worn because the gloves are handled through the sleeves of the
gown. Before these procedures, the nurse dons a hair cover and a mask, and performs a
surgical hand wash.

Donning Surgical Attire

 Surgical nurses are required to wear a surgical mask and a clean cloth or paper cap that
covers all of the hair. After the cap is applied, the nurse positions the mask to cover the
nose and mouth. Protective eyewear [glasses or goggles] is worn during all procedures
that pose a threat of splashing body fluids into eyes.

Surgical handwashing
Surgical handwashing or scrub is used to remove soil and moist transient
microorganisms from the skin. Nurses working in the operating room perform surgical
handwashing to decrease the client’s risk for an infection. The skin on the nurse’s hands
and arms should be intact [free of lesions].

HYGIENE
is the science of health and its maintenance. Personal hygiene is the self-care by which
people attend to such functions as bathing, toileting, general body hygiene, and grooming.

HYGIENIC CARE

Early Morning Care

provided to clients as they awaken in the morning.

e.g. washing face& hands, providing urinal or bedpan to the client confined to bed, and
giving oral care.

Morning Care
often provided after clients have breakfast/ before breakfast/

e.g. elimination needs, bath/shower, perineal care, back massages, and oral, nail, and
hair care.

Afternoon Care
 e.g. providing bedpan/urinal, washing the hands and face, and assisting w/ oral care to
refresh the clients.

Hour of Sleep (HS) Care

provided to clients before they retire for the night.

e.g. providing elimination needs, washing face & hands, giving oral care, and giving a
back massage.

As-needed (PRN) Care

provided as required by the patient.

e.g. A client who is diaphoretic may need more frequent bathing and a change of clothes
and linen.

Factors Influencing Individual Hygienic Practices

Culture- some cultures consider privacy essential for bathing, whereas others practice
communal bathing. A body odor is offensive in some cultures and accepted as normal in
others.
Religion – communal washings are practiced by some religions.
Environment – finances may affect the availability of facilities for bathing.
Developmental Level – children learn hygiene in the home.
Health and Energy – ill people may not have the motivation or energy to attend hygiene.
Personal Preferences- some people prefer a shower bath to a tub bath.

EYES
Normally eyes require no special hygiene because lacrimal fluid continually washes the
eyes, and the eyelids and lashes prevent the entrance of foreign particles. Special
interventions are needed, however, for unconscious clients and for clients recovering
from eye surgery or having eye injuries, irritations, or infections.
General Eye Care
Avoid home remedies for eye problems.
If dirt/dust gets into the eyes, clean them copiously w/ clean, tepid water as an
emergency treatment.
Take measures to guard against eye strain and to protect vision, such as maintaining
adequate lighting for reading and obtaining shatterproof lenses for glasses.
Schedule regular examinations, particularly after age 40, to detect problems such as
cataracts and glaucoma.

Eye Glass Care

glass lenses can be cleaned w/ warm water and dried w/ a soft tissue that will not
scratch the lenses. Plastic lenses are easily scratched and may require special cleaning
solutions and drying tissues.

Contact Lens Care

Contact Lens- thin, curved discs of hard or soft plastic and fit on the cornea of the eye
directly to the pupil.
Hard Contact Lens- made of rigid, unwettable, airtight plastic that does not absorb water
or saline solution.
Soft Contact Lens- cover the entire cornea.
Gas- Permeable Lens- rigid enough to provide clear vision but are more flexible than the
traditional hard lens.

Eye Care for the Comatose Client

administer moist compress to cover the eyes every 2-4 hours.
Clean the eyes w/ saline solution and cotton balls. Wipe from the inner canthus- outer
canthus. This prevents debris from being washed into the nasolacrimal duct.
Use a new cotton ball for each wipe.
Instill ophthalmic ointment/ artificial tears into the lower lids as ordered.
Monitor the eyes for redness, exudate or ulceration.

EARS
Normal ears require minimal hygiene. Clients who have excessive cerumen(earwax) and
dependent clients who have hearing aids may require assistance from the nurse.
Cleaning the Ears
the nurse/client must remove excessive cerumen that is visible or that causes discomfort
or hearing difficulty. Visible cerumen may be loosened and removed by retracting the
auricle up and back. If this measure is ineffective, irrigation is necessary.

Care of the Hearing Aids

Hearing Aid- is a battery- powered, sound amplifying device used by persons w/ hearing
impairments.

Types of Hearing Aids

behind-the-ear (BTE, or postural) aid- this is the most widely-used type because it fits
snugly behind the ears.
In-the-ear(ITE, or intra-aural) aid- this one piece aid has all its components housed in the
earnold.
In-the-canal(ITC) aid- this is the most compact and least visible aid, fitting completely
inside the ear canal.
Eyeglass aid-similar to the BTE aid but the components are housed in the temple of the
eyeglasses.

NOSE

Nurses usually need not provide special care for the nose, because clients can ordinarily
clear nasal secretions by blowing gently into a soft tissue.
 ORAL HYGIENE
Practice of keeping the mouth and teeth clean to prevent dental problems and bad
breath
Helps to maintain the healthy state of the mouth, teeth, gums, and lips.

TOOTH CLEANING
Teeth cleaning is the removal of dental plaque and tartar from teeth to prevent cavities,
gingivitis, and gum disease. Severe gum disease causes at least one-third of adult tooth
loss.

Since before recorded history, a variety of oral hygiene measures have been used for
teeth cleaning. This has been verified by various excavations done all over the world, in
which chewsticks, tree twigs, bird feathers, animal bones and porcupine quills were
recovered. Many people used different forms of teeth cleaning tools. Indian medicine
(Ayurveda) has used the neem tree (a.k.a. daatun) and its products to create teeth
cleaning twigs and similar products for millennia. A person chews one end of the neem
twig until it somewhat resembles the bristles of a toothbrush, and then uses it to brush
the teeth. In the Muslim world, the miswak, or siwak, made from a twig or root with
antiseptic properties has been widely used since the Islamic Golden Age. Rubbing baking
soda or chalk against the teeth was also common.

Generally, dentists recommend that teeth be cleaned professionally at least twice per
year. Professional cleaning includes tooth scaling, tooth polishing, and, if too much
tartar has built up, debridement. This is usually followed by a fluoride treatment for
children and adults.
Between cleanings by a dental hygienist, good oral hygiene is essential for preventing
tartar build-up which causes the problems mentioned above. This is done by carefully
and frequently brushing with a toothbrush and the use of dental floss to prevent
accumulation of plaque on the teeth.

PLAQUE
Plaque is a sticky film that forms on the teeth and gums. The bacteria in plaque releases
acid that attacks tooth enamel. Tooth decay can occur after repeated attacks. You might
not even know it, but some of the foods we eat can cause plaque bacteria that produce
acids. Thorough daily brushing and flossing can prevent tartar from forming on the
teeth.

Plaque can also cause irritation to the gums, making them red, tender, or bleeding
easily. In some cases, the gums pull away from the teeth and causes pockets that fill
with pockets of bacteria and puss. If this is not treated, bones around the teeth can be
destroyed. Teeth may become loose or have to be removed as with periodontal (gum)
disease in mostly adults. Eating a balanced diet and limiting snacks can prevent tooth
decay and periodontal disease. Nutritious foods such as raw vegetables, plain yogurt
cheese, or a piece of fruit are considered good snack foods to grab.

INTERDENTAL BRUSHING
Periodontologists nowadays prefer the use of interdental brushes to dental floss. Apart
from being more gentle to the gums, it also carries less risk for hard dental tissue
damage. There are different sizes of brushes that are recommended according to the
size of the interdental space. It is desirable to clean between teeth before brushing to
enable easy access for the saliva fluoride mix to remineralise any demineralised tooth
often resulting from food left on teeth after every meal or snack.

FLOSSING
The use of dental floss is an important element of the oral hygiene, since it removes the
plaque and the decaying food remaining stuck between the teeth. This food decay and
plaque cause irritation to the gums, allowing the gum tissue to bleed more easily. Acid
forming foods left on teeth also demineralise tooth eventually causing cavities. Flossing
for a proper inter-dental cleaning is recommended at least once per day, preferably
before bedtime, to help prevent receding gums, gum disease, and cavities between the
teeth.

PROCEDURE OF FLOSSING
 Use 18 in of floss, wrapping it around your two middle fingers. Leave an inch or two of
floss to work with.
Holding the floss tightly, gently move the floss up and down between teeth.
Go beneath the gumline by curving the floss around each tooth.
Use a clean section of the floss when moving from tooth to tooth.
To remove floss, use the same back and forth motion to gently bring the floss away from
teeth.

CLEANING THE TONGUE

Cleaning the tongue as part of the daily oral hygiene is essential, since it removes the
white/yellow bad-breath-generating coating of bacteria, decaying food particles, fungi
(such as Candida), and dead cells from the dorsal area of tongue. Tongue cleaning also
removes some of the bacteria species which generate tooth decay and gum problems.

GUM CARE
Massaging gums with toothbrush bristles is generally recommended for good oral
health. Flossing is recommended at least once per day, preferably before bed, to help
prevent receding gums, gum disease, and cavities between the teeth.

ORAL IRRIGATION
Dental professionals usually recommend oral irrigation as a great way to clean teeth and
gums.

Oral irrigators can reach 3–4 mm under the gum line, farther than toothbrushes and
floss. And, the jet stream is strong enough to remove all plaque and tartar. The
procedure does leave a feeling of cleanliness and freshness, and does disrupt more
plaque or bacteria as floss since it cleans deeper.

NURSING MANAGEMENT
Assessing
Nursing History
Physical Assessment
 Identifying clients at risk

Diagnosing
Self-care deficit, inability to brush/floss teeth or clean dentures.
Impaired oral mucous membrane, a state in which an individual experiences
disruptions in the tissue layers of the oral cavity.
Deficient knowledge

Planning
Monitor every shift for dryness of the oral mucosa.
Monitor for signs and symptoms of glossitis and stomatitis.
Assist dependent clients with oral care.
Provide special hygiene for clients who are debilitated, are unconscious, or have lesions
of the mucous membranes or other oral tissues.
Teach clients about good oral hygiene practices and other measures to prevent tooth
decay.
Reinforce the oral hygiene regimen as part of discharge teaching.

Implementing
Promoting oral health through the life span

Infants and Toddlers

Beginning at about 18 months of age, brush the child’s teeth with a soft toothbrush.
Give a fluoride supplement daily or as recommended by the primary care provider or
dentist.
Schedule an initial dental visit for the child at about 2 or 3 years of age, as soon as all 20
primary teeth have erupted.
Some dentists recommend an inspection type of visit.
Seek professional dental attention for any problems.

Preschoolers and School-age children

Fluoride
Parental supervision
Regular dental check ups

Adolescents and Adults

Proper diet and tooth and mouth care

Older Adults
Evaluating
The nurse judges whether desired outcomes have been reached.
If outcomes are not reached, reasons must be explored before modifying the care plan.

HAIR
The appearance of the hair often reflects a person’s feelings of self-concept
sociocultural well-being.

Developmental Variations
Newborns may have Lanugo over their shoulders, back and sacrum. This generally
disappears, and the hair distribution of the eyebrows, head, and eyelashes of young
children becomes noticeable.
Pubic hairs usually appears in early puberty, followed in about 6 months by the growth
of axillary hair.

NURSING MANAGEMENT
Assessing
Assessment of the clients hair, hair care practices, and potential problems includes a
nursing health history and physical assessment.
Physical Assessment
 Hair Problems:
 Dandruff
- A diffuse scaling of the scalp.
o Hair Loss
 - Hair loss and growth are continual processes.
o Ticks
- Small gray-brown parasites that bite into tissue and suck blood.

 Pediculosis (Lice)
- Infestations with Lice.
 Pediculus Capitis
 Pediculus Corporis
 Pediculus Pubis

 Scabies
- Is a contagious kin infestations by the itch mite.

 Hirsutism
- The growth of excessive body hair.

Diagnosing
Self-Care Deficit
 Activity intolerance
 Imposed immobility (bed rest)
 Pain in upper extremities
 Altered level of consciousness
 Lack of motivation associated with depression

Planning
In planning care, the nurse and, if appropriate, the client and/or set outcomes for each
nursing diagnosis. The nurse then performs nursing interventions and activities to achieve
the client outcomes. Identifying Nursing Diagnosis, Outcomes, and Interventions provides
suggested outcomes and interventions for hair grooming.

Implementing
Hair needs to be brushed or combed daily and washed, as needed, to keep it clean. Nurses
may need to provide hair care for clients who cannot meet their own self-care needs.
 BRUSHING AND COMBING HAIR
To be healthy the hair needs to be brushed daily. Brushing has three major functions:
It stimulates the circulation of blood in the scalp
It distributes the oil along the hair shaft
It helps to arrange the hair
Long hair may present a problem for the clients confined to bed because it may become
matted. It should be combed and brushed at least once a day to prevent this. A brush with
stiff bristles provides the best stimulation to blood circulation in the scalp.
The bristles should not be sharp.

Clinical alert

Excessively matted or tangled hair may be infested with lice

PROVIDING HAIR CARE FOR CLIENTS

Purposes

To stimulate the blood circulation on the scalp

To distribute hair oils and provide healthy sheen
To increase the client’s comfort
To assess or monitor hair scalp problems

NURSING MANAGEMENT

Assessment
Determine
History of the following conditions or therapies: recent chemotherapy, hypothyroidism,
radiation of the head, unexplained hair loss, and growth of excessive body hair.
Usual hair care practices and routinely used hair care products

Assess
Condition of the hair and scalp.
 Evenness of hair growth over the scalp, in particular, any patchy loss of hair; hair texture,
oiliness, thickness, or thinness; presence of lesions , infections, or infestations on the scalp;
presence of hirsuitism.
Self-care abilities

Planning
Delegation

Brushing and combing hair, shampooing hair, and shaving facial hair can be delegated to
UAP unless the client has a condition in which the procedure would be contraindicated. The
nurse needs to assess the UAP’s knowledge and experience of hair care for clients of other
cultures, if appropriate.

Equipment

Clean brush and comb

A wide-toothed comb is usually used for many back-skinned people because finer combs
pull the hair into knots and may also break the hair
Towel
Hair oil preparation

Implementation
Performance

1. Prior to performing the procedure, introduce self and verify the client’s identity using agency
protocol. Explain to the client what you are going to do, why it is necessary, and how he or she
can cooperate.
2. Perform hand hygiene and observe other appropriate infection control procedures
3. Provide for client privacy by drawing the curtains around the bed or closing the door to the
room. Some agencies provide signs indicating the need for privacy.
Rationale: Hygiene is a personal matter.
4. Position and prepare the client appropriately
Assist the client who can sit to move to a chair.
o Rationale: Hair is more easily brushed and combed when the client is in a sitting
position.
If the client is in bed, place a clean towel over the pillow and the clients shoulders. Place it over
the sitting clients shoulders.
o Rationale: the towel collects any removed hair, dirt, and scaly material.
Remove any pins or ribbons in the hair
5. Remove any mats or tangles gradually.
Mats can usually be pulled with fingers or worked out with repeated brushings
Comb out tangles in a small section of hair toward the ends. Stabilize the hair with one hand and
comb towards the ends of the hair with the other hand.
 Rationale: this avoids scalp trauma
6. Brush and comb the hair
For short hair, brush and comb one side at a time. Divide long hair into two sections by parting it
down the middle from the front to the back. If the hair is very thick, divide each section into
front and back subsections or into several layers.
7. Arrange the hair as neatly and attractively as possible, according to the individual’s desires
Braiding long hair helps prevent tangles
8. Document assessments and special nursing preventions. Daily combing and brushing of the hair
are not normally recorded.

Variation: Hair care for African American clients

Position and prepare the client

Separate the hair into four sections, proceeding from one section to the next
Untangle the hair first
Use fingers to reduce the hair breakage and discomfort. Move fingers in a circular motion
starting at the roots and gently moving up to the tip of the hair.
Comb the hair
Dampen the hair with water or a leave-in conditioner
Rationale: this will help loosen any tangles
Apply hair oil preparation as the client indicates
Using a large and open-toothed comb, grasp a small section of the hair and holding the hair at
the tip, start untangling at the tip and work down toward the scalp.
Ask the client if he or she would like the hair braided
Rationale: Braiding will decrease tangling, however, the choice is the client’s

Evaluation
Conduct ongoing assessments for problems such as dandruff, alopecia, scalp lesions, or
excessive dryness or matting
Evaluate effectiveness of medication

SHAMPOOING THE HAIR

Hair should be washed as often as needed to keep it clean. There are several ways to shampoo
client’s hair, depending on their health, strength, and age. The client who is well enough to take
a shower can shampoo while in the shower. The client who is unable to shower may be given a
shampoo while sitting on a chair in front of a sink. The back-lying client who can move to a
stretcher can be given a shampoo on a stretcher wheeled to a sink. The client who must remain
in bed can be given a shampoo with the water brought to the bedside.
Water used for the shampoo should be 40.5 Celsius (105 Fahrenheit) for an adult or child to be
comfortable and not injure the scalp.
Shampooing the hair of a client confined to bed
To stimulate the blood circulation to the scalp through massage
To clean the hair and increase the client’s sense of well-being

NURSING MANAGEMENT
Assessment
Determine routinely used shampoo products
Assess:
- Any scalp problems
- Actively tolerance of the client

Planning
Delegation

Brushing and combing hair, shampooing hair, and shaving facial hair can be delegated to UAP
unless the client has a condition in which the procedure would be contraindicated. The nurse
needs to assess the UAP’s knowledge and experience of hair care for clients of other cultures, if
appropriate.

Equipment

Comb and Brush

Plastic sheet
Two bath towels
Shampoo Basin
Washcloth or pad
Bath blanket
Receptacle for the shampoo water
Pitcher of water
Bath thermometer
Liquid or cream shampoo
Hair dryer

IMPLEMENTATION
Preparation

Determine whether a primary care provider’s order is needed before a shampoo can be given.
o Rationale: Some agencies require an order.
 Determine the type of shampoo to be used
Determine the best time of day for the shampoo.

Performance

1. Prior to performing the procedure, introduce self and verify the client’s identity using agency
protocol.
2. Perform hand hygiene and observe other appropriate infection control procedures as needed.
3. Provide for client privacy by drawing the curtains around the bed or closing the door to the
room.
4. Position and prepare the client appropriately
5. Arrange the equipment.
Put the plastic sheet or pad on the bed under the head
Remove the pillow from under the client’s head and place it under the shoulder
unless there is some underlying condition.
Tuck a bath towel around the client’s shoulder.
Place the shampoo basin under the head, putting a folded washcloth or pad where
the client’s neck rest on the edge of the basin.
Fanfold the top bedding down to the waist, and cover the upper part of the client
with the bath blanket.
Place the receiving receptacle on the table or chair at the bed side. Put the spout of
the shampoo basin over the receptacle.
6. Protect the client’s eyes.
Place a damp of washcloth over the client’s eyes.
7. Shampoo the hair
Wet the hair thoroughly with the water
Apply shampoo on the scalp, make a good lather with the shampoo and massage
the scalp.
Rinse the hair briefly, and apply shampoo again.
Make the good lather and massage the scalp as before.
Squeeze as much water possible out of the hair with your count.
8. Dry the hair thoroughly
Rub the client’s hair with a havy6 towel
Dry the hair with the dryer. Set the temperature at “warm”
Continually move the dryer to prevent burning clients scalp
9. Ensure client’s shampoo to sleep and conditional.
Assist the person confined to bed to a comfortable position
Arrange the hair using a clean brush and comb
10. Document the shampoo and any assessments.

Evaluation
 Conduct ongoing assessments with as any as any scalp problem or intolerance. Report any
problems noted to the nurse in change.

BEARD AND MUSTACHE CARE

Bear and mustaches also required daily care. The most important aspect of the care. For
particles tend to collect in beards and mustaches, and they need washing and combing
periodically.

Clinical Alert
A beard or mustached not be shaved off without the client’s consent.
Make clients often shave or are shaved after a bath. Frequently clients supply their own
electric or safety in razors.

Evaluating
Using the data collected during care. The nurse judges whether desired outcomes have been
achieve?
- Perform hair grooming with assistance
- Exhibits clean, well groomed, resilient hair with a healthy sheen.
- Reduce or get rid of scalp lesions or infestation.
- Describe factors interventions and preventive measures for a specific hair problem.

Using a safety Razor to shave Facial hair.

Wear globes in case facial nicks occur and you come in contact with blood.
Apply shaving cream or soap and water to soften the bristles and make the skin more
pliable.
Hold the skin taut, particularly around creases, to prevent cutting the skin
Hold the razor so that the blade is at a 45-degree angle to the skin, and shave in short, firm
strokes in the direction of hair growth
After shaving the entire area, wipe the client’s face with a wet washcloth to remove any
remaining shaving cream and hair.
Dry the face well, then apply aftershave lotion or powder as the client’s prefers
To prevent irritating the skin, pat on the lotion with the fingers and avoid rubbing the face
 FEET

Feet are essential for ambulation and merit attention even when people are confined to bed.
Each foot contains 26 bones, 107 ligaments and 19 muscles.
These structures function together for both standing and walking.

DEVELOPMENTAL VARIATIONS
At birth
A baby’s foot is relatively unformed.
The arches are supported by fatty pads and do not take their full shape until 5 to 6 years of
age.

During childhood
The bones and small muscles of the feet are easily damaged by tight, binding stockings and
ill-fitting shoes.
 Normal development
It is important that the arches be supported and that the bony structure and the feet grow
with no external restrictions.
Feet are not fully grown until about age 20.
An average person takes 10,000 steps per day.
Each step places 2 to 3 times the force of the body weight on the feet.
This repetitive use leads to normal changes associated with aging.
These include wider and longer feet, mild settling of the arches, and loss of natural padding
on the bottom of the heels.
The cartilage around the joints also deteriorates, producing loss of normal range motion of
the foot and ankle.

Elderly
Some elderly individuals, requires special attention for their feet.
For example, reduced blood supply and accompanying arteriosclerosis can make a foot
prone to ulcers and infection following trauma.

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.
Toes are straight and flat.
Common foot problems include calluses, corns, unpleasant orders, plantar warts, fissures
between the toes, and fungal infections such as athlete’s foot.

Calluses
Thickened portion of epidermis, a mass of keratotic material.
Painless and flat. Found on the bottom side of the foot over a bony prominence.
Caused by pressure from shoes.
They can be softened by soaking the foot in warm water with Epsom salts, and abraded with
pumice stones or similar abrasives.
Creams with lanolin help to keep the skin soft and prevent the formation of calluses.

Corns
A keratosis caused by friction and pressure from a shoe.
Commonly occurs on the fourth or fifth toe, usually on a bony prominence such as a joint.
Are usually conical (circular and raised).
 The base is the surface of the corn.
The apex is in deeper tissues, sometimes even attached to bone.
Corns are generally removed surgically.
They are prevented from re-forming by relieving the pressure on the area. And massaging
the tissues to promote circulation.
The use of oval corn pads should be avoided because they increase pressure and decrease
circulation.

Unpleasant Odors
Occur as a result of perspiration and its interaction with microorganisms.
Regular and frequent washing of the feet and wearing clean hosiery help to minimize odor.

Plantar warts
Appear on the sole of the foot.
These warts are caused by the virus papovavirus hominis.
They are moderately contagious.
The warts are frequently painful and often make walking difficult.
The primary care provider may curettage the warts, freeze them with solid carbon dioxide
several times, or apply salicylic acid.

Fissures
Deep grooves
Frequently occur between the toes as a result of dryness and cracking of the skin.
The treatment of choice is good foot hygiene and application of an antiseptic to prevent
infection.
Often a small piece of gauze is inserted between the toes in applying the antiseptic and
left in place to assist healing by allowing air to reach the area.

Athlete’s foot
Tinea pedis (Ringworm of the foot)
Caused by a fungus.
The symptoms are scaling and crackling of the skin, particularly between the toes.
Sometimes small blisters form, containing fluid.
In severe cases, the lesions may also appear on the other parts of the body, particularly
the hands.
Treatments usually involve the application of commercial antifungal ointments or
powders.
Common preventive measures re keeping the feet well ventilated, drying the feet well
after bathing, wearing clean socks or stockings, and not going barefoot in public
showers.
 Ingrown toenail
The growing inward of the nail into the soft tissues around it, most often results from
improper nail trimming.
Pressure applied to the area causes localized pain.
Treatment involves frequent, hot antiseptic soaks and surgical removal of the portion of
nail embedded in the skin.
Preventing recurrence involves appropriate instruction and adherence to proper nail-
trimming techniques.

PROVIDING FOOT CARE

Purposes
To maintain the skin integrity of the feet
To prevent foot infections
To prevent foot odors
To assess or monitor foot problems

NURSING MANAGEMENT
Assessment
Determine
History of any problems with foot discomfort, foot mobility, circulatory problems (e.g.,
swelling, changes in skin color and/or temperature, and pain), structural problems (e.g.,
bunion, hammer toe or overlapping digits).
Usual foot care practices (e.g., frequency of washing feet and cutting nails, foot hygiene
products used, how often socks are changed, whether the client ever goes barefoot,
whether the client sees a podiatrist).
Assess
Skin surfaces for cleanliness, odor, dryness and intactness
Each foot and toe for shape, size, presence of lesions (e.g., com, callus, wart or rash), and
areas of tenderness, ankle edema
Skin temperatures of both feet to assess circulatory status
Pedal pulses: dorsalis pedis and posterior tibialis
Self-care abilities (e.g., any problems managing foot care)

Planning
 Equipments;
Washbasin containing warm water
Pillow
Moisture-resistant disposable pad
Towels
Soap
Washcloth
Toenail cleaning and trimming equipment, if agency policy permits
Lotion or foot powder

Implementation
1. Prior to performing the procedure, introduce self and verify the client’s identity using
agency protocol. Explain to the client what you are going to do, why it is necessary, and how
he or she can cooperate.
2. Perform hand hygiene and observe other appropriate infection control procedures.
3. Provide for client privacy by drawing the curtains around the bed or closing the door to the
room. Some agencies provide signs indicating the need for privacy.
4. Prepare the equipment and the client.
Fill the washbasin with warm water at about 40degrees Celsius to 43degrees
Celsius. (105degrees to 110degrees Fahrenheit).
Assist the ambulatory client to a sitting position in a chair, or the bed client to a
supine or semi-Fowler’s position.
Place a pillow under the bed client’s knees.
Place the washbasin on the moisture-resistant pad at the foot of the bed for a bed
client or on the floor in front of the chair for an ambulatory client.
For a bed client, pad the rim of the washbasin with a towel.
5. Wash the foot and soak it.
Place one of the client’s feet in the basin and wash it with soap, paying particular
attention to the interdigital areas. Prolonged soaking is generally not
recommended for diabetic clients or individuals with peripheral vascular disease.
Rinse the foot well to remove soap.
Rub callused areas of the foot with the washcloth.
If the nails are brittle or thick ad require trimming replace the water and allow the
foot to soak for 10 to 20 minutes.
Clean the nails as required with an orange stick.
Remove the foot from the basin and place it on the towel.
6. Dry the foot thoroughly and apply lotion or foot powder.
Blot the foot gently with the towel to dry it thoroughly, particularly between the
toes.
Apply lotion or lanolin cream to the foot but not between the toes.
o Or
Apply a foot powder containing a nonirritating deodorant if the feet tend to
perspire excessively.
7. If agency permits, trim the nails of the first foot while the second foot is soaking.
8. Document any foot problems observed.
Foot care is not generally recorded unless problems are noted.
 Record any signs of inflammation, infection, breaks in the skin, corns, troublesome
calluses, bunions and pressure areas. This is of particular importance for clients
with peripheral vascular disease and diabetes.

Evaluation
Inspect nails and skin after the soak.
Compare to prior assessment data
Report any abnormalities to the primary care provider.

NAIL

Are normally present at birth.

They continue to grow throughout life and change very little until people are elderly. At that
time, the nails tend to be tougher, more brittle and in some cases thicker.
The nails of an older person normally grow less quickly than those of a young person and
may be ridged and grooved.

PROVIDING NAIL CARE

Planning
The nurse identifies measures that will assist the client to develop or maintain healthy nail
care practices.
A schedule of nail care needs to be established.

Implementing
To provide nail care, the nurse needs a nail cutter or sharp scissors, a nail file, an orange
stick to push back the cuticle, hand lotion or mineral oil to lubricate any dry tissue around
the nails, and a basin of water to soak the nails if they are particularly thick or hard.
One hand or foot is soaked, if needed, and dried.
Then, the nail is cut or filed straight across beyond the end of the finger or toe.
Avoid trimming or digging into nails at the lateral corners. This predisposes the client to
ingrown toenails.
 Clients who have diabetes or circulatory problems should have their nails filed rather than
cut; inadvertent injury to tissues can occur if scissors are used.
After the initial cut or filing, the nail is filed to round the corners, and the nurse cleans under
the nail.
The nurse then gently pushes back the cuticle, taking care not to injure it. The next finger or
toe is cared for in the same manner.
Any abnormalities, such as an infected cuticle or inflammation of the tissue around the nail,
are recorded and reported.

Evaluate
Demonstrate healthy care practices.
Describe factors contributing to the nail problem.
Describe preventive interventions for the specific nail problem.
Demonstrate nail care as instructed.

PERINEAL – GENITAL CARE

Also referred to as “Perineal Care or Peri-care”.
Usually part of the complete bed bath.
The nurse and the patient find it embarrassing.
Particularly with clients of the opposite sex.
Client most in need of peri-care are those of greater risk requiring an infection.
The nurse need to provide peri-care efficiently.
 
PURPOSES
To remove normal perineal secretions & odor.
To promote client comfort.
 

NURSING MANAGEMENT
ASSESSMENT
Assess for the presence of:
Irritation,excoriation,inflammation,swelling
 Excessive discharge
Odor,pain or discomfort
Urinary or fecal incontinence
Recent rectal or perineal surgery
Indwelling catheter

Determine:
Perineal-genital hygiene practices
Self-care abilities
 
IMPLEMENTATION
Preparation:
Determine whether the client is experiencing any discomfort in the perineal-
genital area.
Obtain and prepare the necessary equipment & supplies.

PERFORMANCE

1.       Explain to the client what you are going to do. Why it is necessary, and how he/she can
cooperate, being particularly sensitive to any embarrassment felt by the client.
2.       Wash hands and observe other appropriate infection control procedures (e.g. clean
glasses).
3.       Provide for client privacy by drawing curtains around the bed or closing the door to the
room. Some agencies provide signs indicating the need for privacy. “Hygiene is a personal
matter”.
4.       Prepare the client:
§  Fold the top bed linen to the foot of the bed and fold the gown up to expose the
genital area.
§  Place a bath towel under the client’s hips. The bath towel prevents the bed from
becoming soiled.
5.       Position and drape the client and clean the upper inner thighs.

FOR FEMALES
Position the female in a back-lying position with the knees flexed and spread well
apart.
Cover her body and legs with the bath blanket. Drape the legs by tucking the
bottom corners of the bath blanket under the inner sides of the legs. “Minimum
exposure lessens embarrassment & helps to provide warmth”. Bring the middle
portion of the base of the blanket up over the pubic area.
Put on gloves, wash and dry the upper inner thighs.

FOR MALES
Position the male client in a supine position with knees slightly flexed with hips
slightly externally rotated.
 Put on gloves, wash and dry the upper inner thighs.

6.       Inspect the perineal area:

§  Note particular areas of inflammation, excoriation or swelling, especially between the
labia in females and the scrotal folds in males.
§  Also note excessive discharge or secretions from the orifices and the presence of
odors.
7.       Wash and dry the perineal genital area.

FOR FEMALES
Clean the labia majora. Then spread the labia to wash the folds between the
labia majora and the labia minora. Secretions that tend to collect around the
labia minora facilitate bacterial growth.
Use separate wash cloth for each stroke, and wipe from the pubis to the rectum.
For menstruating women and clients with indwelling catheters use clean wipes,
cotton balls or gauze. Take a clean ball for each stroke. Using separate quarters
of the wash cloth or new cotton balls or gauzes prevent the transmission of
micro-organisms from one area to the other. Wipe from the area of least
contamination (the pubis) to that of greatest (the rectum).
Rinse the area well. You may place the client on a bedpan and use a peri-wash or
solution bottle to pour warm water over the area. Dry the perineum thoroughly
paying particular attention to the folds between the labia. “Moisture supports
the growth of many organisms”.

FOR MALES
Wash and dry the penis, using firm stokes. ‘Handling the penis firmly may
prevent an erection’.
If the client is uncircumcised, retract the procure (foreskin) to expose the glans
penis (the tip of the penis) for cleaning the glans penis. “Retracting the foreskin
is necessary to remove the smegma that collects under the foreskin and
facilitates bacterial growth. Replacing the foreskin prevents constriction of the
penis, which may cause edema.
Wash and dry the scrotum. The posterior folds of the scrotum may need to be
cleaned when the buttocks are cleaned. “The scrotum tends to be most soiled
than the penis because of its usually cleaned after the penis”.

8.       Inspect perineal orifices for intactness.

Inspect particularly around the urethra in clients within clients with indwelling
catheters. “A catheter may cause excoriation around the urethra.

9.       Clean between the buttocks.

Assist the client to turn unto the side facing away from you.
Pay particular attention to the anal area and posterior folds of the scrotum in
males. Clean the anus with toilet tissue before washing it, if necessary.
 Dry the area well.
For post delivery or menstruating females, apply a perineal pad as needed from
front back. “This prevents contamination of the vagina and urethra from the anal
area”.

10.   Document any unusual findings such as redness, excoriation, skin breakdown, discharge or
drainage and any localized areas of tenderness.