assisting with hygiene, personal care, skin care, and the

ASSISTING WITH HYGIENE, PERSONAL CARE, SKIN CARE, AND THE PREVENTION

OF PRESSURE INJURIES

Chapter 19

Objectives – Theory

■ Describe the structure and function of the integumentary system

■ Describe the factors that influence personal hygiene practices

■ List the skin areas most susceptible to pressure injuries

■ Discuss the risk factors for impaired skin integrity

■ Discuss the purpose of bathing

■ Describe how hygienic care for the younger and the older patient differs

Objectives – Skills and Steps

■ Skill 19.1 – Administering a Bed Bath and Perineal Care

■ Skill 19.2 – Administering Oral Care to the Unconscious Patient

■ Skill 19.3 – Providing Denture Care

■ Skill 19.4 – Shampooing Hair

■ Steps:

– Steps 19.1 – Providing a tub bath or Shower

– Step 19.2 – Shaving a male patient

Overview

■ The skin is the largest organ of the body, and it must be kept clean to prevent skin disorders and pressure injuries

■ Hygiene is the proper care of the skin, hair, teeth, and nails to promote good health by protecting the body from infection and disease and to provide a sense of well being,

■ You are responsible for maintaining safety, privacy, and warmth when providing or assisting patients in hygiene practices.

■ Encourage patients to function at their highest level of independence.

What is the Structure of the Skin?

■ The integumentary system contains the skin, hair, nails, sweat and sebaceous glands.

■ The skin is the largest organ in the body. It has two main layers:

– Epidermis: outer, thinner layer.

■ Consists of stratified squamous epithelial tissue and does not contain blood vessels.

■ Receives its nutrition by diffusion from vessels in underlying tissues

■ Also called the stratum corneum

■ Bottom layer contains melanocytes that secrete melanin (main determinant of skin

color)

■ Nails are derived from the epidermis

– Dermis: inner, thicker layer

■ Made of dense connective tissue that gives the skin strength and elasticity.

■ Also called corium

■ The dermis provides the nutrition and hydration for the epidermis.

■ Contains blood vessels, nerves, fibroblasts. The base of hair follicles, and glands.

– Fibroblasts produce new cells to heal skin after injury.

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Cross Section of the Skin Figure 19.1

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What is the Structure of the Skin?

■ Hair and nails are made of keratin and have no nerve endings or blood supply

■ Sebaceous glands secrete an oily substance called sebum.

■ Sweat glands secrete sweat, and ceruminous glands (modified sweat glands) secrete a waxy substance called cerumen

■ Mucous membranes line the cavities or passage ways of the body that open to the outside, such as the mouth and digestive, respiratory, genitourinary tracts. Like the skin they are made of a surface layer of epithelial tissue over a deeper layer of

connective tissue.

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What Are the Functions of the Skin and its Structures?

■ Skin has four main functions:

– Protection, sensation, temperature regulation, and excretion/secretion

■ Skin is first line of defense in protecting the body from bacteria and other invading organisms

– Protects tissues from thermal, chemical, and mechanical injury

■ Sebaceous glands produce sebum, which helps make the skin waterproof by preventing water loss from underlying tissues and too much water absorption during bathing and swimming

■ Melanin absorbs light and protects against ultraviolent rays. When exposed to ultraviolent light, the skin makes vitamin D, which is needed for absorbing phosphorus and calcium.

■ Skin has sensory organs for touch, pain, heat, cold, and pressure.

■ Regulates temperature by dilating and constricting blood vessels and activating or inactivating sweat glands.

– Dilation of vessels – heat loss, constriction of blood vessels – heat retention

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What Are the Functions of the Skin and its Structures?

■ Sweat glands assist in maintenance of homeostasis of fluid and electrolytes.

– Homeostasis – biological systems maintain stability in their internal environment while continually adjusting to changes necessary for survival

– As sweat evaporates, it produces a cooling effect. Sweat glands in the axillae and external genitalia also secrete fatty acids and proteins

■ Sebum lubricates the skin and hair, keeping these structures softer and more pliable. Decreases the amount of heat lost and bacterial growth.

■ Mucous membranes protect against bacterial invasion, secrete mucus and absorb fluid and electrolytes

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What Changes in the System Occur With Aging?

■ Loss of elastic fibers and adipose tissue in the dermis and subcutaneous layers causes skin to be thinner and more transparent, with wrinkling and sagging.

■ Loss of collagen fibers in the dermis makes the skin more fragile and slower to heal.

■ Decreased sebaceous gland activity causes dry and itchy skin.

■ Temperature control is altered by the decreased sebaceous gland activity and the loss of skin density.

– This results in cold intolerance and puts the person at risk for heat exhaustion

■ Hair becomes thin and grows more slowly because a decrease in the number of hair follicles. Hair losses its color from the loss of melanocytes at the hair follicles.

■ Nail growth decreases and the nails thicken.

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Application of the Nursing Process -Assessment

■ The bath provides an excellent opportunity for the assessment of the patient. Assess the individual factors affecting the patient’s hygiene and ability to perform self-care.

■ Assess the condition of the patient’s skin and overall physical appearance, emotional and mental status, and learning needs.

■ Listen to patients statements offered during bathing.

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Factors Affecting Hygiene■ Hygiene practice is affected by many variables such as economics, ability to perform

self care, and personal preference.

■ Social cultural background is one of the most basic factors affecting hygiene.

– Different cultures have different views on hygiene practices.

■ In some cultures people do not use deodorant products or bathe daily’ other

cultures consider the use of deodorant and bathing daily essentials.

■ Economic status may affect hygiene because the money for supplies may or may not be available.

■ The patient may lack knowledge of a particular aspect of hygiene.

■ Ability to perform self care may be affected by patient’s mental or physical condition, which may be altered because of illness or injury.

– Poor vision, decreased sense of touch, limited ROM –they may need assistance if not total help with hygiene

■ Preference may also affect hygiene. Some patients may prefer to bathe at night, whereas another may prefer bathing every 2 days.

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Skin and Pressure Injuries

■ A pressure injury is an injury that forms form a local interference with circulation and may involve either intact or ulcerated skin.

■ Interference with circulation causes skin to blanch (turn white or, in darker skin, become pale)

– If pressure is relieved at this point, the skin will become red or a dark color because of vasodilation

■ Reactive hyperemia is the process in which the blood rushes to a place where there was a decrease in circulation.

■ When assessing for pressure injuries (stage I) in patients with darkly pigmented skin, use natural light or a halogen lamp to look for the skin color changes. Pressure areas may have purple hues. Compare this skin around bony prominences with skin over bony prominences. Damaged skin may be boggy or stiff, or warmer or cooler. Moistening the skin can assist in identifying changes in color.

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Risk Factors for Pressure Injuries■ Major Factors Contributing Factors

– Immobility - Advanced age - Dehydration

– Inactivity - Altered sensory perception - Obesity

– Moisture - Lowered mental awareness - Edema

– Malnutrition - Friction and Shear

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■ The first two risk factors deal with mobility. If the patient is confined to a bed or a chair, the same areas of the body sustain pressure. This also happens if they cannot change positions independently.

■ Moisture can lead to pressure injuries in a patient who is incontinent (lost bowel/bladder control).

– Skin that is frequently wet can lead to maceration (softening of tissue that increases the chance of trauma or infection). Diaphoresis or not properly drying after a bath, and the use of incontinence briefs also place patients at risk because of moisture.

■ Balanced diet is necessary to prevent injury development.

– Without proper calories, protein, fluids, vitamins, and minerals, the body’s cells, capillaries

and tissues are easily damaged.

Skin Assessment for Pressure Injuries

■ Perform a skin assessment for pressure injury risk in admission.

– Braden Scale for predicting pressure sore risk is often used (figure 19.2)

■ After initial assessment assess every 24 hours – can be done while bathing patient

■ Always pay close attention to areas over bony prominences (figure 19.3)

– Check pressure areas when turning and repositioning

■ Redness can normally be expected to be present for ½ to ¾ as long as the pressure prevented blood flow.

– If redness subsides during this time or the area blanches from fingertip pressure, then damage to the tissue is not expected.

– Example: patient has been in supine position for 1 hour and is now turned to right side lying position. You notice 1 inch diameter area or redness on the sacrum. If there has not been damage, then you expect the redness to subside in 30-45 mins. If redness persists, then the pressure has damaged the skin and the underlying tissues because they have not received an adequate supply of blood, oxygen and nutrients. The damage will eventually lead to tissue necrosis and pressure injury.

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Pressure Injury Stages ■ Stage 1- an area of intact skin that is red, deep pink, or mottled skin. Does not blanch

with fingertip pressure. In darker skin people, there may be discoloration of the surrounding skin. Warmth, edema, and induration (area feels hard) in comparison to surrounding tissue may be signs of stage 1 pressure injury.

■ Stage 2 – partial thickness skin loss with exposed dermis. The wound bed is pink or red and moist, may appear as an intact or ruptured bister. (ex: wearing new shoes) No subcutaneous tissue.

■ Stage 3 – full thickness skin loss that looks like a deep crater and may extend to the facia. Subcutaneous tissue is damaged or necrotic; fat is visible. Undermining and tunneling may be present. May have damage to surrounding tissue.

■ Stage 4 – full thickness skin loss with extensive tissue necrosis or damage to muscle, bone, or supporting structures. Sinus tracts may be present. Infection is usually widespread. Injury may appear dry and black, with build up of tough necrotic tissue (eschar) or it can appear wet and oozing.

■ Unstageable – loss of full thickness of tissue. Base of injury is covered by eschar (tan, brown or black) in the wound bed. Base of injury contains slough (yellow, tan gray, green or brown)

■ Deep Tissue – localized discolored intact skin that is maroon or purple or a blood filled blister resulting from damage to underlying soft tissue from pressure or shearing.

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Figure 19-4: Four stages of pressure injuries

Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 19-4: Four stages of pressure injuries

(cont’d)


■ During staging it is important to be aware of the following:

– Stage 1 pressure injuries may be just superficial or may be a sign of deeper tissue damage. They are not always accurately assessed in people with darker skin.

■ When eschar is present, the pressure injury is described as unstageable. Eschar must be removed to stage the pressure injury properly.

■ It may be difficult to assess pressure injuries if patient has a cast or other orthopedic device.

■ Document the location of any abnormality, its color and size and reaction to the blanch test. Include other descriptions such as induration, blisters, drainage, odor or eschar.

■ A Braden scale score of 18 or below indicates pressure injury risk.

■ Healing pressure injuries are not “reverse staged” meaning that it will always remain at that stage even if healing or worsen but never will it be reversed.

– Ex: A stage 4 is healing but it is not called a stage 3 pressure injury as it improves. The injury would be called a “healing stage 4 pressure injury.” Document the pressure injury by objective description and measurement.

Pressure Injury Stages Page 305

Pressure Injury – Life Span Considerations

■ Older adults have increased risk for developing impaired skin integrity from normal aging changes.

■ They have thinner skin, decreased subcutaneous fat, decreased sebaceous gland activity and decreased elasticity in their skin. This makes them less able to tolerate pressure, shearing and friction forces.

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Prevention of Pressure Injuries ■ Excellent nursing care is the main factor in prevention of pressure injuries

■ It is your responsibility to be aware of any risk factors your patient may have attempted to lessen them.

■ Prevention is less time-consuming and expensive than pressure injury treatment; assess skin carefully and frequently

■ Nurses need to:

•Be consistent and vigilant to identify patients at high risk for developing compromised skin and pressure injuries.

•Implement timely, appropriate, and consistent skin care.

•Continually educate the patient, family members, and other members of the health care team.

•Review strategies for nurses to be proactive for skin care.

■ Safety Alert page 306

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Treatment and Care for Pressure Injuries■ The team approach is the most effective method of pressure injury treatment.

■ Include patient, family or caregivers and health care professionals.

■ Treatment options should be explained, and the patient should be encouraged to be an active participant. The plan should be consistent with the individual patient and

family preferences, goals, and abilities.

■ Include education on development and prevention of pressure injuries.

■ The initial care of the pressure involves debridement, wound cleansing, and

application of dressing.

■ The injury may be infected, and antibiotic therapy is used.

■ Surgery is needed to repair some injuries.

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Problem Statements/Nursing Diagnosis

■ Nursing diagnosis for patients with potential hygiene and skin integrity problems are listed on box 19.2 page 306

■ They may include:

– Acute pain

– Chronic low self esteem

– Chronic pain

– Altered self –care ability

– Altered nutrition

– Altered mobility

– Altered skin integrity

– Altered peripheral tissue perfusion

– Potential for altered skin integrity

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Planning■ The data collect will help you plan hygiene care.

■ Include the patient’s ability to perform the hygiene tasks and any personal preferences or habits.

■ Make effort to maintain the patient’s a positive body image.

■ Consider educational needs and home environment.

■ Nursing goals for hygiene might include:

– Patient’s skin integrity will be maintained

– Patient’s hair is cleaned and neatly styled each day

– Patient’s oral mucosa is intact and free from odor

■ Planning must include the times during the day that care will be needed. See Box 19.3 page 307 for examples

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Implementation – Bathing■ Bathing has 4 basic purposes

– Cleanse the skin

– Promote comfort

– Stimulate circulation

– Remove waste products secreted through skin

■ Water should be warm but should not burn the patient (approximately 105 *F) or according to agency policy

■ When water cools, replace it

■ Bed rails must be up when away from that side of bed since the bed is raised at working height

■ Fully draw curtains around the bed to maintain privacy – do not leave gaps that could expose patient to others in room

■ Place a sign on outside of door indicating bath in progress

■ Close door and windows to decrease drafts / appropriately drape patient for warmth and comfort

■ Only part being bathed should be exposed at any one time

■ Encourage independence but offer assistance as needed

■ Depending on patient’s ability and activity level, you may need to give either a partial or complete bath

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Types of Baths■ A bath may be cleansing or therapeutic and complete or partial.

■ With a complete bath, all areas of the patient’s body are washed.

■ The term partial bath has two different meanings depending on your instruction.

– Only certain parts of the body are bathed – such as face, hands axillae, back and perineal area.

– Complete bath is done – partially by the patient (areas that can be reached) and partially by you (all other areas)

■ When assigning baths to UAP be explicit about which type of bath or shower patient requires. Ask them to inspect the skin and report any lesions or problems to you. Ask that patient be allowed to perform as much self care as possible, but not to point of becoming excessively tired.

■ While in hospital chlorhexidine impregnated wipes/ cloths may be used instead of soap to reduce the risk of HAI

■ Moisture the skin immediately after the bath with lotion or cream. Apply this while the skin is still damp to trap additional moisture

■ Evaluate the home environment for safety aids such as nonskid tub or shower mats, safety bars, and shower or bench chairs if appropriate

■ Life Span Considerations page 308

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Cleansing Baths ■ Most common type of bath is a cleansing bath

■ Generally provided in bed, tub or shower

■ Bed baths are given to patients who are unable to use a tub or shower

■ Offer the use of a toilet before running bathwater or placing the patient in the tub or shower

■ A shower chair or bath bench and grab bars are used for the patient who is weak or not ambulatory (figure 19.5)

■ If no balance problem, assist patient to tub that is half filled with warm water, once in the tub or shower add warmer water as desired.

■ Place call bell within easy reach of the independent patient

■ Check on patient every 5 minutes and inform the patient that the bath shouldn’t exceed 15-20 minutes

■ If patient is weak provide assistance and do not leave bathroom

■ Provide towel for patient to drape the genital area while in tub to provide privacy

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Skill 19.1 Administering Bed Bath and Perineal care

■ Page 308

■ 19-1 Bed Bath & Peri Care: https://youtu.be/YRzFw2c5wt8

https://youtu.be/YRzFw2c5wt8

Steps 19.1 Providing a Tub Bath or Shower

■ Page 313

Therapeutic Bath ■ Therapeutic means having healing or medicinal qualities

■ Performed to achieve desire effect

■ Several types of therapeutic baths

– Whirlpool bath is done in a bathtub or special tub that has a device that agitates the water. Heat of the water and agitation gently massage the skin. Used to cleanse, stimulate peripheral circulation, and provide comfort.

– Starch and oatmeal baths (using plain instant oatmeal) are used for patients with dermatitis. The skin is patted dry so to not stimulate the nerve endings by rubbing.

– Sitz baths are used to apply moist and heat and clean the perineal or anal area (figure 19.6 page 309). The bath promotes healing and relieves pain and discomfort. Commonly used after birth and vaginal or rectal surgery.

– Body soaks are usually indicated to cleanse open wounds or apply medicated solutions to the area.

– Cooling sponge baths are also known as tepid sponge baths. An order is usually needed before this type of bath can be used to bring down a fever.

■ Clinical cues page 309

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Variations of Bed Bath

■ Bag bath: a variation of the bed bath

– A self-contained bag containing several premoistened disposable cloths.

– Cloths are moistened with a cleansing agent that does not need rinsing

– Cloths may be heated or used directly from the bag

– The bag contains many cloths, so a different cloth may be used for different body parts

– Cost of this system is major disadvantage

3

Back Massage■ Important part of hygiene care and it involves the sense of touch

■ Benefits of back rub include:

– Communicates caring

– Fosters trust in the nurse-patient relationship

– Provides an opportunity to assess the skin on the back

– Stimulates circulation of blood to the area

– Reduces tension and promotes relaxation

■ Performa back rub with morning care and at bedtime

■ Essential to provide to patients confined to bed

■ Avoid open wounds and areas or pressure injuries

■ Use more pressure on upward strokes toward the head and less pressure on downward strokes

■ Pressure should be firm but not causing tensing or discomfort for the patient

■ Do not massage patient legs as this increases the risk of loosening a thrombus and potential pulmonary embolism

■ Back rubs act as a nonpharmacologic intervention for pain and as a diversion.

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Back Massage

■ During the back rub, remember the following safety and comfort issues:

– Move patient close to you to maintain proper body mechanics and prevent self injury

– Raise the bed to an appropriate height and lower the rail only on the side where you are standing during the back rub

– Make certain your hands are warm and relaxed before beginning. Warm any lotion or oil in your hands before placing them on the patient. Cool lotions and

cold hands cause the patient to tense and pull away.

– An effective back rub should last approximately 3-5 minutes (figure 19.7)

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Perineal Care■ Usually a patient will accept your assistance with perineal care but some refuse as

they are embarrassed.

■ Proper draping helps promote comfort with procedure (figure 19.8)

■ Explain the procedure to reassure the patient and gain cooperation.

■ Maintain a matter of fact attitude and be objective; avoid any sexually suggestive conversations or actions

■ A professional and dignified attitude can help reduce embarrassment

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Mouth Care ■ Mouth care removes food particles and secretions, which prevents halitosis (bad

breath), feelings of uncleanliness, and dental caries (cavities).

■ Oral hygiene promotes a better appetite and maintains the healthy state of mouth, gums, teeth and lips.

■ Lack of oral hygiene can have a serious consequences, including increased risk for a stroke, heart disease, and pneumonia.

■ Provide oral care on a daily basis, ideally, four times a day

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Mouth Care for the Conscious Patient

■ Mouth care for the conscious patient

– Raise the head of the bed 45 to 90 degrees

– Wear gloves with mouth care

– If patient unable to sit up, turn patient to side facing you

– Place a towel under the chin

– Moisten toothbrush and spread it with toothpaste

– Brush from the gum line to the edge of the teeth – all surfaces of each tooth

should be brushed

– Have patient rinse the mouth and spit – repeat as needed

– Provide cloth or tissue to wipe the mouth when finished

– To floss have 12-15 inches of floss. Loosely wrap ends of the floss around index finger on each hand and work the floss between each tooth.

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Mouth Care for the Unconscious Patient

■ Provide full mouth care to an unconscious patient at least every 4 hours especially if mouth breathing.

– Mouth breathing causes the tongue to dry and become crusty

– Remove any dry secretions because they cause halitosis and may obstruct airflow

– Perform moist swabbing of the mouth every 2 hours or as needed to maintain the integrity of the oral cavity

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Skill 19.2 Administering Oral Care to Unconscious Patient

■ Page 316

■ 19-2 Oral Care of the Unconscious Patient: https://youtu.be/dbdmM-Jc2tA

https://youtu.be/dbdmM-Jc2tA

Denture Care

■ Dentures should be cleaned to prevent irritation to the gums and infection

■ Care should be provided in morning and at bedtime

■ Do not place dentures on meal tray because they are often lost when trays are removed

■ Dentures should be removed at least 6 hours daily to relieve pressure on mouth tissues to allow saliva to cleanse the tissues

■ When not in mouth, dentures should be kept in a labeled denture container filled

with water or normal saline

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Skill 19.3Providing Denture Care

■ Page 319

Hair Care■ Provide hair care regularly during illness, during or after morning bath

■ Hair care consists of brushing and combing, shampooing, shaving, and mustache or beard care

■ Morale and body image are improved when the patient is comfortable with the appearance

■ Brushing and coming hair stimulates circulation, which helps to promote hair growth, prevent hair loss, distribute oil along hair shafts, and bring nutrients to roots

■ Use a clean brush or comb to brush from the scalp toward the hair ends to decrease pulling

■ Separate the hair into 3 sections, then each of those sections may be split into smaller sections

■ To decrease may on tangled or matted hair, hold the hair between the scalp and the area you are brushing or combing

■ Braiding hair helps reduce tangles – ask permission before doing so

■ Alcohol, astringents or water may be used to loosen hair strands that are tangled or matted – do not cut hair to remove tangles

■ A written informed consent is necessary to cut patient’s hair

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Shampooing

■ Removes dirt, soil, blood, or solutions from the hair and stimulates circulation of the scalp and eases brushing and combing

■ If patient is out of bed in the chair, you may shampoo the hair in front of the sink

■ You must do the shampooing in bed if the patient is bedridden

■ Dry or rinse shampoo that does not require water is available for cleaning the hair

■ Another option is a shampoo cap such as a ReadyBath shampoo cap.

■ Ensure to check why shampooing could be contraindicated in patients. (lesions,

wounds, neck injuries)

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Skill 19.4Shampooing Hair

■ Page 320

Shaving

■ Removal of hair from the surface of the skin

■ Shaving may be done before, during or after the bath

■ Many patients confined to bed can shave themselves if you set up the equipment

■ A weak or debilitated person will need your assistance with shaving

■ Either a safety razor or electric razor may be used

■ Check electric razor before use for any possible electrical hazards

■ Razors should be used on only one patient to provide infection control

■ Be gentle and use short strokes with the safety razor (figure 19.10)

■ Check patient medical record to see whether the patient has any bleeding tendencies or is receiving medication that would contraindicate the use of a safety razor

■ A safety razor should not be used when a patient has a low platelet count, is receiving an anticoagulant, is undergoing chemotherapy, or is on aspirin therapy

■ You may not shave off a beard or mustache without a written, informed consent

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Steps 19.2 Shaving a Male Patient

■ Page 322

Nail Care■ Most patients can perform nail care for themselves as part of their daily hygiene routine

■ Nail care includes trimming, cleaning under the nails, and cuticle care, and is usually done with the bath

■ Never cut the toenails of a patient with diabetes or circulatory disease of the lower extremities without a written order

– Check facility policy if written order is needed to trim the fingernails of the diabetic patient

■ Soak the nails in warm soapy water for 5-10 minutes, especially if they are dirty or thickened.

■ Use an orangewood stick to clean under the nails because a metal nail file can make nails rough and trap dirt

■ Use nails clippers to cut the toenails straight across to prevent them from growing into skin along the sides (figure 19.11)

■ Patient education page 323

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Eye Care

■ Assess your patient’s eyes for drainage, crusting, or redness

■ Notify PCP if abnormalities are found

■ If crusting is noted, soak the eyelid with a warm, damp washcloth for 2-3 minutes to soften the crust and ease its removal

■ Perform more frequent eye care for unconscious patients, administer lubricating drops as ordered

■ Store glasses in a case when not in use

■ To clean lens, use clean warm water and a soft cloth to wipe dry

– Do not use a paper towel on plastic lenses because they may scratch them

■ Store glasses in a case when not in use

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Ear Care■ Hearing acuity may be affected if cerumen or foreign material collects in external ear

canal

■ Remove these materials by gently washing the external ear canal with warm wash cloths

■ No object, including cotton tipped applicators, should be inserted into the ear canal

– Applicators compact cerumen making it more difficult to clean the ear

– Irrigation may be needed id wax is dried or excessive – notify PCP if needed

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Key Points

■ Page 325

Question 1

Which of the following is not a function of the integumentary system?

1) Protection

2) Provides color

3) Temperature regulation

4) Excretion and secretion


Question 2

Justin has a patient in a long-term care facility with a pressure injury. It can be described as full-thickness skin loss that looks like a deep crater and extends to the fascia. Subcutaneous tissue is damaged. Which stage is this injury?

1) Stage 1

2) Stage 2

3) Stage 3

4) Stage 4


Question 3

Which of the following is not one of the basic purposes of bathing?

1) Cleanses the body

2) Promotes comfort

3) Stimulates conversation

4) Removes waste products


Question 4

Which of the following is true regarding mouth care?

1) Mouth care creates halitosis and dental caries.

2) An unconscious patient should be provided full mouth care at least every 24 hours.

3) When assisting a conscious patient with mouth care, you should raise the head of the bed 15 to 30 degrees.

4) Dentures should be kept in a labeled denture container with saline or water when not in the patient’s mouth.


Question 5

Gary is a nurse working in an acute-care facility. His patient is a 20-year-old male who was in an automobile accident. He has blood and glass fragments in his hair, a fractured femur, a mild concussion, and is negative for any other health problems. Which of the following is not an appropriate nursing intervention?

1) Shampooing the patient’s hair and cutting any glass fragments out of his head and hair

2) Washing his feet and trimming his toenails

3) Asking the patient if he wants you to call any family or friends

4) Allowing the patient time to rest


assisting with hygiene, personal care, skin care, and the

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