ders sunum sablonu 3

gelisimedu igugelisim

Department of Nursing (ENG)

Name of Course: BASIC PRINCIPLES AND PRACTICES OF NURSING II

Name of Lecturer: Assist. Prof. Dr. Funda KARAMAN

e-mail: [email protected]


mailto:[email protected]

6 Credit/12 ECTS

https://gbs.gelisim.edu.tr/ders-detay-5-160-11147-1

Ders Günü ve Saati

Course credit

GBS Linki

Course Information


Week Week 2-3

Let's remember the topics of last week

What will we learn in this week?


Skin and Self-Care Activities, Self-Care Practices

Outcomes Of The Course


Makes skin and self-care applications.


Skin and Skin Layers

The skin is one of the largest organs in the body in surface area and weight.

Skin protects body from external factors,

There are three main layers of the skin.


Epidermis is the top layer of the skin, the part of the skin you see.

Dermis is the second layer of skin. It's much thicker and does a lot for your body.

Subcutaneous fat is the bottom layer.

Function of the Skin


The main functions of the skin include:

Protection of the human body

Sensation (Pressure/touch, heat/cold, pain)

Temperature regulation

Immunity (the role of the skin within the immune system)

Enables movement and growth without injury

Excretion from the body of certain types of waste materials(Excretion of water, urea, ammonia and uric acid)

Endocrine function (Synthesis of Vitamin D)


Skin structure differs according to individual development periods.

This difference is a factor that must be considered in skin care.

Skin integrity assessment


Inspection and palpation methods are used in skinassessment.


Turgor: The elasticity and filling of the skin.

Edema: fluid accumulation in cells and tissues. When the skin is pressed, it moves in.

Causes of deterioration of skin integrity

immobility

Sensory changes

Change in nutrition and fluid intake

The presence of body wastes and

secretions on the skin

Change in Blood Circulation

Mechanical Tools

Skin problems

dry skin

acne

erythema

pubescence

Contactdermatitis

graze

Skin cleaning


The bath provides cleaning by removing sweat, dead skin cells and some microorganisms.

It stimulates the circulation and relaxes the client (patient).


The bath reduces body odors.

The bath increases muscle tone and provides joint movements.

The bathing process allows the patient to be evaluated.

It is a good opportunity to observe the condition of the patient's body as well as communicate with the patient.

Skin cleaning

What should be attention during bathing?


Protecting the privacy of the patient

Providing patient safety

Do not chill the patient

The development of the patient's sense of independence

Attention should be paid to the physical and psychosocial aspects of the patient.

The baths are divided according to the purpose of the application:


Cleaner baths;

* Full baths in the bed

*Partial baths

*Bathtub baths

Therapeutic baths;

* Hot baths

* Medicated baths

Indications of full baths


Unconscious patients

Paralyzed patients

Babies and old people

Patients with bed rest

If the post-operative patient is bed-dependent (eg, Abdomenic surgery)

If the patient is dependent on the bed after acute illnesses,


Partial baths;

Partial baths are given if the patient can not tolerate full bed baths or the whole body needs no cleaning.

In this bath; the face, neck, hands, back, armpit and perineal region of the patient are cleaned.

Bathtub baths;

Bathtub baths are done for patients who move independently or need a little help.

FULL BED BATH


Gather necessary equipments

Wash your hands, Put on the gloves.

Explain what you are going to do.

Get patient permission for the procedure.

Choose a clean and convenient area for the materials and arrange them within easy reach.

Draw curtains around the bed.

Ask the patient if she/he needs to urine/defecation

If there is a need for discharge;

Give a bedpan to the patient.

Place client in supine position near the side of the bed nearest you.

Remove patient' pajamas.

FULL BED BATH


Fill bath basin 2/3 (two over tree) full of warm water (43- 46°C). Check temperature with inner aspect of arm.

Place a towel across the client's chest.

Before starting the application, we can place ready-made washing caps on the patient's hair.

Wipe eyes first. Start at inner corner to outer. Use different washcloth for each eye and wipe the face

NOTE: DO NOT USE SOAP

Oral care is done.

First, the far side, then the near side, the auricle, the ear lob, the back of the ear, the neck, first wipe with soap, then clean water and dry thoroughly.

FULL BED BATH


Place the bath towel under the patient's arm away from you.

It is wiped from the hands upwards, first with soapy and then with clean water, starting from the wrist and upwards to the armpit with a longitudinal motion.

Hands are kept in hot water, it is easy to cut nails.

FULL BED BATH


Place towel across chest.

Wash and rinse chest and breasts while lifting towel.

Dry skin thoroughly.

Keep chest covered with towel.

Wash, rinse, and dry abdomen.

Change bath water in basin. Obtain a clean washcloth.

FULL BED BATH


Expose the farther leg; flex (bend) leg and place bath towel lengthwise under the leg up to the buttocks.

Wash and rinse leg and foot.

Dry leg, foot, and in between toes.

Repeat same steps on leg nearer you

May perform toenail care at this time.

Place the towel and washcloth in a laundry basket and get clean ones.

Change bath water in basin. Obtain a clean washcloth.

FULL BED BATH


Give a lateral lying position to wipe the patient's back.

Cover a towel over the patient's side to expose his back and buttocks; place clean towel parallel to patient's back and hip

Lift one side of the towel and wipe it along the neck and from the shoulders to the hips. Rinse and dry well.

FULL BED BATH


Clean the patient's perineum.

WATER MUST BE CHANGED, CLEAN, (41-43°C).

Give position the patient.

The dorsal recumbent position should be given in female patients and the supine position in male patients.

Anal area cleaning;

Wipe the anal area from the pubis to the anus,

Repeat the process until the area is cleared.

MASSAGE


Massage reduces tension in the muscles, allows relaxation and stimulates blood circulation in tissues.


1. Effleurage: An effleurage movement is a relatively slow and smoothly continuous stroke using the flat of the hand.


2. Petrissage:

Petrissage movement is made to subcutaneous tissues and muscles


3. Frictions:

Circular frictions are applied using the tips of fingers or thumbs using some pressure and some circular stationary manipulation


4. Tapotement:

It is a rhythmic percussion, most frequently administered with the edge of the hand, a cupped hand or the tips of the fingers


5. Vibration:

Vibration massage technique is a trembling movement performed with hands or fingers.

Daily Self Care Applications

Pre-breakfast Care

Morning Care

Night Care


Oral (Mouth) Care

Cleans the inside of the mouth structure

Prevents oral infection

Gets sense of cleanliness and comfort

The most commonly used oral care solution is SODIUM BICARBONATE.

Ready-made oral care solutions are also available.

Oral Care Process

•Gather necessary equipment.

•Wash your hands

•Explain what you are going to do.

• Provide privacy.

•Give the patient lateral, supine or semi-

fowler position.

•Put on clean gloves.

•Open the mouth of the patient if the mouth is closed

•Evaluate tooth, gingival and oral mucosa.

Aspirate the accumulated spit.

•Place the kidney tub under the patient's chin.

Place face towel

If the patient is using a prosthesis, remove the prosthesis first

and clean the prosthesis

∞ Make every

cleaning with

different material

Apply a moisturizer to prevent drying of the lips.

Remove and dispose of gloves. Wash

hands.

Remove and throw the equipment

Record observations and report anything unusual

to nurse/supervisor.


if it is suitable for the

patient, teeth can be

brushed and dental floss

can be used.


Hair bath

Today, with the developing

technology, the hair bath in the bed

has become more practical.


Lay out all your supplies so you know you have everything you’ll need

Protect the bed to keep it from getting wetFill one bucket with warm water

place patient's head into the inflatable basinMake sure the basin is set up to drain into the empty bucketScoop warm water from the full bucket to wet their hair

Use a small amount of shampoo to wash their hair – using too much will make it difficult to rinse out

Hair bath in bed


Scoop warm water to rinse hair completelyIf hair is very dirty, shampoo and rinse againWhen hair is clean, gently remove your

senior’s head from the basinWrap their head in a dry towel to keep them

warm and comfortableMake sure the basin is fully drained


FOOT CARE

Place the patient's feet in hot water.

Place towel under the feet of the feet.

Foot care must be made towards from the clean area to

the dirty area.

If the fingernails are long; cut straight

Apply moisturizer if necessary.


Perineal care

1. Gather necessary equipment.

2. Wash your hands. Put on gloves.

3. Explain what you are going to do.

4. Provide privacy (very important)

5. Female patients should be given dorsal recumbent and male patients should be given supine position.


Perineal care

Male Clients;

the penis is held from its

body and wiped from

urethral meatus to pubis

with circular motion.

Female Clients;

•Clean perineum from the

midline outward in

following order

a. The vulva

b. The labia

c. Inside of labia on both

sides.

d. Outside of labia on both

sides.

Clean the perineal region

and anus thoroughly.


Perineal care

Anal region cleaning;

Clean anal region from the pubis to the anus.


Record the procedure with date and the observations made.

Clean or throw all equipments

Wash hands

Change bed linen and dress if necessary

Make patient comfortable.


Perineal care

Anal region cleaning;

Clean anal region from the pubis to the anus.



Patient Education

a health professional should explain to patients;

What are these???

the importance of individual hygiene

How, how often and what materials hygiene practices should be done?

Why skin integrity is important?


Patient EducationHealth personnel should teach the use of assistive devices to protect the patient from falling and trauma.

REFERENCES


• Ay F. A. (2013). Basic Concepts And Skills In Health Practices. Nobel Medical Bookstore, Istanbul.

• Asti T. A., Karadag A. (2016). Nursing Fundamentals Nursing Science and Art. Academy Press And Publishing, Istanbul.

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