LEARNING OUTCOME 1
Describe hygienic care that nurses provide to clients.
Concepts for Lecture
2.
It is important to know exactly how much assistance a client needs for
LEARNING OUTCOME 2
Identify factors influencing personal hygiene.
Concepts for Lecture
1. Factors influencing personal hygiene care include culture, religion,
environment, developmental level, health and energy, and personal
preference.
The North American culture places a high value on cleanliness.
the availability of facilities for bathing and supplies for hygienic
care.
Children learn hygiene in the home. Practices vary according to
the individual’s age.
LEARNING OUTCOME 3
Identify normal and abnormal assessment findings while providing hygiene
care.
Concepts for Lecture
1. The nurse can use the opportunity of providing hygiene care to phys-
C
HAPTER
33
HYGIENE
S
UGGESTIONS FOR
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LASSROOM
A
CTIVITIES
• Have students provide examples of clients
who may require help with hygiene care.
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UGGESTIONS FOR
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LASSROOM
A
CTIVITIES
• Have the students provide other examples of
the factors influencing personal hygiene.
• Have students investigate the hygienic prac-
tices and preferences of students in the educa-
tional setting from different cultures.
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UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
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UGGESTIONS FOR
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LASSROOM
A
CTIVITIES
• Demonstrate how to perform a head–to-toe
assessment while providing hygiene care. Use
a manikin in the nursing laboratory.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
• Have the students perform assessment of
their assigned clients require for hygiene care
2. Normal and abnormal findings on assessment of the feet are listed in
Table 33–5. Deviations from normal include excessive dryness,
3. Normal and abnormal assessment findings of the nails are found in
Chapter 30. Abnormal findings include spoon-shaped nails, exces-
33–6 and include halitosis, glossitis, gingivitis, periodontal disease,
5. Normal and abnormal assessment findings of the hair are included in
6.
Normal and abnormal assessment findings of the eyes, ears, and nose are
included in Chapter 30. Abnormal findings visible during hygiene care
include loss of hair, scaling, and flakiness of the eyebrows; redness,
LEARNING OUTCOME 4
Apply the nursing process to common problems related to hygienic care of
the skin, feet, nails, mouth, hair, eyes, and ears.
Concepts for Lecture
1. Assessment of the client’s skin, feet, nails, mouth, hair, eyes, ears,
and nose includes a nursing history to determine self–care practices,
2. Nursing diagnoses are derived from the assessment data. Self-Care
Deficit (Bathing/Hygiene, Dressing/Grooming, or Toileting) diagno-
ses are used for the client who has problems performing hygiene
3. When planning care, the nurse and, if appropriate, the client and/or
family set goals/desired outcomes for each nursing diagnosis.
The nurse then identifies interventions to assist the client to
achieve the designated outcomes.
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Discuss possible risk factors and etiologic
factors for the nursing diagnoses related to
hygiene as listed in the text.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
• Have the students develop care plans related
CHAPTER 33 / Hygiene 215
General nursing interventions include assisting dependent clients
with hygiene activities, educating clients and/or family about appro-
LEARNING OUTCOME 5
Identify the purposes of bathing.
Concepts for Lecture
1. The purposes of bathing are to remove transient microorganisms,
LEARNING OUTCOME 6
Describe various types of baths.
Concepts for Lecture
1. There are two categories of baths. Cleansing baths are given chiefly
for hygiene purposes. Therapeutic baths are given for physical
2. Types of cleansing baths include the complete bed bath, self-help
bath, partial bath (abbreviated), bag bath, tub bath, sponge bath, and
shower.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
• Have the students discuss the purposes of
bathing that relate to their clients.
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
•
Obtain a sample of a bag bath and demonstrate
this type of bath on a manikin.
• Discuss situations in which a complete bed
bath may be more desirable than a bag bath.
• Discuss various types of therapeutic baths.
ment for performing baths in the institution.
• Demonstrate how to use shower chairs.
216 CHAPTER 33 / Hygiene
LEARNING OUTCOME 7
Compare and contrast the task-centered approach and the individual-centered
approach to bathing.
Concepts for Lecture
1. The bath routine (e.g., day, time, and number per week) for clients in
health care settings is often determined by agency policy, which
often results in the bath becoming routine and depersonalized versus
2. A nurse who provides individual–centered care asks such questions
as: What is the client’s usual method of maintaining cleanliness? Are
LEARNING OUTCOME 8
Describe guidelines for bathing individuals with dementia.
Concepts for Lecture
1. Providing personal hygiene to a client with dementia is often an
ongoing challenge. Being sensitive to the rhythm of the client’s be-
havior and looking for cues can often offset problems related to this.
2. In addition, collaboration between the nurse and unlicensed assistive
personnel (UAP) is a critical element to implementing the individu-
alized individual-focused approach for cognitively impaired clients
3. General guidelines for bathing individuals with dementia:
• Focus on the individual rather than the task.
• Keep the individual covered as much as possible to maintain
warmth.
• Time the bath to fit the individual’s history, preferences, and
• Consider adapting your methods (e.g., distracting the individual
with singing while bathing), the environment (e.g., correct size
of shower chair, reducing noise, playing music), or the proce-
dure (e.g., consistently assigning the same caregiver, inviting
family to help).
have cries, screams, or protests from the client.
• Stop what you are doing and assess for causes of the distress.
• Adjust your approach.
• Shorten or stop the bath.
LEARNING OUTCOME 9
Discuss the different types of contact lenses.
Concepts for Lecture
1. Contact lenses, thin curved discs of hard or soft plastic, fit on the
cornea of the eye directly over the pupil. They float on the tear layer
2. Contact lenses may be either hard or soft or a compromise between
the two types—gas-permeable lenses.
• Hard contact lenses are made of a rigid, unwettable, airtight
plastic that does not absorb water or saline solutions. They usually
3. Most clients normally care for their own contact lenses. In general,
each lens manufacturer provides detailed cleaning instructions.
4.
All users should have a special container for their lenses. Some contain a
solution so that the lenses are stored wet; in others, the lenses are dry.
LEARNING OUTCOME 10
Discuss the different types of hearing aids.
Concepts for Lecture
1. A hearing aid is a battery–powered, sound–amplifying device used by
individuals with hearing impairments. It consists of a microphone
that picks up sound and converts it to electric energy, an amplifier
that magnifies the electric energy electronically, a receiver that con-
• Behind–the–ear (BTE) with earmold. This is a widely used type
because it fits snugly behind the ear. The hearing aid case, which
holds the microphone, amplifier, and receiver, is attached to the
earmold by a plastic tube (Figure 33–10).
• In–the-ear aid (ITE). This one–piece aid has all its components
observer. It has to be custom designed to fit the individual’s ear
(Figure 33–13).
• Eyeglasses aid. This is similar to the behind–the–ear aid, but the
components are housed in the temple of the eyeglasses. A hearing
aid can be in one or both temples of the glasses.
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UGGESTIONS FOR
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LASSROOM
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CTIVITIES
• If possible, obtain various types of contact
lenses for students to view.
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UGGESTIONS FOR
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LINICAL
A
CTIVITIES
• If the agency has an eye clinic, arrange for
CHAPTER 33 / Hygiene 219
LEARNING OUTCOME 11
Describe steps for removing, cleaning, and inserting hearing aids.
Concepts for Lecture
1. Skill 33–7 provides the steps in removing, cleaning, and inserting a
hearing aid. (See the textbook and the Skill Checklist provided on
the Student DVD–ROM.)
2. Clean the earmold.
Detach the earmold if possible. Disconnect the earmold from the
receiver of a body hearing aid or from the hearing aid case of
behind–the-ear and eyeglass hearing aids where the tubing meets the
3. Insert the hearing aid.
Determine from the client if the earmold is for the left or the
right ear.
Check that the battery is inserted in the hearing aid. Turn off the
hearing aid, and make sure the volume is turned all the way down.
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• If possible, invite a representative from a
hearing aid company to bring samples of
various hearing aids to class and discuss
appropriate care of these devices.
220 CHAPTER 33 / Hygiene
LEARNING OUTCOME 12
Discuss factors that support a positive and safe environment for the client.
Concepts for Lecture
1. Because individuals are usually confined to bed when ill, often for
long periods, the bed becomes an important element in the client’s
LEARNING OUTCOME 13
Identify safety and comfort measures underlying bed-making procedures.
Concepts for Lecture
1. A smooth, wrinkle-free bed foundation minimizes sources of skin
irritation. This is achieved by pulling and tucking the sheet under the
mattress tightly.
To provide for client comfort and safety after making a bed:
Attach the signal cord so that the client can conveniently reach it; if
the bed is currently being used by a client, either fold back the top
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Have the students practice making unoccupied
and occupied beds in the nursing laboratory.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
•
Discuss the schedule for linen changes in the
institution and reasons to deviate from this.
• Have the students perform safety checks of
the environment after completing the linen
change.
CHAPTER 33 / Hygiene 221
LEARNING OUTCOME 14
Verbalize the steps used in:
a. Bathing an adult client.
b. Providing perineal-genital care.
c. Providing foot care.
d. Brushing and flossing the teeth.
e. Providing special oral care.
f. Providing hair care.
g. Shampooing the hair of a client confined to bed.
h. Removing, cleaning, and inserting a hearing aid.
i. Changing an unoccupied bed.
j. Changing an occupied bed.
Concepts for Lecture
ESSENTIAL/
CRITICAL
ELEMENT?
COMPETENCY
DEMONSTRATED?
Yes
No
16. Assisted the client into shower or tub.
ment of the water temperature and water flow pressure.
b. Explained how client can signal for help, left the client for 2 to 5
minutes, and placed an “Occupied” sign on the door.
a. Assisted the client taking a standing shower with initial adjust-
17. Assisted the client with washing and getting out of tub.
a. Washed the client’s back, lower legs, and feet if necessary.
b. Assisted the client out of the tub.
18. Dried the client and assisted with follow-up care.
a. Assisted the client back to his or her bed.
b. Cleaned tub or shower in accordance with agency practice, dis-
carded used linen in laundry hamper, and placed the “Unoccu-
pied” sign on the door.
Variation: Bathing Using a Hydraulic Bathtub Chair
a. Brought the client to tub room in a wheelchair or shower chair.
b. Filled tub and checked water temperature with a bath
thermometer.
c. Lowered hydraulic chair lift to lowest point outside the tub.
d. Transferred the client to chair lift and secured seat belt.
e. Raised chair above the tub.
f. Supported the client’s legs as chair was moved over tub.
g. Positioned the client’s legs down into the water and slowly low-
ered chair lift into tub.
h. Assisted the client in bathing, if appropriate.
i. Reversed procedure when taking the client out of tub.
j. Dried the client and transported him or her to the room.
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 33–2: PROVIDING PERINEAL-GENITAL CARE
COMPETENCY
DEMONSTRATED?
Yes
No
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be
used.
3. Gathered appropriate equipment.
control procedures.
5. Provided for client privacy by drawing the curtains around the bed
or closing the door to the room.
6. Prepared the client:
a. Folded the top bed linen to foot of the bed and folded gown up
to expose genital area.
b. Placed bath towel under the client’s hips.
7. Positioned and draped the client and cleaned the upper inner thighs.
b. Covered all intravenous catheters or wound dressings with plastic
coverings and instructed the client to prevent wetting these areas.
c. Put a rubber bath mat or towel on floor of tub if safety strips were
not on tub floor.
224 CHAPTER 33 / Hygiene
For Female Clients:
a. Positioned the female in a back-lying position with knees
flexed and spread well apart.
sides of the legs.
c. Applied gloves. Washed and dried upper inner thighs.
b. Covered her body and legs with bath blanket positioned so that
For Male Clients:
a. Positioned male client in supine position with knees slightly
flexed and hips slightly externally rotated.
b. Applied gloves. Washed and dried upper inner thighs.
9. Washed and dried the perineal-genital area.
For Female Clients:
a. Cleaned the labia majora. Spread labia to wash the folds be-
tween labia majora and labia minora.
b. Used separate quarters of washcloth for each stroke and wiped
from pubis to rectum.
c. Rinsed the area well. Dried perineum thoroughly.
For Male Clients:
a. Washed and dried the penis, using firm strokes.
b. For uncircumcised client: Retracted foreskin and exposed
glans penis for cleaning. Replaced foreskin after cleaning.
c. Washed and dried the scrotum.
10. Inspected perineal orifices for intactness.
11. Cleaned between the buttocks.
aminer.
ing, if necessary.
c. Dried area well.
a. Assisted the client to turn onto one side facing away from ex-
12. Removed and discarded gloves. Performed hand hygiene.
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 33–3: PROVIDING FOOT CARE
COMPETENCY
DEMONSTRATED?
Yes
No
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
4. Performed hand hygiene and observed other appropriate infection
control procedures.
5. Provided for client privacy by drawing the curtains around the bed or
6. Prepared equipment and client:
a. Filled washbasin with warm water at about 40ºC to 43ºC (105ºF
to 110ºF).
b. Assisted ambulatory client to sitting position in chair or bed cli-
ent to supine or semi-Fowler’s position.
d. Placed washbasin on moisture-resistant pad at foot of the bed for
bed client or on floor in front of chair for ambulatory client.
7. Washed and soaked the foot.
a. Placed one of client’s feet in basin and washed with soap, paying
particular attention to interdigital areas.
8. Dried the foot thoroughly and applied lotion or foot powder, as
appropriate.
9. Trimmed the nails of first foot while second foot is soaking if agency
policy permits.
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 33–4: BRUSHING AND FLOSSING THE TEETH
COMPETENCY
DEMONSTRATED?
Yes
No
1. Introduced self and verified client’s identity.
used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
5. Provided for client privacy by drawing the curtains around bed or
closing door to the room.
6. Prepared the client:
a. Assisted client to sitting position in bed, if health permitted.
7. Prepared equipment:
a. Placed towel under the client’s chin.
b. Applied clean gloves.
dentifrice to toothbrush.
d. Used soft toothbrush and the client’s choice of dentifrice.
e. Placed small curved basin under the client’s chin, fitting small
curve around chin or neck if client must remain in bed.
f. Inspected mouth and teeth.
8. Brushed the teeth:
a. Held the brush against the teeth with bristles at 45-degree an-
gle.
b. Moved bristles up and down gently in short strokes from the
c. Repeated until all outer and inner surfaces of teeth and sulci of
gums were cleaned.
short strokes.
e. Brushed tongue gently with toothbrush.
sin.
g. Repeated preceding step until mouth was free of dentifrice and
food particles.
h. Removed curved basin and helped the client wipe the mouth.
9. Flossed teeth.
a. Assisted the client to floss independently, or flossed teeth of an
alert and cooperative client.
b. Wrapped one end of floss around third finger of each hand.
back of the left side.
d. Flossed lower teeth and used index fingers to stretch floss.
e. Gave the client tepid water to rinse the mouth and a curved ba-
sin in which to spit the water.
c. Flossed upper teeth and used thumb and index finger to stretch
10. Removed and disposed of equipment appropriately.
b. Removed and discarded gloves. Performed hand hygiene.
1. Removed dentures.
a. Applied clean gloves.
denture container.
ing the lips. Placed lower plate in denture container.
b. Grasped the upper plate at the front teeth with thumb and sec-
2. Cleaned dentures.
sink.
dentures with the cleaning agent and tepid water.
c. Rinsed dentures with tepid running water.
a. Took denture container to sink. Placed washcloth in bowl of
3. Inspected dentures and mouth.
4. Returned dentures to mouth.
5. Removed and discarded gloves. Performed hand hygiene.
CHAPTER 33 / Hygiene 227
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 33–5: PROVIDING SPECIAL ORAL CARE FOR
THE UNCONSCIOUS CLIENT
COMPETENCY
DEMONSTRATED?
Yes
No
1. Introduced self and verified client’s identity if the client is con-
scious.
2. Explained procedure to client and discussed how results will be
used.
3. Gathered appropriate equipment.
4. Provided for client privacy by drawing curtains around bed or
closing door to room.
5. Performed hand hygiene and observed other appropriate infection
control procedures.
6. Prepared the client:
head of bed lowered.
c. Placed curved basin against the client’s chin and lower cheek.
d. Applied gloves.
a. Positioned unconscious client in a side-lying position, with
7. Cleaned teeth and rinsed mouth.
a. Brushed natural teeth or cleaned artificial teeth.
each side of the mouth.
c. Made sure that all of the rinsing solution ran out of the client’s
needed.
used.
b. Rinsed the client’s mouth by drawing about 10 mL of water or
8. Inspected and cleaned the oral tissues.
a. If tissues appeared dry or unclean, cleaned them with foam
swabs or gauze and cleaning solution following agency policy.
b. Wiped mucous membrane of one cheek with moistened foam
clean next area.
separate applicators.
lesions.
e. Rinsed the client’s mouth.
9. Ensured the client’s comfort.
a. Removed basin and dried around the client’s mouth with tow-
el. Replaced artificial dentures if applicable.
b. Lubricated the client’s lips with water-soluble moisturizer.
c. Removed and discarded gloves. Performed hand hygiene.
228 CHAPTER 33 / Hygiene
ESSENTIAL/
CRITICAL
ELEMENT?
COMPETENCY
DEMONSTRATED?
Yes
No
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 33–8: CHANGING AN UNOCCUPIED BED
COMPETENCY
DEMONSTRATED?
Yes
No
1. Introduced self and verified client’s identity.
2. Explained procedure to client.
3. Gathered appropriate equipment.
tion control procedures.
5. Provided for client privacy.
6. Placed fresh linen on the client’s chair or overbed table.
7. Assessed and assisted the client out of bed using assistance de-
vices, if needed.
8. Raised the bed to a comfortable working height.
secretions and/or excretions.
9. Applied clean gloves if linens and equipment were soiled with
10. Stripped the bed.
a. Checked bed linens for any items belonging to the client and
detached the call bell or any drainage tubes from the bed
linen.
b. Loosened all bedding systematically, starting at head of bed
on the far side and moving around the bed up to the head of
the bed on the near side.
c. Removed pillowcases, if soiled, and placed pillow(s) on
bedside chair.
d. Folded reusable linens.
e. Removed incontinent pad and discarded if soiled.
f. Rolled all soiled linen inside bottom sheet, held it away
from uniform, and placed directly into linen hamper.
g. Wiped the mattress with disinfectant if soiled.
bed.
i. Removed and discarded gloves if used. Performed hand hy-
giene.
11. Applied the bottom sheet and drawsheet, if needed.
13. Applied or completed the top sheet, blanket, and spread.
a. Optional: Made a vertical or horizontal toe pleat.
15. Provided for client comfort and safety.
a. Attached the call light.
b. Folded back top covers to make it easier for the client to re-
turn to bed.
c. Placed bedside table and overbed table so they were availa-
ble to the client.
d. Left the bed in appropriate position, depending on the situa-
tion of the client.
Variation: Making a Surgical Bed
a. Stripped the bed.
b. Placed and left pillow(s) on bedside chair.
c. Applied bottom linens. Placed a bath blanket on foundation
of bed if this is agency practice.
d. Placed top covers on bed.
e. Made a cuff at top of bed. Folded top linens up from bottom.
the middle of the bed, forming a triangle.
wise to the side of the bed opposite from where the client is
to enter the bed.
h. Left bed in high position with side rails down.
i. Locked wheels of bed if bed is not to be moved.
230 CHAPTER 33 / Hygiene
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 33–9: CHANGING AN OCCUPIED BED
COMPETENCY
DEMONSTRATED?
Yes
No
1. Introduced self and verified client’s identity.
2. Explained procedure to client.
3. Gathered appropriate equipment.
tion control procedures. Put on disposable gloves if linen was
4. Performed hand hygiene and observed other appropriate infec-
5. Provided for client privacy.
6. Removed the top bedding.
a. Removed any equipment attached to bed linen.
c. Left top sheet over client or replaced it with bath blanket.
7. Changed the bottom sheet and drawsheet.
a. Raised side rail that the client turned toward.
b. Assisted the client to turn on the side away from the nurse
and toward raised side rail.
c. Loosened bottom linens on side of bed near the nurse.
d. Fanfolded dirty linen toward center of bed as close to and
under the client as possible.
client as possible. Tucked sheet under near half of the bed.
bed.
g. Assisted the client to roll over toward the nurse onto the
clean side of the bed.
h. Moved pillow(s) to the clean side for the client’s use.
Raised the side rail before leaving the side of the bed.
i. Moved to the other side of the bed and lowered the side
rail.
j. Removed used linen and placed in portable hamper.
k. Unfolded the fanfolded linen and tucked excess under mat-
tress.
8. Repositioned the client in the center of the bed.
9. Applied or completed the top bedding.
the client when bath blanket or used sheet was removed.
b. Completed putting on remaining linens for top of bed.
10. Ensured continued safety of the client.
a. Raised side rails. Placed bed in low position.
b. Attached call light to bed linen within the client’s reach.
c. Put items used by the client within easy reach.
CHAPTER 33 / Hygiene 231
LEARNING OUTCOME 15
Recognize when it is appropriate to delegate hygiene skills for clients to unli-
censed assistive personnel.
Concepts for Lecture
1. The nurse often delegates the skill of bathing to UAP. However, the
nurse remains responsible for assessment and client care. The nurse
needs to do the following:
• Inform the UAP of the type of bath appropriate for the client and
2. Perineal-genital care can be delegated to UAP; however, if the client
3. Foot care for the nondiabetic client can be delegated to UAP.
4. Oral care, brushing and flossing of teeth, and denture care can be
delegated to the UAP. After performing the previously described as-
5. Brushing and combing hair, shampooing hair, and shaving facial hair
can be delegated to UAP unless the client has a condition in which
6. A nurse can delegate the task of caring for a hearing aid to the UAP.
It is important, however, for the nurse to first determine that the
7.
Bed-making is usually delegated to UAP. If appropriate, inform the UAP
of the proper disposal method of linens that contain drainage and the ex-
tent to which the client can assist or if another individual will be needed
232 CHAPTER 33 / Hygiene
LEARNING OUTCOME 16
Demonstrate appropriate documentation and reporting of hygiene skills.
Concepts for Lecture
1. Document the following:
• Type of bath given (i.e., complete, partial, or self-help). This is
usually recorded on a flowsheet.
2. Document any unusual findings such as redness, excoriation, skin
4. Document assessment of the teeth, tongue, gums, and oral mucosa.
5. Document assessments and special nursing interventions. Daily