oral care_dep and indep_foot and toenail care

7/29/2019 Oral Care_dep and Indep_foot and Toenail Care

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ORAL CARE- Independent

-Dependent

FOOT AND TOENAIL CARE


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ORAL CARE FOR INDEPENDENT

PATIENTS


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Oral Hygiene includes cleansing of the mouth,

gums and teeth or dentures. This procedure

should be done before breakfast, after all

meals and at bedtime.


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Purpose:

To improve appetite, communication and

dental health.

To give the patient a feeling of well-being.

To decrease mouth odor.


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Equipments:

Fresh Water

Cup

Straw, if necessary

Toothbrush and toothpaste

Emesis basin

Face towel


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ASSESSMENT

1. Check the chart for any information related to

the patients ability to participate in the

procedure being planned.To know your limitations & to know the condition

of the patient.

Assess the patient for specific symptoms related

to diagnosis, for fatigue and for hygiene

preferences.PLANNING

3. Wash your hands To break the cycle of infection.4. Assemble the equipments


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IMPLEMENTATION

5. Identifies the patient and explains theprocedure An explanation facilitates cooperation

6. Provides for privacy The patient may be embarrassed if cleansinginvolves removal of dentures.

7. Raises the bed to a working height Promotes good body mechanics8. Assists the patient to sit up A sitting or side-lying position prevents aspiration

of fluids into the lungs.

9. Spreads the towel across the patients chest

The towel protects the patient from dampness.Raising the bed promotes efficient body

mechanics.

10. Offers the client water to rinse his mouth The nurse should encourage the patient toexercise as much independence as possible.


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11. Moistens the toothbrush with water from theglass. Spreads a small amount of toothpasteonthe toothbrush.

Water softens the bristles.

12. Offers the toothbrush to the patient if

he/she is able. If unable, brushes patients

teeth using gentle motion starting above thegum line and going down the teeth. Repeats

the stroke until to all the teeth.

Brushing facilitates the removal of plaque and

tartar.

13. Offers water to rinse patients mouth. Vigorous swishing helps remove loosed debris

14. Wipes the patients mouth and makes

patient comfortable.


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15. Returns bed to its comfortable position.

Opens curtains or screens.

16. Cleans equipments and places them

properly.

17. Washes hands

18. Documents pertinent observations.


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ORAL FOR DEPENDENT PATIENTS


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Purpose:

Due to high level of dependence, some patients mayrequire special oral hygiene methods. Unconsciouspatients are prone to drying of salivary secretionsdue to their incapacity to eat or drink and renderingthem unable to swallow salivary secretions. Theadverse effect of certain procedures (i.e.,chemotherapy, radiation and nasogastric tubeintubation) may cause the patient to develop

stomatitis. In cases like this, gentle brushing isrecommended and use of commercial mouthwashshould be avoided.


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Equipments:

Gloves

Paper Towels

Suction (if necessary)

Emesis basin

Tongue depressor

Toothbrush

Toothpaste

KY Jelly


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ACTIONS RATIONALE

1. Wash hands. Wear gloves Reduces transmission of microorganisms

2. Assess patient for the presence of gag reflex. Gag reflex may cause aspiration

3. Examine patients oral cavity. Determines frequency and extent of oral hygiene

needed.

4. Assess patient for risk of oral hygiene

problems.

Alterations in the oral cavity indicate frequency or

precautions in oral care.

5. Remove gloves and wash hands. Hand washing and gloving deters the spread ofmicroorganisms.

6. Position the client to lie on side with head

turned toward dependent side.

Prevents risk of aspiration


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7. Explain procedure to the patient. Reduces anxiety and promotes cooperation

8. Wash hands and don gloves. Reduces transmission of microorganisms

9. Assemble equipment on over bed table the

bedside table. Prepare suction if necessary.

Organization facilitates task performance. Suction

may be needed to prevent aspiration.

10. Raise bed to working height. Elevate head of

bed, as high as possible

11. Lower side rail on working side and turn

patients head toward you. (If patient can not lean

forward, position head slightly forward.

To facilitates drainage of fluid and secretions

during procedure

12. Place a towel across the chest and an emesis

basin against patients chin.

A towel and kidney basin protect the patient from

dampness


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13. Gently open patients mouth and insert a

padded tongue depressor between the back

morals.

A padded tongue depressor keeps the mouth

open for easier cleaning and prevents the patient

from biting down on the nurses hands or

utensils

14. Moistens toothbrush very lightly and brush all

tooth surfaces. Dip applicator into water of

mouthwash and wipe gums, teeth, tongue and

inside of mouth with applicator. (repeat if

necessary)

An applicator or toothbrush provides friction to

clean areas accumulated by tartar and plaque.

15. Discards used applicators appropriately into

plastic bag.

To prevent spread of microorganisms

16. Rinses the patients mouth with small

amounts of water, either allowing it to drain into

the emesis basin or used an asepto-syringe to

aspirate it.

Rinsing helps to remove debris from the mouth.


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17. If secretions accumulated, use suction. Prevents aspiration.

18. Wipe the patients mouth. To prevent skin irritation.

19. Apply lubricant to tips. Uses a water

soluble lubricant

Lubricants prevent drying and cracking of lips.

20. Leave the patient in a lateral position with

head toward the side for 30 60 minutes afteroral hygiene. Removes towel and raises side rail.

Prevents aspiration.

21. Lowers height of bed. Return patient to a

comfortable position.

Restores patients comfort.

22. Clean equipments and put away. To maintain medical asepsis.


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23. Remove gloves and discard appropriately.

Washes hands.

Hand washing deters the spread of microorga-nisms.

24. Document procedure and pertinent

observations.

Documentation facilitates communication to other

health personal and may also serve for legalpurposes.

21. Lowers height of bed. Return patient to a

comfortable position.

22. Clean equipment and put away. To maintain medical asepsis.

23. Remove gloves and discard appropriately.

Washes hands.

Hand washing deters the spread ofmicroorganisms.

24. Document procedure and pertinent

observations.

Documentation facilitates communication to other

health personal and may also serve for legal

purposes.


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PROVIDING FOOT AND TOENAIL CARE

Purposes:

To cleanse the feet

To stimulate circulation to the lower extremities.

To prevent injury.

To maintain the integrity of the integument.

To promote comfort to the feet.

To treat local infections by soaking the feet in amedicated solution.


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Equipment:

Wash basin

Soap

Warm water in pitcher

Hand towels, 2

Nail cutter or scissors

Nail file

Lotion (optional)

Powder (optional)

Paper lining (as the case may be)

Working gloves

Nail brush


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ACTIONS RATIONALE

1. Assess the condition of the feet and toenails. An appropriate plan for foot care cannot beindividualized.

2. Discuss any identifiable foot and nail problems

with the client. The client should be informed of potential andactual health problems.

3. Explain the procedure to the client. An explanation allays tear and aid in acquiringthe clients cooperation.


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4. Wash your hands Hand washing deters the spread ofmicroorganisms.

5. Gather the equipment Organization promotes efficient timemanagement.

6. Provide privacy to the client Providing privacy shows respect for the clientsfeeling

7. Do your working gloves

8. Protect the bed linen with towel beneaththe clients feet. - Dead cells and dirt trapped between the nail andthe toe may require mechanical removal.


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9. Soak each foot one at a time in warm (40C or

104F) of water for approximately 3-5 minutes. Soaking softens nails and helps to loosen dryskin and debris. Warm water dilates circulationsand promotes comfort.

10. Wash each foot with liberal amount of

lathered soap.

11. Brush the toenails.

12. Changes the water between the care of

each foot. The water should be clean and maintained at atemperature that promotes comfort.13. Cut the nails straight across ensuring thatthey are even with the tip of the toes. Cutting straight across is less likely to result ininjury to adjacent tissues or to potentiate the risk

of ingrown nails.


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14. Dry each foot thoroughly. Moisture allows the growth of fungi and can alsotend to lacerate skin if it cannot evaporate

15. Apply lotion or powder to the legs or

feet if needed. Powder absorbs perspiration.Lotion lubricates dryskin

16. Discard the water and do after care of

equipment.

Caring for soiled articles supports the principle of

medical asepsis.

17. Remove gloves then wash hands. Hand washing deters the spread of themicroorganisms

18. Document the care given, the response of theclient. And the necessary observations you made. Written information is a permanent record of thecare provided for the client.