Functional Assessment and Wound Care in Older Adults, Exams of Nursing

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Introduction to Functional Ability How would your daily activities change if you fell and broke both of your arms and had casts on them for the next six weeks? Consider your routine from the time you get out of bed until you are ready to first leave your home. Since the casts extend from your fingers to your elbows, count the number of routine tasks that will be more difficult, or even impossible, for you to do for yourself. How would you say your broken arms have impacted your ability to function? Functional ability refers to the capacity a person has to care for themselves. Assisting With Activities of Daily Living A client experiencing temporary functional ability of the right arm and hand will need assistance with which activities of daily living (ADLs) while hospitalized on a medical-surgical unit? Select all that apply. Hygiene, dressing, and feeding are considered activities of daily living. If the client has issues with the right arm and hand, ADLs that require both hands, such as buttoning a shirt, would be difficult. Since the right hand is used to bathe the left side, the client will need assistance with this as well. Components of Functional Ability The nurse considers which factors when assessing the functional ability of a client? Select all that apply. Factors that can affect functional ability are physical and cognitive abilities such as mobility, cognition, and the senses. Marital status and self-sufficiency are factors in discharge planning but are not considered part of the functional assessment or ability. Purpose of a Functional Assessment The nurse is completing a functional assessment on a client. The client asks what the purpose of the assessment is. How should the nurse respond? The goal of a functional assessment is to help the client maintain as much independence as possible. For example, if the client can brush their teeth, the nurse should assemble the supplies but let the client perform their own oral care. The nurse should not perform oral care just because the client is in the hospital. Assessing Functional Ability A functional assessment measures the client's ability to complete the tasks and activities associated with daily living. A functional assessment is completed as part of the complete health assessment to:  Measure the impact of an illness on the person’s ability to care for themselves.  Determine the scope of assistance required by an individual.  Monitor changes in the functional ability of a client living with a chronic alteration in health.

A full functional assessment is used to gather data related to a client’s ability to care for themselves in their home. Questions relate to their current physical health and health maintenance behaviors, their capacity to care for themselves, their mental skills (including coping mechanisms), economic stability, and the social aspects of their life. Types of Assessments  Social  Roles  Interpersonal relationships  Partner violence  Economic  Education  Financial status  Transportation  Mental health  Coping mechanisms  Spiritual practices  Physical health  Activity and exercise  Sleep  Nutrition  Elimination  Personal habits (alcohol or drug use)  Self-care capacity  Ability to complete activities of daily living (examples: feeding, bathing, dressing)  Environmental hazards Illness and Functional Ability An individual's functional ability often decreases due to alterations in health caused by an illness or accident. In addition, many treatments used to restore health (e.g., casts and braces, intravenous [IV] therapy, and confinement to bed) hamper the person's ability to care for themselves independently. The impact can range from needing a little help walking to the bathroom to dependence on others while having casts on both arms. It is the nurse's responsibility to work with the client to determine their level of functional ability and plan interventions that promote the client's independence while assuring they receive the assistance they need. Meet Steve Steve (pronouns they/them/their) recently fell from a ladder and broke both wrists. During the first follow-up appointment at the clinic, the nurse plans to discuss how Steve is coping with the decreased

use of their hands. What questions should the nurse ask? Reflect on your daily routine and how it would change for ideas before moving to the next page. Determining Functional Ability During the assessment of functional ability, information is collected related to how the client perceives their health impacts their ability, their ability to care for themselves at home and when away, prioritizing the client’s needs, planning interventions and alternatives, and supporting the client’s acceptance of temporary or permanent changes in their functional ability. Client Perception A person’s overall self-perception influences their self-esteem, cognition, behavior, and activities of daily living (ADLs). Listen to the nurse’s question and Steve’s response. Nurse Steve, please tell me how the limited use of your hands will impact your daily life. Steve I love all outdoor activities, especially biking and swimming. I am most concerned that the casts will prevent these activities as well as bathing, grooming, dressing, cooking, and keeping the house clean. And, since I work with my hands, I will be out of work until the casts come off. My biggest fear is that I will sit around all day eating junk food and feeling sorry for myself. Ability To Care for Self Understanding how a client currently performs the basic activities of daily living (ADLs), such as bathing, dressing, toileting, transferring or moving, remaining continent, and feeding themselves, is critical to creating a plan that supports the client’s needs. Nurse Thank you for sharing. I agree that figuring out how to care for yourself is important. Tell me about your current routines and any specific concerns you have. Steve

My roommate and I enjoy cooking together. Luckily, they do most of the work and I clean up behind them. We work at the same company, so getting to work is not an issue. It is just that I work the assembly line and cannot do that with these casts. I can probably shower, but cleaning myself after using the toilet is not going to be simple. My mom will probably be over to help, which is great! Prioritizing Interventions The same illness or injury can impact the functional ability of two people very differently depending on their health history. For example, a client with chronic obstructive pulmonary disease (COPD) with casts on both arms may not be able to administer their own medications or breathing treatments. If they live alone, they may not be able to go home. Finding a place to go, or someone to come every day, can be a challenge. Nurse What are your biggest concerns right now? Steve I have always been healthy and know that I’ll be okay. But honestly, being unable to clean myself after a bowel movement is freaking me out. I am a private person, so the thought of someone having to help me is depressing. I really think the rest will work itself out with a lot of help from my roommate, family, and friends. Nurse You have such a great attitude, which will help a lot. As for toileting, the clinic’s occupational therapist has worked with people in your situation and will be in to speak with you about caring for yourself. I know they have a couple of gadgets that should help you remain independent. If you are willing to speak with them, I can get them now. Steve Thanks, I appreciate the support. Recovery Ups and Downs The same illness or injury can impact the functional ability of two people very differently depending on their health history. For example, a client with chronic obstructive pulmonary disease (COPD) with casts on both arms may not be able to administer their own medications or breathing treatments. If they live alone, they may not be able to go home. Finding a place to go, or someone to come every day, can be a challenge. Nurse What are your biggest concerns right now?

Steve I have always been healthy and know that I’ll be okay. But honestly, being unable to clean myself after a bowel movement is freaking me out. I am a private person, so the thought of someone having to help me is depressing. I really think the rest will work itself out with a lot of help from my roommate, family, and friends. Nurse You have such a great attitude, which will help a lot. As for toileting, the clinic’s occupational therapist has worked with people in your situation and will be in to speak with you about caring for yourself. I know they have a couple of gadgets that should help you remain independent. If you are willing to speak with them, I can get them now. Steve Thanks, I appreciate the support. Tools to Assess Functional Ability A variety of tools are used to assess a person’s functional ability with basic activities of daily living (ADLs) and the instrumental activities of daily living (IADLs). Katz Index of Independence in Activities of Daily Living From a nursing care perspective, the most important assessment of the functional ability of the client in a hospital or other health facility is their ability to perform the basic activities of daily living, which include bathing, dressing, toileting, transferring (mobility), continence, and feeding. Using the Katz Index of Independence in Activities of Daily Living, the client is given one point for being able to perform these tasks independently and no points if the client needs assistance. The higher the score, the more independent the client is. The lower the score, the more dependent the individual will be on others for performing these basic ADLs. Lawton Instrumental Activities of Daily Living Scale The Lawton Instrumental Activities of Daily Living Scale assesses the client’s ability to complete more complex daily activities including using a telephone, shopping, preparing food, keeping a home, doing laundry, getting from place to place, managing their medications, and handling their finances. Like the Katz scale, the examiner gives the client a score of one if able to complete and zero if assistance is needed. The higher the score, the more independent the client is. The lower the score, the more dependent the individual will be on others for performing these complex daily activities. Steve’s Functional Ability The nurse determines that Steve’s casts will interfere with both basic and complex activities of daily living. While dressing and feeding himself may be more challenging, Steve still has limited use of the fingers and may be able to button a shirt, pull on elastic waist pants, and eat finger foods. Of the

more complex tasks, Steve may not be able to manage his medications in containers with safety (childproof) caps or drive a car, but has family and friends who are willing to help. Functional Ability in a Healthcare Setting From a nursing care perspective, the most (not least) important assessment of a client’s functional ability in the hospital (not at home or while traveling) is their ability to perform the basic (not complex or routine) activities of daily living (ADLs), which include bathing, dressing, toileting, transferring (mobility), continence, and feeding. The nurse and client collaboratively plan care to support the client's needs while hospitalized. The more complex activities, including using a telephone, shopping, preparing food, keeping a home, doing laundry, getting from place to place, managing their medications, and handling their finances, influence what support the client will require to safely leave the hospital. Nursing Application of Functional Ability One tool used frequently by nurses is the Braden Scale, which measures the risk of pressure wounds. This evidence-based scale rates six factors associated with pressure sores:  Sensory perception: The ability to respond meaningfully to pressure-related discomfort.  Moisture: The degree to which skin is exposed to moisture.  Activity: The client’s level of physical activity.  Mobility: The client’s ability to change and control body position.  Nutrition: The ability of the client to take in enough food and liquids.  Friction and Shear: The effects of moving while all or part of the body is in contact with surfaces that rub against the skin. Individuals with a total score of 16 or less are considered at risk.  15–16 = low risk  13–14 = moderate risk  12 or less = high risk Walk through each section of the Braden Risk Assessment Chart and assign Mrs. Smith the appropriate scores. Make a note of each score you give Mrs. Smith and add them together to answer the final question. As you complete the upcoming activity, consider which activities of daily living (ADLs) are key to preventing pressure wounds and what priority care needs must be addressed when caring for this client. Using the Braden Scale Consider the following client: Mrs. Smith had a stroke. She has limited use of her left side. She is 180 kg and unable to move in the bariatric bed. She is due to have a swallow study completed tomorrow morning. She has an order for

all liquids to be thickened. Due to her poor appetite, she has had limited caloric intake. The chart indicated she is only eating about 25-50% of her meals. The dietitian ordered thickened boost to start tomorrow morning. *Be sure to write down the individual scores as you will need to calculate the total score at the end. Sensory Perception  The ability to respond meaningfully to pressure-related discomfort. Select the score you believe to be the proper fit for Mrs. Smith’s assessment.

1. Completely Limited 2. Very Limited 3. Slightly Limited 4. No Impairment Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to a diminished level of consciousness or sedation OR Limited ability to feel pain over most of the body Responds only to painful stimuli and cannot communicate discomfort except by moaning or restlessness OR Has a sensory impairment that limits the ability to feel pain or discomfort over half of the body Responds to verbal commands but cannot always communicate discomfort or the need to be turned OR Has some sensory impairment that limits the ability to feel pain or discomfort in one or two extremities Responds to verbal commands and has no sensory deficit that would limit ability to feel or voice pain or discomfort Mrs. Smith has a sensory impairment due to her stroke (left side weakness), so her score for sensory perception is 3. Moisture  The degree to which skin is exposed to moisture. Select the score you believe to be the proper fit for Mrs. Smith’s assessment.

1. Constantly Moist 2. Very Moist 3. Occasionally Moist 4. Rarely Moist Skin kept moist almost constantly by perspiration, urine, and so forth, with dampness detected every time the patient is moved or turned Skin often but not always moist, with linen needing to be changed at least once a shift Skin occasionally moist, requiring an extra linen change approximately once a day Skin usually dry, with linen only requiring changing at routine intervals Mrs. Smith’s score here would be a 3 due to her weight and being on bed rest. Activity  The degree of physical activity. Select the score you believe to be the proper fit for Mrs. Smith’s assessment. 1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitation Confined to bed Ability to walk severely limited or nonexistent and cannot bear own weight and/or must be assisted into chair or wheelchair Walks occasionally during the day but for very short distances, with or without assistance and spends the majority of each shift in bed or chair Walks outside room at least twice a day and inside room at least once every 2 hours during walking hours Mrs. Smith’s score would be 1 because she is on bed rest. Mobility  The ability to change and control body position. Select the score you believe to be the proper fit for Mrs. Smith’s assessment.

1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitation Does not make even slight changes in body or extremity position without assistance Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently Makes frequent though slight changes in body or extremity position independently Makes major and frequent changes in position without assistance Mrs. Smith’s score here would be a 1 due to the fact that she is unable to move without assistance. Nutrition  The client’s usual food intake pattern. Select the score you believe to be the proper fit for Mrs. Smith’s assessment. 1. Very Poor 2. Probably Inadequate 3. Adequate 4. Excellent Never eats a complete meal, rarely eats more than one-third of any food offered, eats two servings or less of protein (meat or dairy products) per day, takes fluids poorly, does not take liquid dietary supplement OR Is NPO and/or maintained on clear liquids or IVs for more than 5 days Rarely eats a complete meal and generally eats only about half of any food offered, protein intake includes only three servings of meat or dairy products per day, occasionally will take a dietary supplement OR Receives less than optimum amount of liquid diet or tube feeding Eats over half of most meals, eats a total of four servings of protein (meat, dairy products) per day, occasionally will refuse a meal but will usually take a supplement when offered OR Is on a tube-feeding or TPN regimen that probably meets most nutritional needs Eats most of every meal, never refuses a meal, usually eats a total of four or more servings of meat and dairy products, occasionally eats between meals, does not require supplementation Mrs. Smith’s score for nutrition would be 2 because she is eating 25-50% of her food and will be starting boost in the morning. Friction and Shear

Select the score you believe to be the proper fit for Mrs. Smith’s assessment.

1. Very Poor 2. Probably Inadequate 3. Excellent Requires moderate to maximum assistance in moving, complete lifting without sliding against sheets impossible, frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance, with spasticity, contractures, or agitation leading to almost constant friction Moves feebly or requires minimum assistance, during a move skin probably sliding to some extent against sheets, chair, restraints or other devices, maintains relatively good position in chair or bed most of the time but occasionally slides down Moves in bed and in chair independently and has sufficient muscle strength to life up completely during move and maintains good position in bed or chair Mrs. Smith’s score for friction and shear is 1. She requires maximum assistance. Mrs. Smith’s Braden Scale Score Based on your assessment of Mrs. Smith, what score would she receive on the Braden Scale? Mrs. Smith’s score should be 10 , which makes her high risk.  Sensory perception = 3; stroke left side weakness  Moisture = 3; over weight on bed rest  Activity = 1; confined to bed  Mobility = 1; unable to move in need  Nutrition = 2; eating 25-50% food, starting boost  Friction & Shear = 1; requires assistance Functional Ability A nurse is planning a presentation about functional ability in older adults. Which statements should be included in the presentation? Select all that apply. Assistive devices, such as hearing aids, are used to help clients maintain independence. In addition, all illnesses can affect a person’s functional ability. Determining Functional Ability A client with a physical and cognitive impairment was just admitted to the unit from the Emergency Department. Which statement is true about the functional ability of this client?

It is important to assess first. Evaluate what the client can and cannot do. Providing total care to clients when not required is not a client-centered approach to care. Assessment of Clients Which client’s functional ability will be most impacted by their health? Drug-induced psychosis can affect a client's ability to perform all activities of daily living (ADLs). Nursing Intervention for Vision Deficit While caring for a client who wears glasses to correct severely impaired vision, the unlicensed assistive personnel (UAP) notices the client is not wearing their glasses. Which action should the UAP take first? The UAP should first introduce themselves when entering the client’s room so the client knows who they are. After introducing themselves, the UAP should find the client’s glasses and encourage them to put them on. Documentation Review the following nurse’s note: Date Time Progress Note 11/8/20XX 08:00 Client needs moderate assistance with hair hygiene and no assistance with What is the purpose for placing this note in the client’s chart? The nurse documents the client’s functional abilities so that the healthcare team can maintain continuity of care and thus maintain the client's independence. For example, if a new care member joins the healthcare team, they can use this documentation for baseline care. This documentation can also indicate if there is a decline in the functional abilities of the client. Instrumental Activities of Daily Living Assessment The nurse is assessing a client with a left-sided weakness and wants to gain insight into the client’s instrumental activities of daily living (IADL) functional ability. What question would be most appropriate? Asking, "Are you able to shop independently for yourself?“ will assist the nurse in determining the instrumental activities of daily living, which are more complex tasks. Outcomes The client was admitted to the medical-surgical unit for management of a stage 3 pressure injury on the right heel. What is an achievable outcome to maintain and promote skin integrity? Select all that apply.

Repositioning every 15 minutes, maintaining a balanced, healthy diet, and using extra pillows to cushion bony areas are achievable goals to maintain skin integrity. These interventions are client- centered and encourage movement, nutrition, and protection. In addition, these outcomes are measurable. Activities of Daily Living Versus Instrumental Activities of Daily Living The nurse completed a functional ability assessment on a newly admitted client. Sort the client data into the appropriate category. Activities of daily living (ADL) are basic tasks such as bathing, dressing, toileting, transferring, continence, and feeding. Instrumental activities of daily living (IADL) are the ability to use a telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for one’s own medications, and the ability to handle finances. Introduction to Hygiene Merriam-Webster (n.d.) defines hygiene as “a science of establishment and maintenance of health” and “conditions or practices (as of cleanliness) conducive to health” (hygiene). Often, illness decreases a person’s desire or ability to maintain the usual hygiene routine. In healthcare facilities, it is the nurse or unlicensed assistive personnel (UAP) who provide hygiene to those who cannot. Influences on Hygiene Practices A client is admitted for pain control post knee replacement. The nurse observes that the client always washes the upper body before praying. How should the nurse interpret this behavior? In some cultures or religions, cleaning before praying is a common practice. Bathing Order A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area? The sequence for giving a bath is as follows: eyes, face, arms and chest, hands and nails, abdomen and legs, perineal hygiene, back, buttocks, and anus. Head to toe, leaving the perineum last on the front side (switch the side of the washcloth or obtain a new one). Then move to the back side of the client—again the cleanest to the dirtiest. Hygiene Risk Factors Match each client condition to the hygiene risk. Reduced sensation : Client unable to sense skin injury. Does not receive normal transmission of nerve impulses when applying excessive heat or cold, pressure, friction, or chemical irritants to the skin. Increases risk for pressure injuries. Altered cognition: Client unable to verbalize skin care needs. Does not realize the effect of pressure or prolonged contact with excretions or secretions, requiring more vigilant assessment.

Limited protein : Predisposition to impaired tissue synthesis. The skin becomes thinner, less elastic, and smoother with the loss of subcutaneous tissue. Poor wound healing results and impaired skin turgor. Excessive secretions : Moisture is a medium for bacterial growth and causes local skin irritation, softening of epidermal cells, and skin maceration. Maintaining Hygiene Always use good hand hygiene before and after client care! Skin The skin often reflects a change in physical condition through alterations in color, thickness, texture, turgor, temperature, and hydration. As long as the skin remains intact and healthy, its physiological function remains optimal. Hygiene practices frequently influence skin status and can have beneficial and negative effects on the skin. Feet, Hands, and Nails The feet, hands, and nails often require special attention to prevent infection, odor, and injury. The condition of a client's hands and feet influences the ability to perform hygiene care. Without the ability to bear weight, ambulate, or manipulate the hands, the client is at risk for losing self-care ability. Oral Cavity The oral cavity consists of the lips, the cheeks, the tongue, and the hard and soft palate. Saliva cleanses the mouth, dissolves food, promotes taste, moistens food, and breaks down starchy foods. Difficulty in chewing develops when surrounding gum tissues become inflamed, infected, or when teeth become loosened. Regular oral hygiene helps to prevent gum inflammation and tooth decay. Clients who have had a stroke may have difficulty handing oral care and having a suction device nearby can prevent aspiration. Hair Hair growth, distribution, and pattern indicate a person's general health status. Hormonal changes, nutrition, emotional and physical stress, aging, infection, and some illnesses affect hair characteristics. Eyes, Ears, and Nose When providing hygiene, the eyes, ears, and nose require careful attention because of their sensitive anatomical structures. To clean the nose, have the client gently blow your nose into a tissue to remove loosened dirt and mucus. To clean the eyes, wipe away any drainage from around the eye. Moisten a clean face cloth with warm water, and gently wipe from the inner to the outer part of the eye; with each wipe, utilize a clean part of the face cloth. When cleaning the ears, only clean the outside of your ear with a damp cloth. Don’t insert cotton swabs directly into the ears. Hygiene Best Practices Clients differ in how much physical assistance they need when bathing. Regardless of the type of bath a client receives, the following guidelines should be followed: Provide Privacy

 Close the door or pull the room curtains around the bathing area.  While bathing a client, expose only the areas being cleaned by using proper draping. Maintain Warmth  Keep the room warm.  Control drafts by closing doors and windows.  Keep the client covered, exposing only the body part being washed. Promote Independence  Encourage the client to participate in as many bathing activities as possible.  Help when needed. Anticipate Needs  Bring a new set of clothing and hygiene products to the bedside or bathroom.  NOTE : Linens brought to the bedside that remain unused should never be used on other clients. Order of Bathing Bathing a client should begin with the cleanest areas (e.g., eyes and face) and proceed to areas that are dirty (perineum and buttocks). The nurse should encourage the client to perform as many tasks as possible, observing to assure cleanliness is achieved. Select each tab to learn more. Order of Bathing Cleanse the front of the client first, in this order, changing washcloths as needed:

1. eyes
2. face and head
3. arms
4. chest
5. hand and nails
6. abdomen
7. legs
8. perineum Access the back of the client to clean their back, buttocks, and anus, in that order. Cleaning Parts of the Body Explore the interactive below for information on cleaning select areas of the body. Eyes

 Wearing clean gloves, assess the internal and external appearance of the eye for discharge, bruising, or inflammation.  Using a clean, damp washcloth, gently wipe the upper lid from the medial canthus (by the nose) outward. Change to a different portion of the washcloth and repeat for the other eye. Face, Head, and Neck  The washcloth used to cleanse the eyes can be used for the face if not soiled or the client does not have an eye infection.  Use a wet washcloth and mild or no soap, depending on needs.  Wash the external ears gently, without entering the ear canal.  Finish with the neck. Arms, Chest, and Hands  Cleanse both arms first, then the chest and underarms, finishing with the hands and nails. Abdomen and Legs  Change washcloths, if not done previously due to soiling.  Wash the abdomen and legs, avoiding the perineum. Perineum  Using mild soap and warm water, cleanse the perineum.  Change the washcloth after the perinium is clean. Back  Starting with a clean washcloth, use long, slow, gliding strokes to relax the client. Buttocks and Anus  Clean the buttocks first.  Inform the client before washing their anus. Foot Care In general, the feet are cared for the same as the rest of the skin, with warm water and soap. For clients with diabetes mellitus or other conditions that decrease circulation to the feet, leaving them at risk for complications, extra care is required. Foot Care for Clients With Decreased Circulation  Inspect the feet each time they are washed.

 Wash the feet in warm (not hot) water.  Dry the feet thoroughly, including between the toes.  Apply lotion to the foot surfaces, but not between the toes.  Put on shoes (preferred) or slippers when the client is out of bed.  If the nails need to be trimmed, contact the healthcare provider.  Although policies may vary by facility, nurses should not cut a client’s toenails.  Report any wounds or abnormalities to the healthcare provider. When caring for a client with decreased circulation to the lower extremities, reinforce the need for them to follow these same steps daily or when the feet become soiled. Factors Impacting Hygiene When interacting with clients, especially those whose background is different than yours, it is essential to avoid assumptions. Instead, become informed about the client’s preferences for cleanliness by asking questions about each person’s current practices and limitations. Age and Development Stage Based on one’s age they can care for themselves. Those with disabilities or who are younger may not have access to the resources or understand the importance of hygiene. Support from Nurses Nurses must care for all clients regardless of their gender identities. Some clients may not want to allow providers to see their genitals or could be in the midst of the gender reassignment process. Personal Preferences Some people may like certain hygiene products or enjoy baths more than showers. Some may choose not to wear deodorant or perfumes based upon how they were raised, allergies, or avoidance. Body Image Some clients are self-conscious about their weight, a birthmark, or scar. Socioeconomic Status Some clients may not be able to afford hygiene products or have regular access to showers and running water to bathe. Health Beliefs and Motivation Clients may believe in handling their health issues at home and prefer not to meet with a provider. Some see their health as a priority, and some are not concerned with watching their diet and exercise. Hygiene Influences Based on age, which client is most likely to require assistance with hygiene? The hygiene practices of a preschooler are influenced by their primary caregivers. This includes when and how often the child bathes, washes their hands, and brushes their teeth. Ideally, the child client’s routine can be accommodated while the client is in the hospital.

Personal Hygiene Preferences Watch video Mental Images During report, you are informed that a new client who does not speak is bald and incontinent. What is your mental image of the client? A newborn infant? An adolescent who recently had brain surgery and is in a medically-induced coma? Or perhaps an older adult receiving chemotherapy for bladder cancer? The description might fit each of these clients, yet each has their own unique needs. The nurse should perform a complete assessment to determine what care this client, who is bald, non-verbal, and incontinent, will need. About Our Mental Images Most individuals believe that they are not susceptible to biases and stereotypes, that everyone engages in them whether they like it or not. Luckily, this does not mean that everyone is prejudiced or inclined to discriminate. Instead, it simply means that the brain works in a way that makes associations and generalizations. Societal stereotypes influence people and it is generally impossible to separate yourself from the influence of society. People's expectations are influenced by both direct and indirect experiences. For example, cultural conditioning, media portrayals, and upbringing can all contribute to the implicit associations people form about other social groups' members. Illness and Hygiene Can you remember a time when you were sick? Did you have the energy to bathe or even brush your teeth? Illnesses can affect hygiene care. Some clients may not have the stamina to perform hygiene care. In other instances, an ill person may just neglect their hygiene. Wayne’s Story Wayne (preferred pronouns: he, him, his) is a retired bowling alley owner. He has emphysema and uses supplemental oxygen but refuses to give up smoking. He occasionally needs the assistance of a walker. Wayne does not have the stamina to stand and take a shower. His daughter states that Wayne usually washes while sitting in front of the sink. Five days ago, Wayne was admitted for dehydration and shortness of breath. He was diagnosed with pneumonia. He is having difficulty getting out of bed and completing any self-care. Upon discharge, Wayne will move into a rehabilitation facility until his strength increases and his independence is improved. Hygiene Assessment

When the nurse assesses the hygiene needs of the client, they have multiple cues to process. Let’s look at Wayne’s case as an example. Wayne’s Assessment What hygiene care will Wayne need in the hospital if his baseline was washing in the sink at home? Will Wayne have the stamina to wash his face and shave? Can Wayne perform oral care without becoming short of breath? Important! The nurse should evaluate all of the following factors when planning hygiene care for Wayne. Ability to Perform Self-Care Safely The first step is to ask Wayne about his normal hygiene practices and how they have been impacted by his health. This information is used by the nurse to plan a safe hygiene routine with Wayne that includes providing support, as needed. Factors that indicate a client will need assistance when in a healthcare facility include weakness, intravenous (IV) catheters, activity limitations (e.g., bed rest, traction, casts, pain), and altered cognition (e.g., dementia, side effects of medications, head injury). Feet, Hands, and Nails Assess the feet and nails while wearing gloves, noting any lesions or tears. Ask Wayne to describe their normal routine for foot care. Observe how well Wayne can reach his feet. Oral Cavity While wearing clean gloves, assess Wayne’s teeth for cleanliness and cavities. Observe the oral mucosa and tongue for dryness and lesions. Ask Wayne about dentures and their normal oral care routine. Because Wayne is a smoker, his teeth may be stained. Hair Assess Wayne’s hair for thinning or bald areas and pediculus humanus capitis (head lice). Assess if Wayne can lift their hands to their head as if shampooing or brushing their hair. Inquire about shaving and facial hair preference. Eyes, Ears, and Nose Check if Wayne can perform hygiene on his own ears, nose, and eyes. Sensory Aids Ask Wayne about the use of dentures, eyeglasses or contacts, and hearing aids. If used, discuss the care of each and ask if supplies are needed. Note down the sensory aids Wayne brought to the facility on the admission assessment form. Planning and Interventions After analyzing the multiple cues from the assessment, the nurse can then plan hygiene interventions that meet Wayne's needs. Nursing actions and interventions for Wayne include:

Intervention Rationale Educate Wayne's family to promote autonomy and to intervene if the client becomes tired, not capable of carrying out a task, or becomes extremely aggravated. This displays care and concern and does not hinder the client’s efforts to attain autonomy. Inform Wayne's family members to allow him to perform his own self-care. His family can assist him, but we want to promote self-care. Request Wayne's input on planning and scheduling. The client’s outlook improves when wishes or likes are taken into consideration. Establish short-term goals with Wayne. Realistic goal setting will reduce the client's frustration. Assessing Hygiene Needs Select all the assessment findings that influence the client's hygiene care. An older adult client is on bed rest due to right-sided weakness from a recent stroke. The client is sitting in bed visiting with family. Heparin is infusing intravenously via an IV in the left upper arm. Assessment data that indicates this client will need assistance includes bed rest, right-sided weakness, a recent stroke, and an IV in the left upper arm. Combined, the weakness and IV limit the client’s use of their arms to perform hygiene. The client’s age alone is not a factor to be considered, as they may have been independent before the change in their health. The client is sitting in bed because they are on bed rest and should not impact care decisions. The heparin, an anticoagulant, increases the client’s risk of bleeding, but the presence of the IV in the client’s stronger arm will limit their ability to care for themselves. Setting Goals An older adult client is on complete bed rest after a heart attack. The client has limited use of the right arm and a heparin intravenous (IV) infusion in the left upper arm. The client prefers bathing

at night because it relaxes them before bed. They state that they prefer to clean their hands and upper body before every meal and that they use an electric razor at home. Which are achievable goals for this client? Select all that apply. The client will maintain intact clean skin and the client will use an adaptive measure to shave with the left hand are achievable and measurable goals. Nursing Interventions and Medical Devices Mike is a young adult admitted to the medical unit with a chest tube in the right lower lung and various other injuries sustained in a motorcycle crash. The nurse understands this client will need assistance with hygiene care. The Nurse’s Role in Hygiene Care The nurse’s role in the care of Mike is to maintain and promote his independence with hygiene care. Nursing actions for Mike include:  Promote independence and clean body parts Mike is unable to reach.  Administer pain medication before performing hygiene care.  Educate Mike about adaptive techniques that will assist in hygiene care, such as crutches, a walker, or supplies provided at the bedside.  Collaborate with physical therapy and a discharge planner to support Mike's needs in the healthcare facility and to plan for assistance at home. Delegating Hygiene Activities  In many healthcare facilities, client hygiene assistance is provided by unlicensed assistive personnel (UAP), rather than a registered nurse (RN). While spending time bathing, the client provides the RN with a chance to complete a physical assessment or provide health education while, at times, the priorities for the nurse are in caring for others.  Before delegating a task such as hygiene activities, the nurse must consider the needs of the client and the skills of the UAP to whom the care is being delegated, give clear instructions, and plan time to supervise and evaluate the care given. Right Circumstance : Is the client’s condition stable enough for the task to be delegated? Right Person : Does the delegatee (UAP) have the knowledge, skills, and attitude to complete the task safely? Right Communication/Direction : Has the delegator (nurse) provided clear instructions related to both the client’s needs and condition as well as the extent of the task? Right Supervision/Evaluation : Is the nurse available to supervise or assist, as needed? When will the nurse follow up to assure the task was completed?

Providing Eye and Oral Care While many clients require assistance with complex hygiene tasks, such as bathing and grooming, other tasks, such as washing the face and brushing the teeth, are within their abilities during illness. Although these are tasks people do for themselves every day, care should be taken when providing them to clients. Select each tab and review the best practices for eye and oral care. After hygiene is completed, dispose of single-use equipment, clean reusable equipment, assure the client has no needs and is comfortable, and they can reach the bed controls, phone, and call light. PROVIDING EYE CARE Often done while providing a complete bath, cleansing a client’s eyes can be completed at any time of day. Follow these steps when performing eye care:

1. Assemble equipment, including clean, warm water, washcloth, and towel.
2. Introduce yourself and state the purpose of being in the room.
3. Identify the client using two identifiers.
4. Position the client sitting comfortably with the head tilted back.
5. Perform hand hygiene.
6. Assess the external and internal eye for discharge, bruising, or inflammation.
7. Moisten a washcloth with warm water and gently clean the upper eyelid from the medial canthus outward.
8. Using a clean portion of the washcloth, repeat the same process on the other eye.
9. Remove gloves and perform hand hygiene.
10. Return the client to a position of comfort. PROVIDING ORAL CARE Brushing cleans the teeth of food particles, plaque, and bacteria. It also massages the gums and relieves discomfort resulting from unpleasant odors and tastes. Daily flossing removes food particles, plaque, and tartar that collect between teeth and at the gum line. Rinsing removes dislodged food particles and excess toothpaste. Complete oral hygiene enhances well-being and comfort and stimulates the appetite. Follow these steps when providing oral care:
11. Assemble equipment, including clean water, toothbrush, oral swabs, toothpaste, emesis basin, dental floss, mouthwash, and towel.
12. Introduce yourself and state the purpose of being in the room.
13. Identify the client using two identifiers.
14. Position the client sitting comfortably with the head tilted back.
15. Perform hand hygiene and don clean gloves.
16. Assess the integrity of the lips, teeth, oral mucosa, gums, palate, and tongue.
17. Assess gag reflex and ability to swallow.
18. Remove gloves, perform hand hygiene, and apply clean gloves.
19. If using a toothbrush and toothpaste, apply toothpaste to the length of the toothbrush.
20. Perform oral care in this order:

 Clean chewing surfaces and inner teeth on top and bottom.  Clean outer surfaces of teeth.  Use an oral swab soaked in water or mouthwash to clean the roof of the mouth, gums, and internal cheeks.  Gently brush the tongue, being careful to avoid stimulating the gag reflex.

11. Ask the client to rinse with mouthwash, discarding rinse in an emesis basin. Proper Order for Eye Care A client is unable to wipe their own face or perform eye care. Place the steps in providing eye care, while preventing infection and cross-contamination, in order from first to last. The correct steps in performing eye care are:
12. Assemble equipment and ensure the bed is at the correct working height.
13. Position the client sitting comfortably with the head tilted back.
14. Decontaminate both hands and put on gloves.
15. Assess the external and internal appearance of the eye for discharge, bruising, or inflammation.
16. Moisten a washcloth and gently clean the upper eyelid from the medial canthus outward.
17. Using a clean portion of the washcloth or a new one, repeat the same process on the other eye. Prioritizing Hygiene Needs While planning morning care, which client is the highest priority to receive a bath first? The client with incontinent stools has a greater risk for skin breakdown and should be the highest priority. Pediculus humanus (Lice) The three varieties of lice that infect humans are:  Pediculus humanus capitis (head lice)  Pediculus humans corporis (body lice)  Pediculus pubis (crab lice) The presence of lice does not mean that a person practices poor hygiene, since lice spread quickly, particularly among children who play closely together. Head lice and crab lice attach their eggs, which look like dandruff, to the hair shaft. Head lice and body lice are very small with grayish-white bodies, whereas crab lice have red legs. Observe small, red, pustular eruptions in the hair follicles and areas where skin surfaces meet, such as behind the ears and in the groin, to identify infestations better. A person often has intense itching of the scalp,

especially on the back of the head or neck. Combing with a fine-toothed comb reveals the small oval- shaped lice. The discovery of lice requires immediate treatment. Client Education: Lice Basic Knowledge About Hygiene Instruct the client about basic hygiene practices for hair and scalp care. Head Washing Instruct the client who has head lice to shampoo thoroughly with pediculicide (shampoo available at drugstores) in cold water in a basin or sink.  Do not use a tub or shower, where the medication can reach other body parts.  Comb thoroughly with a fine-toothed comb (following product directions) and discard the comb.  Caution: Do not use products containing Lindane, a toxic ingredient known to cause adverse reactions.  Repeat the shampoo treatment 12 to 24 hours later. After shampooing, remove any detectable nits or nit cases with tweezers or a metal nit comb.  A dilute solution of vinegar and water helps loosen the nits.  When using a nit comb, start as close to the roots as possible and comb all the way down the strands of hair.  Discard the comb after one use. Instruct the client and caregivers about ways to reduce the transmission of lice.  Do not share hairbrushes, combs, hairpieces, hats, bedding, towels, or clothing with someone who has head lice.  Vacuum all rugs, car seats, pillows, furniture, and flooring thoroughly and discard the vacuum bag.  Seal non-washable items in plastic bags for 14 days if unable to dry clean or vacuum.  Use thorough hand hygiene practices.  Launder all clothing, linens, and bedding in hot water and detergent and then dry in a hot dryer for at least 31 minutes.  Dry clean non-washable items.  Do not use insecticide.  Instruct the client to notify their partner if lice were sexually transmitted.  Avoid physical contact with infected individuals and their belongings, especially clothing and bedding.  Soak any comb or brush used to remove lice for 15 minutes in very hot ammonia water (1 tsp ammonia to 2 cups of hot water) or boiling water for 10 minutes.

Evaluation strategies use the principles of teach-back to evaluate the client’s or family caregiver’s learning. For example:  "Tell me how you care for your hair and scalp."  "Explain to me the steps you will take to reduce lice transmission in your home." Treating Lice There are multiple options for treating head lice. The medication that is contraindicated in the pediatric population is called. When using a fine-toothed comb there is a specific process that is recommended to remove lice. Which statement demonstrates that process? Products containing lindane , a toxic ingredient, often cause adverse reactions. Instruct caregivers who have children with head lice to shampoo thoroughly with pediculicide (shampoo available at drugstores) in cold water in a basin or sink, comb thoroughly with a fine-toothed comb , starting as close to the roots as possible, and comb all the way down the strands of hair. Discard the comb. A dilute solution of vinegar and water helps loosen the nits. Client Support During Bathing Which actions are appropriate for the nurse bathing a client with dementia? Select all that apply. Being calm, gathering supplies in advance, and empowering the client to feel in control can create a positive bathing experience. Assessing and Planning Which individuals would need help with hygiene? Physical impairment (upper extremity rigidity and first postoperative day), cognitive impairment (confusion), and emotional distress (grieving a spouse’s death) are indicators that a client may require assistance with bathing to assure their safety and cleanliness. Hypertension alone is not typically a condition that will impair the client’s ability to bathe themselves. Assessing Hygiene Needs

The nurse completing an admission assessment on a client with diabetes mellitus type 2 observes that the client is wearing dirty clothing and requires bathing and foot care. When questioned about hygiene habits, the client states they take a bath once a week and a sponge bath every other day. To provide care for this client, which principle should the nurse keep in mind? Habits that worked before for the client may not be enough based on the fact that they have been diagnosed with diabetes. The client needs to be more diligent with their care and prevent drying out their skin. A client with diabetes mellitus has special needs, specifically for nail and foot care. Knowledge about the pathophysiology of diabetes and its potential effects on the client’s peripheral circulation and sensory status provides the scientific knowledge base needed to implement safe and effective foot care. Oral Care The nurse is providing oral care to a client. Place the steps for cleaning the oral cavity in the correct order, from first to last. Oral care is provided in the following sequence:

1. Clean chewing and inner tooth surfaces first.
2. Clean outer tooth surfaces.
3. Moisten the brush with chlorhexidine rinse to rinse.
4. Use a toothette to clean the roof of the mouth, gums, and inside cheeks.
5. Gently brush the tongue but avoid stimulating the gag reflex.
6. Rinse the mouth. Discharge Planning A client with diabetes mellitus has special hygiene needs for nail and foot care to prevent injury and infection. Which discharge information should be given to the client and family to provide preventative hygiene care? Place the teaching instructions into the correct category. Safe and appropriate hygiene practices:  Assess skin for redness and open areas daily.  Apply lotion to the feet daily.  Dry between toes after bathing.  Wash hands frequently.  Involve family members in client education. Unsafe hygiene practices:  Cut toenails and keep them short.  Soak feet in hot water at least 10 minutes before nail care.