ACTIVE LEARNING TEMPLATE: Nursing Skill
.
STUDENT NAME _____________________________________
Hygiene
SKILL NAME____________________________________________________________________________ 31
REVIEW MODULE CHAPTER ___________
Description of Skill
Describe how you will:
assist patients with hygiene measures, including scalp, hair, and nail care, oral care, skin care, personal care
give a bed bath
Indications CONSIDERATIONS
Pt is unable to ambulate due to intubation
Nursing Interventions (pre, intra, post)
sedation resulting in reduced ability to P: Knock, gel/in, confirm patient identity using patient armband. Close curtain and prepare necessary materials (2-3 full towels, 2-3
wash cloths, basin with tepid water, soap, bath blanket, clean gown, clean bedding, toothbrush/toothpaste, emesis bin, shampoo cap,
provide proper hygiene practices for self - a nail trimmers, emollient, clean socks). Still communicate with pt procedure though response may not be able to be given
I: Wash hands and don gloves. Cover pt with bath blanket and remove soiled top blanket/sheet and soiled gown (caution w/ IV),
head-to-toe bed bath and oral care is keeping pt covered. Before adding soap, use dampened wash cloth and gently wipe eyes laterally from medial canthus, rotating cloth
between swipes. Add soap to basin and begin gently cleaning the rest of the face and evaluating head/neck/mouth/eyes/ears for any
abnormalities. Begin revealing chest and cleaning, quickly drying after. Then, cover the chest with the towel and clean the abdomen,
quickly drying after. Cover chest/abdomen. Place 1 arm on top of a towel and begin cleaning, moving proximally, quickly dry. Clean
recommended to maintain patient health hand and scrub under nails, trim nails PRN. Repeat with other arm, keeping previous arm covered. Perform a similar service to each
leg. Using another aid, rotate pt into lateral recumbency, shift the soiled bedding and don clean bedding, lay a towel on top of bedding
and as far under pt as possible, then scrub back and bottom area; dry thoroughly (remove soiled wash cloth, towel, and gloves).
Provide massage as able. Rotate pt the other way to finish bedding change. Cover chest/abdomen/UE with bath blanket, and LE with
clean bedding and clean groin area well. Dry and cover pt with clean bedding and return to position. Clean hair with shampoo cap and
place on pillow w/ clean pillow case. Place socks on feet. Remove soiled linens by placing in linen basket. Brush teeth by keeping
mouth angled in a downward position, with emesis bin available for water collection. Brush teeth (45 degree angle, circular motion) and
tongue, floss, rinse mouth using gauze-soaked mouth wash. Apply chapstick.
P: Confirm pt temperature is stable and not hypothermic and all materials are disposed of properly/area is tidy
Gel out
Document all interventions as well as any abnormal findings
Outcomes/Evaluation
Client Education
- Pt is kept clean and tidy
- Evaluation for integumentary cleanliness Although Pt may display minimal response,
and integrity ideally communicate throughout procedure
- Improved relationship with involved visiting
family
- Opportunity to promote
circulation/humanizing treatment
Potential Complications Nursing Interventions
- Pt is excessively soiled - Perform multiple gentle cleanings and
- Skin has wounds that must be appropriately change bedding PRN
cared for - Document wounds (size, color, shape,
- Abnormal findings are appreciated during location, etc) and perform wound
evaluation management
- Notify Dr. and document in detail in EHR,
and provide care accordingly
ACTIVE LEARNING TEMPLATES
.
STUDENT NAME _____________________________________
Hygiene
SKILL NAME____________________________________________________________________________ 31
REVIEW MODULE CHAPTER ___________
Description of Skill
Describe how you will:
assist patients with hygiene measures, including scalp, hair, and nail care, oral care, skin care, personal care
give a bed bath
Indications CONSIDERATIONS
Pt is unable to ambulate due to intubation
Nursing Interventions (pre, intra, post)
sedation resulting in reduced ability to P: Knock, gel/in, confirm patient identity using patient armband. Close curtain and prepare necessary materials (2-3 full towels, 2-3
wash cloths, basin with tepid water, soap, bath blanket, clean gown, clean bedding, toothbrush/toothpaste, emesis bin, shampoo cap,
provide proper hygiene practices for self - a nail trimmers, emollient, clean socks). Still communicate with pt procedure though response may not be able to be given
I: Wash hands and don gloves. Cover pt with bath blanket and remove soiled top blanket/sheet and soiled gown (caution w/ IV),
head-to-toe bed bath and oral care is keeping pt covered. Before adding soap, use dampened wash cloth and gently wipe eyes laterally from medial canthus, rotating cloth
between swipes. Add soap to basin and begin gently cleaning the rest of the face and evaluating head/neck/mouth/eyes/ears for any
abnormalities. Begin revealing chest and cleaning, quickly drying after. Then, cover the chest with the towel and clean the abdomen,
quickly drying after. Cover chest/abdomen. Place 1 arm on top of a towel and begin cleaning, moving proximally, quickly dry. Clean
recommended to maintain patient health hand and scrub under nails, trim nails PRN. Repeat with other arm, keeping previous arm covered. Perform a similar service to each
leg. Using another aid, rotate pt into lateral recumbency, shift the soiled bedding and don clean bedding, lay a towel on top of bedding
and as far under pt as possible, then scrub back and bottom area; dry thoroughly (remove soiled wash cloth, towel, and gloves).
Provide massage as able. Rotate pt the other way to finish bedding change. Cover chest/abdomen/UE with bath blanket, and LE with
clean bedding and clean groin area well. Dry and cover pt with clean bedding and return to position. Clean hair with shampoo cap and
place on pillow w/ clean pillow case. Place socks on feet. Remove soiled linens by placing in linen basket. Brush teeth by keeping
mouth angled in a downward position, with emesis bin available for water collection. Brush teeth (45 degree angle, circular motion) and
tongue, floss, rinse mouth using gauze-soaked mouth wash. Apply chapstick.
P: Confirm pt temperature is stable and not hypothermic and all materials are disposed of properly/area is tidy
Gel out
Document all interventions as well as any abnormal findings
Outcomes/Evaluation
Client Education
- Pt is kept clean and tidy
- Evaluation for integumentary cleanliness Although Pt may display minimal response,
and integrity ideally communicate throughout procedure
- Improved relationship with involved visiting
family
- Opportunity to promote
circulation/humanizing treatment
Potential Complications Nursing Interventions
- Pt is excessively soiled - Perform multiple gentle cleanings and
- Skin has wounds that must be appropriately change bedding PRN
cared for - Document wounds (size, color, shape,
- Abnormal findings are appreciated during location, etc) and perform wound
evaluation management
- Notify Dr. and document in detail in EHR,
and provide care accordingly
ACTIVE LEARNING TEMPLATES
