Personal Hygiene Care


By Lindsay Dingwall

John Wiley & Sons

Copyright © 2009 John Wiley & Sons, Ltd
All right reserved.

ISBN: 978-1-4051-6307-1


Chapter One

Assessing Your Patient

INTRODUCTION

This chapter is intended to illustrate why maintaining the personal hygiene needs of patients is so important. General principles of assessment will be identified relating to the patient's normal living routines, safety of the patient and the care environment. More specific assessment and nursing interventions to meet specific hygiene needs, such as ear care or oral hygiene, will be introduced throughout each chapter.

The aim of this chapter is to help the reader understand the role of general comprehensive nursing assessment in meeting personal hygiene needs.

LEARNING OUTCOMES

After reading this chapter, the reader will be able to:

Discuss the principles of assessment for individualising patient care, including the use of assessment tools.

Identify infection control measures which require to be assessed.

Outline the health and safety issues which require assessment before agreeing nursing interventions.

Discuss the importance of assessing the environment before meeting hygiene needs.

Describe assessment measures while carrying out prescribed care.

Discuss the role of evaluating nursing interventions and the role of documentation.

THE IMPORTANCE OF PERSONAL HYGIENE IN GENERAL PATIENT CARE

Any person who is unable to meet their own hygiene needs risks not only feeling psychologically worse but also deteriorating physically.

Historically, good patient hygiene has been seen as important for preventing the spread of disease. The skin is the first defence against disease and there is evidence that keeping the skin clean reduces the number of microorganisms, for example bacteria that can cause the spread of infection (Horton & Parker, 2002).

However, other benefits to the patient should be considered: looking and feeling clean is important for a patient's feeling of well-being and confidence to interact socially.

When we are no longer able to initiate our own personal hygiene at a time of our choosing and in the manner we prefer, our feeling of social and psychological well-being is reduced (Switzer, 2001). For some people even the motivation to meet their hygiene needs can reduce as the process becomes more difficult. This may be for many reasons: the impact of illness, mobility difficulties, pain, psychological distress or embarrassment at requiring intimate care from a stranger.

The practice of assisting a person to meet their hygiene needs as well as helping the patient can develop the nurse-patient relationship and allows a skilled practitioner to assess how the patient is progressing physically and mentally. Any changes to the patient's physical condition and ability or their mood can be noted and acted upon. Of equal importance is the role that meeting a person's hygiene needs in terms of skin, hair and nail care has in promoting individualised care and dignity.

Nursing staff have a duty to meet the fundamental needs of patients under their care; however, according to the Healthcare Commission (2007), around 30% of the complaints received about hospital care relate to nurses not meeting the patients' basic needs, such as personal hygiene or nutrition. Indeed, the Department of Health (DH; 2000) reached consensus in its document No Secrets that 'acts of neglect or omission' constitute abuse of vulnerable adults. These include ignoring physical or medical needs, failing to provide access to appropriate healthcare services and withholding necessities. Personal hygiene, including washing and oral health, is included among these necessities. The Essence of Care (Department of Health, 2001) outlines the need for healthcare staff - and nurses in particular - to meet the fundamental needs of patients in care. Personal and oral hygiene are among the areas of care particularly focused on in this document.

Nursing staff, however, are not the sole healthcare professionals involved in assisting patients to maintain their hygiene needs. Box 1.1 illustrates an example of some other healthcare professionals and allied health professionals who may also be involved, as well as the patient's family should the patient wish.

A SYSTEMATIC APPROACH TO MEETING PATIENT NEEDS

At any time the patients in care will be diverse in terms of age, ability, culture and physical and mental abilities; certain patient populations are more likely to have particular difficulty in meeting their own hygiene needs (Box 1.2).

However, an individual patient's ability to self-care may also vary on a daily basis or even more frequently within a period of admission. For example, a patient may be independent before an operation but may take several days post-surgery to reach this level again; a patient may react badly to medication and become too confused to manage independently for some time and a patient who is undergoing a period of rehabilitation after a stroke may take several weeks to reach the level where they can self-care. Therefore, hygiene needs must be evaluated and reassessed whenever a patient's condition improves or deteriorates (Ashurst, 2003) and the nurse must be responsive to the continual changes in the needs and concerns of each patient.

In order to treat each patient as an individual, the nursing process or systematic approach to nursing is used in the majority of healthcare situations in Britain.

Identified as the core and essence of nursing (Pope et al., 1995), the nursing process ensures that nurses employ a logical, systematic and rational approach towards care delivery. Where possible, the patient should have an active and equal role in the nursing process unless physical or emotional limitations reduce their ability to participate. Therefore, the patient is placed at the centre of the care process and, in conjunction with the patient's continuous input regarding their condition, the nurse will use a problem-solving approach in order to meet the needs of the patient.

The nursing process comprises five components, or stages, which are followed in order. The process is also cyclical, that is using the process requires the nurse to assess, follow the stages and reassess throughout the patient's care episode. Table 1.1 illustrates the components and the activities carried out under these headings (Holland, 2008; Kozier et al., 2008).

Using the nursing process ensures patient-centred care of a high quality and that clinically effective care is carried out. The cornerstone of the nursing process is nursing assessment where the patient's own particular care needs are identified (Hamilton & Price, 2007).

Nursing assessment

The purpose of nursing assessment is to collect and process data (information) about the patient in order to develop a clear picture about the patient and his/her needs. Assessment therefore has to be 'holistic' in that all aspects of the patient's life are assessed and not only the physical aspects of their condition (Table 1.2). The components of holistic assessment are discussed in more detail later in this chapter.

Data can be objective, that is measured (e.g. temperature or urine output) or seen/felt/smelled (e.g. the nurse may smell that a patient has been unable to meet their own hygiene needs) or subjective, that is what the patient feels (e.g. pain or fear of falling while having a shower).

Assessment on admission or at the beginning of a care episode helps the nurse to establish a baseline of the patient's condition. Having a clear baseline allows the nurse to measure any subsequent improvement or deterioration in the patient's condition. For example, assessing a patient's ability to wash at the first opportunity allows the nurse to decide at a later date whether the patient's ability is improving.

Assessment at the initial stage of admission to care is also vital to identify any risk to the patient, other patients in the clinical area or healthcare staff. For example, patient allergies can be determined and the level of mobility and mobility aids used can be assessed, as can the risks of infection and pressure sores.

Data can be sourced from many people. The patient is the most direct source of data; however, not all patients will be able to supply the information required to safely proceed with nursing care. The patient may be too young to understand/ answer questions or may be too ill to respond. In these types of circumstances, secondary sources of information should be explored. These may be the relatives or carers of the patient, other healthcare professionals known to the patient (e.g. the general practitioner or community nurse) or staff from other hospital departments (e.g. the admissions department). Documentation can be useful in relaying information about a patient (e.g. nursing care plan, doctor's referral letter or transfer letter from a different care setting). Interaction with the patient also provides a clear opportunity for nursing assessment using a range of nursing skills (Box 1.3).

The data gathered about the patient should be documented in the patient's care plan as evidence of the decision-making process and to inform other members of the healthcare team.

Screening as part of assessment

The terms 'screening' and 'assessment' have become so confused as to be used interchangeably, but in fact they are two discrete nursing approaches (Mousley, 2006). Screening could be defined as a 'public health service in which members of a defined population, who do not necessarily perceive they are at risk of, or are already affected by, a disease or its complications, are asked a question or offered a test to identify those individuals who are more likely to be helped than harmed by further tests or treatment to reduce the risk of disease or its complications' (National Screening Committee, 2006). Assessment, on the other hand, provides an in-depth approach to establish a diagnosis and to identify management or treatment strategies. For example, a patient may have an oral health screening which may establish the presence of oral disease - perhaps plaque or painful gums - and assessment will establish whether this is a physical, psychological or social problem and nursing care can be established with the patient to treat or alleviate the problem(s).

Nursing diagnosis

The nursing diagnosis is made after the assessment stage on considering the patient's physical, psychological, spiritual or sociocultural reaction to their disease process or medical condition. The nursing process involves dealing with all aspects of a patient's care, including but beyond their original diagnosis. For example, a doctor may diagnose a patient with a chest infection and it will be up to the nurse to (know to) help the patient wash because the patient is too breathless to wash themselves. This is a new component of the nursing process.

This diagnosis of patient's problems then allows the nurse and the patient to prioritise the problems, which may be actual or potential.

Actual problems are those that exist at the time of assessment, for example breathlessness due to a chest infection. Potential problems are those that are at risk of developing if nursing interventions are either not implemented or are ineffective. For example, breathlessness may reduce the patient's ability to wash or remain continent, which in turn can lead to pressure sores. Therefore, although pressure sores are not present on admission, they may develop if nursing interventions are not put in place, or if the interventions are not effective.

An inability to meet personal hygiene needs may be an actual problem, but this inability can lead to several potential problems for the patient. If, for example, toenails are not cared for, the patient's mobility may be reduced; if dentures are ill-fitting, the patient may develop abrasions of the gums and reduce their nutritional intake. Both scenarios will in turn lead to an increased risk of pressure sores.

Planning stage

The nursing role is to prevent potential problems occurring and to solve or alleviate patients' actual problems. Once the patient's actual and potential problems have been identified, explained and discussed with the patient, the planning stage can commence. Planning involves discussing and identifying with the patient how these problems can be addressed in order to achieve the desired (by both the patient and nursing staff) outcome of nursing care. This involves establishing realistic goals (written statements of outcomes) which nursing interventions can help the patient achieve. Determining timescales for achievement of the goals is also important. For example, a patient may require education and help to achieve independence in meeting oral hygiene needs after a stroke. This may not be achievable in three days but may be achievable in two weeks. Often a series of small/short-term goals are required in order to achieve a longer-term overall goal. The plan of care is written to identify the nursing interventions, patient input and length of time required to achieve these goals. This care plan may be uni-disciplinary (i.e. a nursing care plan only) or multi-disciplinary (i.e. whereby all healthcare professionals contribute to the patient's plan of care).

Implementation stage

The implementation stage centres on carrying out the interventions identified in the care plan and monitoring the patient's reaction to them. This stage should support the medical input as well as the input of other professionals, for example the occupational therapist or the dietician. The core aspect of nursing interventions at this stage is to achieve the agreed goals and outcomes while alleviating illness and promoting health and, where possible, optimum independence.

Part of the nurse's role during this stage is to act as an educator and teach the patient. This may be about how to learn new ways of achieving hygiene after illness or trauma or to explain why aspects of maintaining hygiene may be important to the patient's overall health. For example, the patient may not realise the links between ill-fitting or broken dentures, poor nutritional status and delayed wound healing.

Therefore, for a nurse to be able to carry out interventions effectively with the patient's knowledge and cooperation, knowledge of theory and clinical procedures is vital.

Evaluation

Sometimes described as the final part of the nursing process, evaluation of the effectiveness of the implementation stage (and nursing interventions) allows the nurse and patient to monitor and judge whether the goals and outcomes have been achieved. However, the systematic approach is a continuous process and evaluation is a constant aspect of nursing care. Depending on the care situation and the health status of the patient, some care interventions will need to be evaluated on an hourly, and sometimes daily, weekly or even monthly, basis.

Patients in a high-dependency ward or intensive care may require their condition to be monitored hourly; patients in a residential home specialising in caring for older people may need some aspects of care, for example pain control, continuously monitored and oral health care monitored weekly or monthly.

Methods of evaluation are similar and use the same tools as initial assessment. The new data collection allows the nurse to identify if there are changes in the patient's condition and to determine whether the nursing care has been effective or whether the assessment phase must be repeated. Non-achievement of goals may be due to a variety of influences; the patient's overall physical condition may have deteriorated, for example through acquiring an infection; the data collected may not have provided all the information required; the interventions chosen to meet the goals may not have been the correct choice; or the goals may have been too ambitious and therefore unachievable.

The nurse will then have to reassess the patient and, using the data collected, proceed through the nursing process, changing the goals and/or nursing interventions if necessary.

(Continues...)



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