Chapter 30

Hygiene- measure of personal cleanliness

Factors affecting it: culture, economic class, spiritual practice, health state

Assessing the Skin

• Head-to-toe sequence

• Compare bilateral for symmetry

• What to consider?

• Cleanliness, color, temperature, turgor, moisture, sensation, vascularity, 

evidence of lesions (ABCDE)

Assessment of Oral Cavity

• Lips- color/moisture

• Buccal mucosa- color/nodules/bleeding

• Color and surface of gums

• Teeth- loose/missing/dentures (if they fit well)

• Hard & soft palate- intact/patches

• Oropharynx- movement of uvula (grading of tonsils)

• Halitosis/bad taste in mouth

• BOHSE- brief oral health status exam

• Observe for oral problems- dental caries (cavities), gingivitis, periodontal disease

• Mouth breathers/comatose patients

Oral Hygiene

• Moistening/cleaning the mouth

• Caring for dentures- remove when sleeping; wear gloves when cleaning

• Using mouthwashes- for children must contain fluoride

Early Morning Care

• Assist patient with toileting

• Provide comfort measures

• Wash face and hands

• Provide mouth care

Morning Care (AM care) *after breakfast unless patient wants it done first

• Toileting

• Oral care

• Bathing

• Back massage/ special skin measures

• Hair care/cosmetics/dressing

• Position for comfort

• Refresh or change bed linens/tidying up bedside

Afternoon Care (PM care) *ensure patients comfort after lunch

• Offer assistance with toileting, hand washing, oral care

• Straighten bed linens

• Help patient with mobility to reposition self

Hours of Sleep Care (HS care) *before patient goes to bed

• Offer assistance with toileting, washing and oral care

• Offer back massage

• Change any soiled linens

• Position patient comfortably

• Ensure call light or any other objects are in reach

As Needed Care (PRN care)

• Offer individual hygiene as needed

• Change clothing and bed linens to diaphoretic patients

• Provide oral care every 2 hours as needed