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Personal Cleanliness of the patient
• Hygiene is the science of Health and its maintenance.Personal hygiene is the self care by which people attend to such function
Bathing ,Toileting , General body hygiene , Grooming
• It is personal matter depend their value and Practice it involves care of the skin ,hair , nails ,teeth ,oral and nasal cavities ,Eyes ,Ears and perineal –genatic areas.
• Factors influence Hygienic Practices
• Culture
• Religion
• Enviroment
• Development level
• Health and injury
• Personal Perference
• Oral Hygiene
• Student should be able to appreciate the value of Hygiene
Care of the mouth
v Normally the mouth is kept clean in health
v Because the mouth is the portal of entry for food , Digestion is started at mouth condition of the mouth directly affect health.
• Oral or buccal cavity is formed as follows.the lips infront ,the cheek on the sides and the back communicate with the pharynx
LIPS
When clean the mouth nurse should consider the colour and condition of the patient .lips are normaly pink colour smooth and moist
• Lips colour can be changed
• Pale
• Cyanosis
• Discolouration
• Swelling
• Crack
• Dryness
• Ulceration
• Mucus membrane
• Mouth is lined with mucosa
• A delicate epithelial tissue – outer protective layer of the skin.
• Healthly person’s mucus membrane is pink color and moist
• Tongue
• The tongue is composed of multiple
• muscles and covered with mucous
• membranes that make it moist ,flexible orgen
• The papilae on the tongue contains taste buds
• Teeth
The teeth consist of three parts
• The Crown , the neck and the root, Eruption of deciduous teeth begin 6 months of age
• Temporary or Deciduous teeth 20
• Permanent are 32 in number
• The teeth are covered by a dense fibrous membrane over which is smooth mucous membrane called gums
• Each tooth has three part – A Root ,neck , and a Crown
• The out side of the crown is enamel which is the hardest substance in the body affected only by acids
• Purpose
• To feel fresh and clean and socially accepted
• Prevent and treat mouth infections
• stimulate salivation
• Prevent infection of parotid glands
• Help to increase appetite.
• Commen Problem of the oral cavity - complication
• Halitosis – off ensive odour of breath.
• Dental caries – It is a destructive process
Causing decalcification of the enamel and dentin with resulting caviation of the mouth
• Dental Plaque
It is a soft thin film of food debris , mucin and dead epithelial cells that is deposited on the teeth and provides a medium for the growth of bacteria.
• Calculus or tartar
• When dental plaque remains on the it becomes hardened (calcified) and
• Bottle mouth syndrome
• Infant’s dental caries can be caused by allowing the infant to go to bed with a bottle filled with a liquid other than water
• Periodontal diseases or pyorrhoea
• It is pus formation in the sockets of the teeth
• This is the common cause for loss of teeth in pepole over 40 years of age
• First stage
• Gingivitis
is an inflammation of the gum usually manifested by the primary symptom of bleeding from the gums
• Second stage
• Periodontitis
Chronic gingivitis causes the inflamation to spread and destroy the underlying bone causing periodontitis
• Third stage
• Acute necrotizing ulcerative gingivitis develops which causes mobility of the teeth . Purulent discharges and tissue atrophy
• Fourth stage
• in this stage destruction of the teeth supporting structure.
• The Periodontium atrophies so that the gums appear to have reduced completely away from the tooth
• Sordes – Brown crusts which are formed on the teeth and lips
It is a collection of food ,mucus and bacteria
• Cheilosis
Cracking or ulceration of the lips and angles of the mouth .It can occur in riboflavin deficiency
• Bleeding Gums
It can occur in vitamin –C deficiency (Scurvy)
• Glossitis
It is an inflammation of the tongue
• Root abscess
It is pus formation in the root of the teeth
• Cancrum Oris
It is gangrenous stomatitis
• Stomatitis
It is the inflammation of the mucus membrane of the mouth
• Infection of the Neighboring structures
• Parotiditis – Inflammation of the parotid gland
• Sinusitis - Inflammation of the sinus cavity
• Otitis media - Inflammation of the middle ear
• Tonsilitis - Inflammation of the tonsils
• Systemic infection
• Rheumatic arthritis - Inflammation of the joint
• Bacterial endocarditis - Inflammation of the endocardium
• Nephritis - Inflammation of the kidney
• Gastritis - Inflammation of the Stomach
• Anorexia – Loos of appetite
• Patient who may require mouth care
• Unconscious patient and helpless patients
• Patient with high fever
• Paralysed Patients
• Seriously ill patients
• Patients having a local disease of the mouth
• Patient who are on artificial feeding and who are not taking oral feed
• Malnourished and dehydrated patients
• Prevention complication
• Health education to have brushing of teeth in the morning as well as in the evening.
• who are unable to attend the mouth should be assisted to clean the mouth
• Prevent dehydration of the tissues by the administration of enough fluids
• Not to cause any injury to the gums by the hard bristles. After brushing the teeth , the gums should be massaged with the fingers to stimulate the circulation
• the use of emollients such as cream , aids in softening the dry lips and prevent cracking of the lips
• Mouth washes may be used to prevent or treat unpleasant odours of the mouth
• well balance diet is necessary .Regular check up by a dental surgeon can minimize complication
• Care of Dentures (Artificial Teeth)
• Debris ,dental plaque and calculus collect on dentures as with natural teeth
• The same type of tooth brush and tooth paste that are used for the natural teeth can be used for dentures
• Discourage the use of brushes with hard bristles because they cause grooves in dentures
• Dentures can be brushed at sink under the running water
• While cleaning the denture, grasp it in the plam of one hand brush with the other hand
• Encourage the client to wear the dentures during the day , eating technique , speech , appearance and contour of the mouth.
• seriously ill client or a client who is under anesthesia or an unconscious client the dentures are removed
• when the dentures are removed from the client
• mouth , they should be stored in a labelled container to prevent loss and breakage.
• Dentures are expensive
• Many people having dentures are sensitive about it.
• Privacy should be maintained.
• Skin
• The skin is the largest organ in the body and surface area about 1.5 to 2 m2
• There are two main layers
• The epidermis
• The dermis
• Under the dermis Hypodermis
• Function of the skin
• Protection – invasion by micro - organisms
Chemicals
Physical agents
Dehydration
• Regulation of body temperature.
• Formation of vitamin D
• Sensory organ containing sensory receptors.
• Assessment of the Skin
• Colour of the skin
Normally colour is determined by pigments and capillary blood
v Colour – Normal – Ivory to dark brown
Abnormal – Pallor
- Flushing
- Jaundice / Icterus
2) Texture and Turgor
Ø Normal – Smooth ,soft and flexible
Ø Abnormal – Dry ,Flaking , wrinkled
Ø Execessive moisture , Dehydration
2) Pigment spots
3) Temperature
• Skin Lesion
ü macule Pustule
ü patch Erosion
ü papule Ulcer
ü plaque Fissure
ü nodule crust
ü tumor scale
ü wheal
ü vesicle
ü buila
• Principles of skin care
• Intact skin and mucus membrane serves as the first line of defence for the body against injury and diseases
• Excessive moisture in contact with the skin for a period of time can result in the tissue irritation
• Pathogens grow well in a warm and moist environment . Greater the number of organisms the greater is the possibility of infection.
4. Pathogenic organisms may be transferred from the source to a new host by direct or indirect method.
The nurse takes care to prevent the transference of micro – Organisms from or to the client.
5. The skin that is poorly nourished and dry has less ability to protect and is more vulnerable to injury.
6. Poor circulation impedes nutrition to the skin and causes skin damage
7. Sensory receptors in the skin are sensitive to heat ,pain ,touch and pressure.
8.Soap acts by lowering surface tension of water which aids in the emulsification of fat
9. Hygienic practices vary between individuals ,between people of different economic status and between cultures
10.Systematic ways of working saves times , energy and material
11. Any unfamiliar situation produce anxiety
12. The movements of the body take place by means of muscles and bone functioning
• Bath
• Bathing is an important intervention to promote hygiene
• Choice of the method depend on the client’s activity level ,mental and physical capabilities.to perform self care
• Tow type cleansing or therapeutic bath.
• Type of Therapeutic Bath
• These baths are performed for their healing effect on the skin and ordered by physician
• A whirlpool bath
bath is used to apply moist heat to large body area
• A sitz bath
A type of whirlpool bath focused on the pelvis of perineal area
• A medicated
Bath is perfomed in a tub or a whirlpool with a medication or substance such as ostmeal or cornstarch
• Bed Bath
• Bed bath means bathing a client who is confined to bed and who does not have physical and mental capability of self bathing.
• The Client who need bath in bed
• unconscious
• Operated patients
• Patients on strict bed rest
• Paralysed
• Patient with heart failure
• Patient in plaster cast and traction serious patient
• Purposes for giving bed bath
• Clean the skin and refresh the patient
• Prevent bed sore
• Stimulate circulation
• Increase elimination through skin
• Regular body temperature
• Improve general muscle tone
• Provide active and passive exercises
• Provide comfort to the patient
• Relieve fatigue
• Induce sleep
• Give patient a sence of well being
• General instructions for giving bed bath
• Maintain privacy of the patient by means of screens curtains or drapes
• Explain the procedure to win the confidence and the cooperation of the client
• wash hand before and after the procedure
• All articles used in bed bath should be absolutely clean
• Client should be warm and free of draughts
• All needed equipment should be at hand and conveniently place
• Conserve the energy of the client by avoiding unnecessary exertions
• Remove the soap completely to avoid the drying effects of soap residue left on the client skin
• Only small area of the body should be exposed and bath at a time
• The wash clothes should be held with the corners tucked securely on the palm of the hand to avoid dragging its cold and wet ends over the skin
• Nurse’s responsibility in giving bed bath
• Check the medical order to see the specific precautions if any ,regarding the positioning and movement of the patient
• Assess the patient’s need for bathing
• Assess the patient’s ability for self care
• Assess the cardio – Respiratory functioning (check vital signs)
• Assess the patient ‘s mental state to follow directions
6.Check the patient’s preferance for soap powder
7. Check the linen and equipment available in the patient unit
8.Check whether the patient has taken the meal in the previous one hour
• The wash clothes should be held with the corners tucked securely on the plam of the hand to avoid dragging its cold and wet ends over the skin
• Each stroke should be smooth and long rather than short and jerky.support should be given to joints in the arms and legs while washing and drying these areas.
• provide active and passive exercise whenever possible .unless it is contraindicated
• Wash the hands and feet by placing them in the basin because it promotes thorough cleaning of the finger nails and toe nails
• Cut short the nails ,if they are long
• A thorough inspection of the skin especially at the back should be done to find out the early signs of bedsore.
• A redness in the skin , an excoriation of the skin should be reported immediately and teated adequately to prevent development of bed sorse.
• All the skin surfaces should be included in the bathing process with special care in cleaning and drying the creases and folds and the body prominences
• Special attention is given to axillae and groins to prevent disagreeable body odours due to the decomposition of organic materials
• Cleaning is done from the cleanest area to the less lean area ,
Eg :- upper parts of the body would be bathed before the lower parts
• Avoid bathing a client immediately after a meal as it depletes the blood supply to the digestive organs and interfere with the digestion
• Frequency and the time at which a cleaning bath is given should be adjusted for the comfort of the clients and on the physician’s orders.A critically ill client may tolerated only a partial bath.
• Do not touch the body with hands It is unpleasant to the clients
• The temperature of the water be adjusted for the comfort of the client and the water should be charged at intervals to maintain a comfortable temperature. The temperature for the sponge bath should be 110 F0 to 115 F0 (43.3 to 46.1 C0 ) for tub baths or bathroom bath the temperature of the water should be 90 F0 to 100 F0 (32.2 to 37.8 C0)
• Powders are used to prevent friction and to absorb moisture but they should not be used on open draining areas.
• Decubitus ulcer / Pressure sore / Bed sore
• Ulcerated or sloughed area of tissue subjected to pressure from lying on mattress or sitting on a chair for a prolonged period of time . Resulting in the slowing of circulation and finally necrosis of tissues
• Common sites
• Pressure points are that bear weight and the skin subject to pressure.
• This may happen more frequently over the body prominences of the body
• Where there is no rich blood supply or nourishment.
• There is a thin layer of skin may affected easily
• Common sites depend upon the position of the patient in bed
• The pressure points in the supine position are back of the head (occiput) Scapula , sacral region , elbows and heels.
• In a side lying position ,the pressure points are the ears ,acromion process of the shoulder,ribs , greater trochanter of the hip ,medial and lateral condyles of the knee and malleolus of the ankle joint
• In aside lying position
• The ears
• Acromion process of the shoulder
• Ribs
• Greater trochanter of the hip
• Medial and lateral condyles of the knee and malleolus of the ankle joint
• In a prone position
• Ears
• cheek
• acromion process
• Breasts (Femal)
• Genitalia
• knees
• Toes
• Causes of Pressure sorse
• Direct or immediate causes
q Pressure
In a sick person the areas of tissue resting against the matterss are vulnerable area . Depletion of blood supply with the failure of circulation to the weight bearing area resulting in the tissue damage following condition
• May help to increase the problem
• Lumps and creases on the bed
• incorrect positioning of the body
• infrequent change of position
q Friction
Friction of the skin with a rough or hard surface can cause tissue damage .contact with the rough surface of the bed, wrinkles on the bed cloth ,hard surfaces of the plaster casts , splints , presence of foreign bodies on the bed.
Rough sponge clothes and prolonged massage without lubricant may causes for friction.
q Moisture.
Skin ,contact with moisture for a period of time can help to maceration of the skin. Patient who are sweating profusely ,with incontinence of urine and stool are liable to pressure sores.
q Presence of pathogenic organism
Lack of cleanliness harbours pathogenic organisms and infection settles on the skin
• Predisposing causes
• Impaired circulation
• Lowered vitality
• Emaciation
• Oedema
• obesity.
• Patient who are susceptible to Pressure sores.
• Acutely ill patient whose general condition is rapidly deteriorating
• Elderly bed ridden patients , who make who make very little movements in bed
• Obese patients
• Very thin and emaciated patient .having very little subcutaneous tissue to pad the bony prommence.
5. Paralysed patient who have suffered spinal cord injuries
Paraplegia , Hemiplegia , Quadreplegia
6. Neurologic patients with lack of sensation that they cannot feel any irritation of the skin
7. Oedematous patient , especially those with oedema of the sacrum and buttocks
8.Patient on complete bed rest or with limited movements
Eg :- Patient with fractures
Plaster casts
Cardiac diseases
9. Surgical patient with limitted movements
10.Patient with incontinence of urine and stool
11.Diabetic mellitus patients
12. Patient with excessive bodily discharges or drainage from the wounds.
• Signs and symptoms of pressure sore
• Early symptoms
v Redness
v Tenderness
v Discomfort
v The area become cold to touch and insensitive due to continued pressure
v The circulation is cut off
v The gangene develops
v The affected area is sloughed off
• Prevention of pressure sores
• Identification of patient who are particularly prone to the development of decubitus ulcer
• Daily examination of the more prone patient for redness, discolouration or blister on the pressure points and they should be reported and treated immediately
• Keep the patient clean and dry
• change the position of the patient every 2 hours
• keep the patient’s skin well lubricated to prevent cracking by using powder
• Protect the damaged skin avoid irritation from urine
• Provide adequate fluids and nourishing diet which high in protein and vitamins
• Give the care to the pressure points to stimulate circulation.
• Provide , frim, smooth bed , for the patient to take rest
• Cut the finger nails in short
• Use adequate amount of cotton under splints and plaster casts to prevent friction
• Use comfort device to take off the pressure.
• Encourage the patient to move in bed as far it is allowed
• Change the linen as soon as they become wet
• Teach the patients and their relatives the hygienic care of the skin.
• Signs and symptoms of Pressure sore.
• Early symptoms
Redness
Tenderness
Discomfort
Smarting
• The area becomes cold to touch and insensitive . There is local oedema.
• Later the area become
• Blue
• Purple or mottled . Due to continued pressure,the circulation is cut off, the gangrene develops and the affected area is sloughed off
• Treatment
• The decubitus ulcers once developed are difficult to treat.
• The nurse should remember that the decubitus ulcers are prone to infection. Moist and poorly nourished tissue is a good medium for the growth of pathogenic bacteria.
• The nurse should taken the following steps report early symptom s of a bed sore so that steps may be taken as early as possible to prevent further damage.
• When ever possible , take off the pressure from the decubitus ulcers by placing the client on pillows or foam cushions or change the position of the client
• Prevent the ulcerated area from becoming infected , infection will retard healing of an ulcer.follow strict aseptic technique.
• A cleaning agent is used to clean the ulcerated area Eg :- normal saline
• Apply all the possible measures for the healing of the wound.
Heat is applied
Application of waterproof ointment
The slough is present ,clean thoroughly with hydrogen peroxide with distil water
Delay in healing of the wound surgeon debride the ulcer and a skin graft applied.
• Care of Hair
• The appearance of one’s hair and the skin reflects the general health of a person
• The cleanliness and grooming of hair is frequently related to one’s sense of well – being
• Normal hair and scalp are neither dry nor oily and show no evidence of flaking.
• Healthy hair of a healthy scalp is constantly dropping out being replaced new growth.
• The general health of a person affects the growth of hair
• A well – balanced diet is essential for the health of the hair
• Hair needs light and fresh air
• Stimulation of circulation by massage and brushing is essential
• illness , worry , grief affects the health of the hair
• often by loss of hair alopecia
• Various endocrine abnormalities and imbalance
• An unclean scalp containing dirt , dandruff, excessive sebum and sweat will allow the growth of micro – Organisms and parasites on the scalp
• oily hair accumulates dirt more quickly than the dry hair.
• Keeping the scalp clean by and shampooing will help to relieve the dandruff
• Cleanliness of the hair and scalp will
• Keep the pediculi away from the scalp
• Scabies, ringworms ,dandruff and pediculi are seen in neglected scalp.
• Purpose
• To keep the hair clean and healthy
• To promote the growth of hair
• To Prevent loss of hair
• To Prevent itching and infection
• To prevent accumulation of dirt , dandruff and oils
• To prevent tangles
• To provide a sense of well – being
• To Stimulate circulation
• To destroy pediculi
• To appear heat (Well groomed)
• To observe the scalp
• Nurse’s responsibility.
• Hair needs to be brushed daily in order to be healthy
• Long hair should be combed at least
• Once a day to prevent it from matting
• Hair can be combed and brushed in the morning
• Preliminary Assessment
• Check the physician's orders to see the specific precautions for the client movements and positioning
• Assess the general condition of the client and the ability for self care
• Assess the condition of the scalp and hair
• Assess the client ‘s mental state
• Check the articles available in the client ‘s unit.
• Care of the Eyes , Nose and Ears
• The eyes ,nose and ears are important organs ,which require no special care in daily life
• Hygienic care of the eyes, ears and nose prevent infection and help to functions
• Hygienic care of these organs is always done as part of the general bathing procedure.
• Care of the Eyes
• A common problem of the eyes are secretions that dry on the lashes as crusts
• This may need to be softened and wiped away under sterile condition
• In newborns the eyes are treated soon after the baby is bron to prevent ophthalmia neonatorum
• Eye are cleaned from the lnner to the outer canthus
• This prevent the particles and fluid from draining into the nasolacrimal duct
• During a bath , each eye is cleaned with a separate portion of the wash cloths
• Care of Nose and Ears
• The nose and ears require minimal care in the daily life
• Excessive accumulation of secretions make the client sniff or blow the nose
• The secretions can become Crusted and obstruent the airway
• For clients who cannot remove the secretions , assistance is necessary to clear the congestion and protet the nasal mucosa.
• External crusted secretions can be removed with a wet wash cloth or a cotton application moistened with oil ,normal saline or water
• When there is poor hygiene of the ears , debris may accumulate behind the ear and in the anterior aspect of the external ear .This can lead to ulceration of the skin
• A common Problem of the ears is the collection of sermon or ear wax in the external auditory canal This may cause a person some difficulty in hearing
• It can cause discomfort when it hardens
• May people remove wax from their ears by using sharp objects ,which can traumatize the ear drum.
• Warm liquid paraffin or a vegetable oil instilled in to the ear can soften the wax and it can be easily removed when it cannot be removed Consult the ENT surgeon
• Care of the perineum
• Perinea hygiene involves cleaning the external genitalia and surrounding area
• The perinea area is conductive to the growth of pathogenic organisms
• Because it is warm ,moist ,well ventilated
• There are many orifices ( meaitus ,vaginal orifice and anus)
• The pathogenic can enter into the body
• Thorough cleanliness is essential to prevent bad odour and to promote comfort
• The most pertinent principle for the perinea care is to clean the perineum from the cleanest to the less clean area.
• The urethral orifice is considered as the cleanest area
• Because the orifices in the perinea area in proximity ,cross
• Cross contamination is a potential problem
• The normal flora of the urinary system is different from in the gastrointestinal system
• Entry of organisms from the anal orifice can cause – urinary tract infection
• Because these organisms are foreign to the urinary tract
• During the perinea care ,clean the area around the urinary meatus before cleaning the area around the anus
• The following Clients require special attention to the perineal area
• Client who are unable to do self care
• Clint with genito – urinary tract infections
• Client with incotinence of urine and stool
• Client with excessive vaginal discharge
• Client with indwelling catheters
• Post partum clients
• Client after surgery on the genito – urinary system
• Client with injury , ulcer or surgery on the perineal area.
• Nurse’s Responsibility in the perineal care ( for a female client )
• Preliminary Assesment
• Assess the condition of the perineal skin – any itching , irritation , ulcers , Oedema , Drainage.
• Assess the need and frequency of perineal care
• Assess whether the perineal care should be done under an aseptic technique or clean technique “(remember when there is a wound .the perineal care should be done under aseptic technique)
4. Check the physician’s orders for any specific instruction
5. Assess the client’s ability for self care
6. Assess the client ‘s mental state to follow instruction
7 Check the articles available in the client’s unit.
UNIT VII
Eating and Drinking
Anorexia - It means loss of appetite
Dyspepsia - It means indigestion, A feeling
of fullness, discomfort, nausea,
anorexia
Dysphagia - Difficulty in swallowing
Food - Any substance which can be
used by the body for its growth,
development and repair.
Nausea - A sensation of sickness with inclination to vomit.
Nutrients - It means the constituents of food for example carbohydrates, proteins, minerals, fats, vitamins.
Belching - It means to let out air through the mouth with noise
Regurgitation – It is the backflow for example, backflow of partially digested food into the mouth from the stomach.
Vomiting - It is the expulsion of stomach contens via oesophagus and the mouth.
Nutrition.
nutrition is the science of food and nutrients and of the process by which an organism takes them in and uses them for producing energy to grow , maintain function and renew itself.
Nutritional status
The condition of the body resulting from the use of essential nutrient available to it.
A client’s nutritional status may be good, fair, or poor depending on the intake of dietary essential.
On the relative need for them and on the body’s ability to use them.
Nutrients.
Macronutrients micronutrients
Protein fat carbohydrate Vitamins
Minerals
The food Guid Pyramid
Fat,oils,sweets use
sparingly
milk , Cheese, Yourgt 2—3 Meat , fish , poultry dry beans
servings (2 – 3 servings) eggs and nuts
Vegetable group fruits 2 – 4 servings
3 – 5 servings
Bread Rice Cereal , Rice and pasta
6 – 11 servin
Energy intake
Protein 4 Calories / gram
Carbohydrate 4 Calories / gram
Fat 9 Calories / gram
Alcohol 7 Calories / gram
Energy out put
BMR
The basal metabolic rate {BMR}. Is the rate at which the body metabolizes food to maintain the energy requirements of a person who is awake and rest.
Men 1 cal 1 kg of body weight per hour. Women 0.9 cal 1 kg of body weight per hour
Factors affecting nutritional status / requirement
Physiologic and physical factors.
Socio cultural and psychosocial factors.
Religion
E coromic
Culture
Life style factors.
Factors affecting nutritional intake.
Decreased food intake
Anorexia.
Psychosocial Causes
Fear, anxiety, depression
Impaired ability to smell and taste.
Can develop secondary effect to drug therapy or medical treatment.
Clients who have undergone certain surgical procedures.
Clients on inadequate food budget
Belief systems of clients.
Not able to afford due to poverty.
Beauty consciousness.
Increased food intake
This may lead to obesity.
Obesity presents a series of health problems, physically, socially and emotionally.
Increases the risk for numerous medical
Problems
Increases the risk associated with hurgery
Increases the risk for complications during pregnancy, labour and delivery.
Increases mortality and morbidity.
General assessment of nutritional status.
Dietary History
Evaluation of food intake
Physical examination
Diagnostic tests
Methods used to take dietary history
24 – hour recall method
food frequency questionnaire
food diary
Household food consumption
Evaluation of food intake is done for adequacy, three methods are used
Food group method
Nutrient composition method
Caloric count
Physical Examination
Help to detect physical signs of nutritional deficiencies.
Anthropometric measurements are used to determine body dimensions.
In children this is used to assess growth rate.
In adults they can give indirect measurements of body protein and fat stores .
1 Height and weight measurement
2 Body mass index (BMI)
BMI = Weight in kilograms
Square of height in meters
Normal BMI = 18.5 -24.5
3 Body Composition
Triceps skin fold measurement
Mid – arm muscle circumference
Mid – arm Circumference.
Diagnostic tests
The most common laboratory indices of nutritional status.
Serum pre albumin
Albumin
Transferring
Lymphocyte count
Haemoglobin
Haematocrit
Urine specific gravity
24 – hour urine tests
Characteristics of well – Nourished person
1.Normal weight and height for age, body build and developmental stage.
2.Adequate appetite
3.Active, alert and able to maintain adequate
span
4.Firm healthy skin and mucus membrane
5.Erect posture with straight arms and legs.
6. Well – developed muscle without excess body fat.
7. Normal urinary and bowel elimination patterns
8
9. Normal sleep patterns
10. Normal haemoglobin, haematocrit and serum protein levels.
11. Absense of diet – related abnormalities.
Signs of poor Nutrition
Hair - Thin, coarse, lacking luster, breaks easily.
Skin - Excessive bruising, bleeding, pressure sores, poor wound healing
Skeletal - Poor posture, painful joints, bowed legs, increase in bone fracture.
Mental - Confusion, motor weakness.
Diet in sickness.
Diet is as important as medicine in the treatment of diseases. A modification in the diet or in the nutrients can cure certain diseases.
Eg - Client suffering from peptic ulcer needs a bland diet for his recovery.
Hypertension
salt free diet can reduce the blood pressure.
For everyone, eating food is and enjoyment.
When the person is ill, the food intake becomes a problem.
Nutrition can be analyzed into four major areas.
Assisting clients to obtain needed nourishment either through feeding or assisting with eating
E.g tube feeding, feeding a helpless client to eat his food.
Motivating client to eat
Assisting client to obtain needed nourishment by proper planning of the diet.
Assisting clients with special problems about therapeutic diets.
e.g :- Helping a client to accept a salt free diet.
Principles involved in the Diet therapy.
The diet must be planned in relation to changes in metabolism occurring as a result of disease.
The diet must be planned according to the food habits of the client based on culture, religion, socioeconomic status. Personal references {likes and dislikes) Physiological and Psychological conditions, hunger, appetite and satiety.
As far as possible, changes in the diet should be brought gradually and adequate explanations are given with
In short and acute illness, the food should not be forced because his appetite is very poor but he may soon recover. The normal appetite. But in prolonged illness it is essential to provide adequate amount of food to prevent wasting of tissues.
Whatever the diet prescribed, there should be variety of food for selection.
Small and frequent feeds are preferred to the usual three meals.
Hot foods should be served hot and cold foods should be served cold.
Modification of Nutrients in there peptic diet.
01.Carbohydrate
Carbohydrates are well tolerated and are necessary to maintain the stores of liver glycogen.
- It is particularly important in clients with high fever, liver diseases, hyperthyroidism.
- In the absence of Carbohydrate, the body fat may be used for energy which may result in the formation of ketone bodies and they accumulated in the blood a condition known as ketosis.
Adequate amount of carbohydrate intake can prevent ketosis.
- Carbohydrates are given in easily digested forms such as glucose, sugars, gruels.
- The fat is often not tolerated in illness especially if nausea and vomiting are present. Adequate amount of carbohydrate can replace the requirement of the body for fat.
02. Protein
In illness, especially when there is infection, the protein metabolism is usually greatly increased because of the increased destruction of protein.
If an adequate amount of protein is not given, the body will use up the tissue protein and the client will loose weight. In illness, unless, there are kidney and liver damages, the protein intake should be high.
03. Minerals should be maintained in illness especially that of calcium and iron.
Sodium and potassium may sometimes need to be restricted especially when there is hypertension, Oedema, ascites.
04.Vitamins must always be adequate
Fat soluble vitamins, vitamin A and vitamin D need to be added if the client is on fat restricted diet.
In pathological condition of the gastro intestinal tract and in antibiotic therapy, Vitamin B complex should be supplied.
The demand for vitamin C is greatly increased in fever and is especially necessary for the healing of wound after surgery.
05. Fluid
Fluid are very important to prevent dehydration.
Especially when the fluid is lost from the body in excess amount in the form of sweat, urine, stool, blood and other body fluids.
If adequate fluids con not be given by mouth, they must be given intravenously.
Today daily fluid intake averages from 2 to 3L for an average adult in normal conditions.
It is nurse’s responsibility to maintain the fluid balance by maintaining the intake and out put chart carefully.
The amount of fluid intake would be sufficient in case of adults. If there is 1000 to 1500 ml of fluid per Kg of body weight.
Factors Affecting Appetite.
The appetite is increased by.
Sight and smell of food. (attractive serving)
Food preference (like and dislikes of the individual)
Physical and mental relaxation (freedom from hurry, worry, pain, stress and fatigue)
Regularity in eating (spacing of meals)
Pleasant environment (attractive and cheerful atmosphere)
Exercise.
The appetite is decreased by :
Physical and mental fatigue
Hurry, worry and fear.
Unpleasant environment and experiences.
Lack of exercises
Irregular meals.
Long spacing of meal timings.
Types of diet served in the hospital.
Full Diet /Normal diet.
It is a regular, well- balanced and normal diet.
It is either vegetarian or non – vegetarian.
It is served for clients who do not need any modification.
• Soft Diet
it is full diet but consisting of food substances that are easy to chew and digest
Some clients , particularly the aged and convalescing clients cannot take food which require chewing or the food that is difficult to digest
A soft diet is enjoyed by these clients
A soft diet may include double boiled rice, conjee , custards , ground or chopped meat ,sliced bread , seived cooked vegetables , cooked or ripe bananas.
Bland Diet
Which the foods are easily digestible.
Free from substances which might cause irritation of the gastrointestinal tract
Generaly of low roughage content
Following point should be kept in mind when supplying a bland diet.
01 The diet must be free from all mechanical and chemical irritant
Mechanical irritant are mainly edible skins , seeds and fibres
Fibres composed of cellulose in fruit and vegitables
Foods which contain a lot of cellulose should be rubbed through sieve or strainer after cooking
Chemical irritants are mainly the condiments and seasonings used in cookery.
The hot seasoning particularly chillies , pepper , ginger and spices should be avoided when preparing a bland diet,
02.For a bland diet , food should not be fried , either in deep or shallow fat .Baking , boiling , steaming and grilling are used
03.Stimulating foods such as soups ,meat extracts , strong tea and coffee ,alcohol are to be avoided.
04. Strong sugar solutions should be avoided
05.Avoid fatty foods ,since it takes a long time to digest
06.Milk should be given in plenty.
Liquid Diet
Liquid Diets must be used for clients who are unable to take or tolerate solid food
It consists of clear fluids – non residual diet and full fluid diet (residual fluid diet)
Clear Fluid Diet
Clear fluids are used when there is a marked intolerance to foods and roughage. These include clear tea, weak black coffee, clear soups, whey water,strained fruit juices,soda water and other aerated beverage.
Such fluids have particularly no food value, but can help to maintain the fluid balance of the body.
Calories can be added by the use of sugar or glucose
Clear fluid diet should be used only for a short time since the clients may develop deficiency symptoms
Full Fluid Diet
Full fluid diet is given when the total nutrition of the client has to be maintained by fluids for a considerable time.
This is necessary when a client is unable to swallow solid food or if the client is fed by tube feeding
Milk forms the basis of the diet
To this can be added egg in the form of eggf lips ,thin custard to supply calcium , protein ,vitamin A and iron
Calories can be made up from carbohydrate in the from of starch in thin cereal preparation or by adding sugar or glucose.
Adequate amounts of vitamins can be supplied in the from of medical concentrates.
salt should be added unless it is restricted.
Special Diets (Therapeutic Diet)
Many pathological condition Bring About Changes in the body process which necessitate addition or omission of certain nutrients in the diet as part of the treatment
High caloric or low caloric diet
High protein or low protein diet
fat free diet
Low salt or salt free diet
Sippy’s diet , Bull’s diet
General Instructions for a nurse in the food service
The diet of every client in the hospital should be planned according to his need, metabolic changes , food
Create a pleasant environment for the client .Room should be well-ventilated,quiet,decorated and in order during meals.
The environment should be free from anything offensive to the senses , such as noise, disorder , confusion , dirt , unpleasant odours
Eg:- sputum cups ,bed pans , all equipment or nursing procedure.
See that client appear neat (well groomed) Hair are combed , mouth care
Place the client in a comfortable position in bed or out of bed
Unless contraindicated a fowler’s position is given with an overbed table in front of which the food tray can be placed conveniently for the feeding of the client.
Provision should be made to wash hands and the face of the client before and after meals.
Dressing and painful treatments are finished at least 1 hour before meal is served.
Offer bedpans or urinals about half an hour before serving meals so that the clients will not be disturbed during their meals.
physical and mental fatigue should be avoided
If the nurse sits near the client and engages in the conversation.
it makes the meal a pleasure experience for the client.
Meals should be served in clean and covered containers
small and frequent feeds are appreciated Never force For the food
Fluid requirement should be met to prevent dehydration
Fluids are given at the end of a meal or in between the meals
The nurse should take every chance to teach the client and his relatives about well – balance diet, food hygiene
The bed client should see the food or they should be told what food is served in front of them ,because the sight, smell and the thought of temping dish can arouse the appetite in a client with anorexia. The client on tube feeding may be given a chance to taste the food to arouse his appetite and for his satisfaction of tasting food
Tube feeding
Gavage (gastric) feeding is an artificial method of giving fluids and nutrients through a tube,
That has passed in to the Oesophagus and stomach through the nose ,mouth or through the opening made on the abdominal wall.when oral intake is inadequate or impossible.
Indications for tube feeding
• When the client is unable to take food by mouth unconscious , semiconscious ,semiconscious , delirious
• For a client who refuses food.client with psychosis
• when condition of mouth or oesophagus make the swallowing difficult or impossible,
for example – fracture of the jaw,
Repair of the cleft palate and cleft lips ,surgery of the mouth , throat and oesophagus ,paralysis of face and throat ,stricture of the oesophagus.
4. When the client is unable to retain the food,
Anorexia , nervosa and vomiting
5.When the client is too weak to swallow food or when the conditions make it difficult to take a large amount of food orally.
Advantages of tube feeding
• An adequate amount of all types of nutrients including distasteful food and medications can be supplied
• Large amount of fluids can be given with safety.
• The dangers of parenteral feeding are avoided {eg venous thrombosis}
• Tube feeding may be continued for weeks without any danger to the client.
5. The stomach may be aspirated at any time if desired.
6. Overloading of the stomach can be prevented by a drip method.
Principles involved in gastric Gavage
Tube feeding is a process of giving liquid nutrients or medications through a tube into the stomach when the oral intake is inadequate or impossible.
A thorough knowledge of the anatomy and physiology of the digestive tract and respiratory tract ensures safe induction of the tube (avoid misplacement of the tube)
Micro – Organisms enter the body through food and drink
Introduction of the tube in to the mouth or nostrils is a frightening situation and the client will resist every attempt.
Mental and physical preparation of the client
facilitates introduction of the body
Systematic ways of working adds to the comfort and safety of the client and help in the economy of material ,time and energy.
General Instructions
1. Tube feeding is given only by a doctor’s order
2. If the client is conscious , explain the procedure and reassure the client to win his confidence and cooperation.
3.Remove the dentures if any. To prevent it from dislodging and blocking the respiratory tract
4. A rubber tube may be placed in a bowel of ice to cool and stiffen
5. Lubricate the tube with a suitable lubricant preferably with a water soluble jelly, If mineral oils (Glycerin , liquid , paraffin ) are used ,it should be applied to the tube to the minimum with a paper square . A drop of mineral oil ,if dropped into the respiratory passage acts as a foreign body because it is not absorbed by the lung tissue .
6.If the tube is dipped in a liquid or lubricant before the insertion ,make sure that the blind end is not left filled with fluid or lubricant , because this may drop into the larynx and strangulate the client.
7. All equipment used for feeding should be clean the food has to be prepared , handled and stored under “Hygienic conditions” Because many organisms enter the body through the food and drink.
8. Every time before giving the feed ,make sure that the tube is in the stomach by aspirating a small quantity of 5 to 10 ml stomach contents.
9.While removing the tube ,pinch the tube and pull it out getting and quickly so that the fluid may not trickle down the trachea.
10. During the introduction of the tube, never use force as it may cause injury to the mucus membrane.
11. Avoid introducing air into the stomach during each food
Expel the air from the tube by lowering the tube below the level of the stomach
Pinch the tube before the fluid run into the stomach completely from the tube.
12. Restraints used if any , should be limited to the minimum. For infants and irrational clients , some from of restrains may be necessary . But they should not feel that they are punished
13. Feeding may be given at intervals of 2 , 3 , or 4 hours and at amount is not exceeding 150 – 300 ml per feed, The total amount in 24 hours varies between 2000 and 3000 ml.
If drip method is used .
The speed of flow should not exceed 30 to 60 ml per minute,
This minimize the distention ,nausea, regurgitation and excessive peristalsis usually associated with too much and too rapid administration
14. Intake and out put is recorded accurately
15. Watch for complication such as nausea , Vomiting , Distension , Diarrhoea , aspiration Pneumonia , asphyxia , fever , water and electrolyte imbalance.
The water and electrolyte imbalance may be reflected in changes in the ,skin ,thirst , vital signs ,intake and out put level of consciousness , body weight , moisture of the mucus membrane and serum analysis .If the dehydration is not corrected ,it may result in high fever ,disorientation , drying of the mucus membrane.
16. Client receiving tube feeding should receive frequent mouth care to prevent complications of a neglected mouth.
Preliminary Assessment
• Identify the client with name , bed no , O.P Mo.
• Chest the doctor’s orders for any specific precautions if any , regarding the tube feeding, movement of the client , positioning of the client.
• Check the level of consciousness and the ability to follow directions
Check the ability for self care, ability to more and to maintain a desired position during the insertion of the tube. check whether the feed is ready at hand.check the articals available in the client units.
Gastrostomy Feeding / Jejunostomy Feeding
Feeding by gastrostomy and jejunostomy had been used when tumors ,fistulas or operations on the upper alimentary tract make it impossible for food to reach the stomach and intestine by the normal route.
A part of the stomach or small intestine is brought to the abdominal wall and an opening is made into it through the abdominal wall
A tube is inserted in to it through which feeding can be given,
It is essential that the area of the skin around the tube be kept clean and dry.
A water proof Ointment such as zinc oxide may be applied around the tube to protect the skin from the irritation of the hydrochloric acid
Food given through the gastrostomy tube are same as those given by nasogastric tube and the same amount s are given at the same intervals.
Position to be kept when giving tube feeding
Semifowler Position
Supine Position
side line Position
Need for fluids and electrolyte balance
fluid, electrolytes and acid base balance, with in the body are necessary to maintain health and functioning of all systems. These balance are maintained by the intake and out put of water and
An electrolytes is an element or compount which, on melting or dissolving in water or another solvent dissociates in to irons and is able to conduct and electric current.
Movement of body fluids body fluids and electrolytes move from one compartment to another for meeting metabolic needs such as oxygenetion,acid base disturbances and response to drug therapies.
Diffusion it is a process in which solid matter ,such as sugar ,in a fluid moves from one area of higher concentrations to an area of lower concentration,through a semi permeable cell membrane.
Osmosis it is the movement of a pare solvent such as water, through a semipermeable membraine ,from a solution,that has a lower solute concentration,to one that has higher solute concentration
Active transport it is the movement of materials across a cell membraine by chemical activity. it requires metabolic activity and energy.
Patient Unit
Patient Unit
Client’s unit is the area furnished equipped according to the necessity for the care of the client.
Units vary in Sizes
It may be – living room, bed room, include bath room, and latrine
OR single room with furnishings and supplies for the care of one client
OR it may be the immediate surrounding of client in general ward – where several clients are looked after.
Bed
Hospital beds are usually 66 cm [26 ’) height
0.9m [3+t] wide, narrower than the usual bed 36”
Length 1.9m [6.5ft] 78”
Standard hospital beds made of metal.
Simple in design. Easily movable, handle, clean strong, durable.
Stand hospital bed 78 inches long, 38 inch wide, 28 inch high from the floor.
[Reffere from NANCY ]
Over bed table
Client can use over bed table or cardiac table for such activities. Eating , reading, writing, place articles for self care.
Generally this is used for the client suffering cardiac disease to lean, Rest, Breathing difficulty
Bed side looker.
The bed side locker is used to store the client’s unit is most comfortable for him if he has with in his easy reach those items he frequently uses. such articles can be kept on and inside the bed side locker.
Bed side table
The client who are allowed to move about can use the beside table for taking the meals and for other purposes.
Chair and stool
Most client’s units have at least on straight back chair with or without arms and a stool.
Bed side commode
Bed side commode is a chair or wheel chair that has an opening in the centre of the seat under which a bedpan can be inserted.
Bedpans and Urinals.
For a client confined to bed, bed pans and urinals are used for defecation and urination.
Sputum cup
Sputum cups are used to collect the sputum and sitings.
Kidney trays
Kidney trays are usually used for collecting the vomits, soilded dressings or for collection of body fluids.
Water flasks and drinking glasses.
The water flask is filled with drinking water and is given to the client with in his reach.
Plate, spoon, fork, knives.
These are used to serve the meals for the clients and is kept in the client unit.
Call signal
A bell is usually kept near the client to call the nurse in their need.
Toilet articles.
Soap and soap dish, tooth brush and tooth paste, mouth wash, comb, are kept in the client unit.
A waste basket
It is used to collect the rubbish
Bucket, mug, basin
These are kept in the bathing room for taking bath.
Bedding and bed linen
Mattress
Mattress used for the client should be firm, thick and smooth.
It gives support to the client
Mattresses are made by fillings with horse hair coir, Dunlop, air and water.
All should have washable cover.
Size 190cm width.
Pillow
Pillows are usually made out of strong cotton or Dunlop-
Size 60 cm long, 45 cm wide and 10 cm thick.
Sheets
The bed sheets are made of strong cotton material.
They are used to protect the mattress from boiling and to cover the client
They should be sufficiently long and wide to tuck in well at the head, foot and sides.
Size 108 inches ling and 76 inches wide.
Draw mackintosh and draw sheet.
They are drawn from side to side and usually extends from the client’s shoulders to below knees.
Draw mackintosh is a waterproof sheeting, made up of either rubber or plastic material.
It used to protect the mattress and the bottom sheet from soiling.
Draw sheet is made of the same cotton.
Material as the sheet and is used to cover the mackintosh.
It should be long enough to tuck well under both sides of the mattress.
The average size 65cm long 50cm wide.
Blanket
Blankets are usually made up to woolen material-
It should be light and warm.
It is used to protect the client from draught and chill.
Bed spread or counterpane
It is used to give a neat appearance to the bed.
It protects the blankets and the bed as a whole from dust.
Size 3m long 3m wide.
Comfort devices of mechanical devices.
Back rest.
It is a mechanical device which provides support for the client in the sitting position.
Knee rest .
Knee rest may be substituted by a pillow, gives relaxation and thus relieves pain on abdominal muscles and on tendons beneath the knees.
Foot rest
It is a device so placed that the feet rest firmly against it.
It helps to maintain the normal position of the feet, at right angles to the leg.
It is used for the comfort and to prevent foot drop.
Hart pillows, sand bags, foot board substituted.
Bed Cradle
Bed cradles support and take off the weight of the top bed clothing.
Prevent the top cloth coming in contact with the client as in case of clients.
With burns or to apply heat as in case of drying plaster casts.
Bed blocks –
Bed blocks made up of wood or metal
Used to rise the foot end or head end of the bed.
Prevent shock, Arrest hemorrhage to retain enema, after giving spinal anesthesia.
Sand bags
Used to immobilize a part as in fractures and to relive discomfort.
Used to give support to any part of the body and prevent foot drop or wrist drop.
Air Cushion.
Made up of rubber.
It can be inflated with air.
It is used to take off the weight of the body and to relieve pressure on certain part of the body.
Air and water mattresses.
Use for very thin and obese clients . Those who are prone to pressure sores.
Bed Making
The purpose of bed making.
To provide the clients with a safe and comfortable bed to take rest and sleep.
To give to the unit neat appearance.
To adapt to the needs of the client and to be ready for any emergency or critical condition of illness.
To adapt to the needs of the client and to be ready for any emergency or critical condition of illness.
To economize time, material and effort
To observe the client, Presence of bed sore. Oral Hygiene, Client ability to self care.
To promote cleanliness.
To establish an effective nurse client relationship.
To provide active and passive exercise to the client.
To help the relatives to learn to care for the sick at home.
Principle involved in Bed making
01. Micro – organisms are found every where on the skin
The nurse takes care to prevent the trans e-------------- of micro-organisms from the source to the new host.
02. A safe and comfortable bed will ensure rest, sleep and prevent several complication, Bed sore, foot drop.
03. Good body mechanisms maintain the body alignment and prevent fatigue.
04. Systematic ways of functioning. Save time, energy and material.
General Instructions for Bed making.
Wash hand before and after the procedure
Do not expose the client unnecessarily.
Protect the client from draught.
Do not cover the Client’s face while placing the linen.
Do not mix clean linen with soiled linen
Never place the woolen blanket next to the client’s body
Shake the linen gently.
Do not let the linen touch your body or uniform.
Maintain good body mechanics.
Make the bed firm, smooth and unwrinkled.
Practice economy of time, energy and material.
Arrange the bed clothes in such a way that they allow free.
The cotton mattress must be turned, aired and made free of lumps and creases.
Make adaptation according to the weather, climatic, difference, individual needs customs and habits of our client
Always get extra help to make a bed for helpless clinents and prevent them from falling.
Nurses Responsibility in Bed marking {Open Bed}
Check the doctor’s order for specific precautions regarding the movement and positioning of the client.
Abbess the client’s ability for self care check the furniture and linen available in the client’s unit.
Abbess the client’s ability for self care.
Check the furniture and linen available in the client’s unit.
Abbess the number of clean linen needed
Abbess the articles needed for the comfort of the client. Blankets, back rest.
Preparation of the Articles.
• Bed
• Mattress and Pillows
• Chair or stool
• Bedside table or locker.
• Mackintosh
• Blanket
Articles needed for the complete change of linen are
• Mattress cover
• Two sheet
• Pillow case
• Counterpane
Additional articles
• Laundry bag
• Duster 2
• A bowl with antiseptic lotion
After care of the client , unit and Equipment
1.Help the client to get into the bed. One corner of the top linen is folded back to let the client in.
Cover the client with the top linen.
2.Any comfort devices used by the client should be replaced.
3.See that the whole unit is clean and tidy before you leave the unit.
The beds in general ward should be arranged in a straight line
The bed pans, Urinals, Sputum cups/ kidney trays lying in the client’s unit are to be taken away.
The windows and doors should be dusted to keep them dust free.
The cupboards are to be dusted and the articles are to be arranged in order and according to use.
The water flasks should be washed and filled with clean water.
The flower vases may be arranged and replaced.
The washing sinks if provided in the unit should be cleaned with some abrasive.
Send the laundry bag with the soiled linen to the laundry.
If stains are present on the sheets, remove them by appropriate methods before it is bent to the laundry.
Wash hands thoroughly
Record in the nurse’s record any observations made on the client.
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