Hygiene and Activities of Daily Living (ADLs)

Definition and Importance

Hygiene refers to practices that maintain cleanliness and health, especially in the care of the skin, hair, nails, eyes, ears, nose, mouth, feet, and perineal area. These activities are essential components of activities of daily living (ADLs) and are crucial for preventing infection, promoting comfort, and supporting overall well-being.

• Etiologic factors of hygiene ADL deficit: Sensory, cognitive, endurance, mobility, or motivation deficits; low value attached to regular habits; pain; dental examinations; and physical limitations.

Oral Care

• Assessment: Odor, moisture, lesions, edema, bleeding, color, function, cheek, lips, gums, buccal mucosa, teeth, tongue, hard/soft palate, and oropharynx.

• Brushing and Flossing: Brush teeth twice a day and rinse the mouth after meals. Therapeutic mouthwash may be used to reduce bacteria, reduce plaque, gingivitis, tartar, and freshen breath. Oral health is directly related to systemic health; poor oral health is associated with diabetes, cardiovascular disease, and metabolic syndrome.

• Denture Care: Store dentures in cold water in a denture cup, advise patients not to wrap dentures in tissue or leave them in the sink, and brush with toothbrush and toothpaste or soak in denture cleanser. Always rinse teeth and patient’s mouth before putting dentures back in.

Ear Care

• Assessment: Look for dryness, crusting, presence of foreign body, buildup of cerumen (earwax).

• Wash and dry around outer ear; do not use cotton swabs or force any object into ear canal.

Hair Care

• Assessment: Check hair condition, texture, cleanliness, oiliness. Check scalp for lesions, inflammation, infection, dandruff, alopecia, or infestations.

• Brush hair to distribute oil along the hair shaft and stimulate circulation to the scalp. If tangled, remove small sections at a time. Braiding long hair decreases matting and tangling. Never cut hair without permission. If patient cannot perform shampooing, special basins and no-rinse shampoo caps are available.

Shaving

• Never trim or shave hair without permission. Apply warm washcloth to skin, apply shaving cream, shave with direction of hair growth for face and against direction for hair growth for legs. Remove residual shaving cream at the end.

Nursing Process and Clinical Judgment

Overview

The nursing process is a systematic, evidence-based approach to patient care, involving assessment, diagnosis, planning, implementation, and evaluation. It ensures individualized, safe, and effective care.

Steps of the Nursing Process

1. Assessing: Collect and analyze data about the patient’s health status.

2. Diagnosing: Identify actual or potential health problems (nursing diagnosis) using data.

3. Planning: Set priorities, establish goals, and select interventions to address diagnoses.

4. Implementing: Carry out interventions and document care.

5. Evaluating: Assess effectiveness of interventions and modify plan as needed.

IDEAL: 5 Key Actions

• I – Include the client and caregivers

• D – Discuss the 5 key areas: meds, home, test results, warning signs, next steps

• E – Educate the client: condition, discharge process, next steps

• A – Assess effectiveness of education

• L – Listen to the client’s goals and preferences

Prioritization and Maslow’s Hierarchy

Prioritization in Nursing Care

• Care is prioritized based on urgency or importance of client needs.

• Critical interventions are completed first (e.g., airway, breathing, circulation).

• Maslow’s Hierarchy: Physiological needs (food, fluids, oxygen, elimination, warmth, comfort) are prioritized before safety, love/belonging, esteem, and self-actualization.

Classes of Triage

Delegation and Quality Assurance

Delegation in Nursing

• Delegation is appropriate when the delegatee is performing a specific nursing activity, skill, or procedure that is within their scope of practice and not routinely performed by the RN.

• RN is responsible for initial assessment, discharge planning, care planning, patient education, and interpretation of patient data.

• RN can delegate basic care activities, specimen collection, and vital signs to assistive personnel.

5 Rights of Delegation

1. Right task

2. Right circumstances

3. Right person

4. Right directions and communication

5. Right supervision and evaluation

Quality Assurance Programs

• Promote excellence in nursing and accountability for quality of care.

• Focus on finding and correcting deficiencies (quality by inspection) and fostering improvement (quality as opportunity).

Medication Administration

3 Checks for Safe Medication Administration

• Check when you reach for the container.

• Compare with MAR (Medication Administration Record) immediately before pouring.

• Check just before giving the unit dose to the patient or upon replacing the container.

Routes of Administration

• Oral (swallow): Enteral (tube), sublingual (under tongue), buccal (cheek)

• Parenteral (injectable): Subcutaneous, intramuscular, intradermal, intravenous

• Topical: Vaginal, rectal, instillation (placing drug in direct contact with mucous membrane), inhalation, skin application (transdermal patch)

Verifying Orders

• MAR, computerized forms, checking transcribed order and signing, knowledge of any medication given and correct dosage, questioning the order.

• Nurses are legally responsible for the drugs they administer.

• All suspected errors or unclear orders should be questioned.

• Nurses have the right to refuse to administer any medication that, based on their knowledge and expertise, may be harmful to the patient.

Multidose Vials

• Nurses can remove several doses from the same container.

• To prevent microbial growth, multidose vials are usually good for only 24 hours after opening.

• Label with date and time when first used.

• Inject the same amount of air as the desired quantity of solution.

• Tip of vial must be cleaned prior to each entry; new sterile needle and syringe is used with each entry.

MDI (Metered-Dose Inhaler) Administration

• Shake the inhaler well.

• Remove mouthpiece cover, attach inhaler to spacer if needed.

• Place mouthpiece in mouth, seal lips tightly, breathe in slowly and deeply through mouth, press down on inhaler to release medication.

• Hold breath for several seconds, then exhale slowly.

• Rinse mouth after use to prevent irritation.

Insulin Administration

• Use insulin syringe with orange cap; may use insulin pens or pumps.

• If mixing NPH (cloudy) and regular (clear) insulin, draw up regular insulin first.

• Rotate injection sites to prevent tissue damage.

Parenteral Sizes and Gauges

Injection Sites and Techniques

• SUBQ: Outer upper arm, abdomen, anterior thigh, upper back, upper ventrogluteal, over ventrogluteal.

• ID: Inner forearm, upper back, under scapula.

• IM: Deltoid, vastus lateralis, ventrogluteal.

Maximum Volumes

• SUBQ: 1 mL

• ID: 0.5 mL

• IM: 1-3 mL (deltoid: 1 mL max)

Techniques

• SUBQ: Pinch skin, insert needle, release before injecting, do not aspirate, do not massage.

• ID: Hold skin taut, bevel up, inject slowly, create wheal, do not aspirate, do not massage.

• IM: Stretch skin, insert needle at 90°, aspirate (except for vaccines), inject slowly, do not massage.

Key Terms and Definitions

• ADL (Activities of Daily Living): Basic self-care tasks such as bathing, dressing, eating, and hygiene.

• MAR (Medication Administration Record): Legal record of drugs administered to a patient.

• Delegation: Assigning responsibility for certain tasks to another healthcare worker while retaining accountability.

• Clinical Judgment: The process of integrating evidence, experience, and patient preferences to make decisions about care.

Example: Application in Clinical Practice

• When caring for a patient with diabetes, oral care is especially important due to increased risk of periodontal disease. The nurse should assess the oral cavity, provide assistance with brushing and flossing, and educate the patient on the importance of regular dental visits.

• When administering insulin, the nurse must use the correct syringe, rotate injection sites, and follow the correct order when mixing insulins (clear before cloudy).

Additional info: These notes integrate foundational concepts from anatomy, physiology, and nursing practice, providing a comprehensive overview for exam preparation.