Basic Physiologic Needs · 3 min read
Hygiene and Skin Integrity
Hygiene care maintains skin integrity, prevents infection, promotes comfort, and gives the nurse a structured opportunity to assess the skin, mobility, and mood. Bathing, oral care, perineal care, and foot care are often delegated to assistive personnel, but the nurse remains responsible for assessing the skin and evaluating the care.
Bathing and Perineal Care
- Clean from clean to dirty areas: face and eyes first (inner to outer canthus, no soap on the eyes), perineum last.
- Female perineal care: wipe front to back (pubis toward rectum) to reduce urinary tract infection.
- Uncircumcised male: retract the foreskin, clean, and always return the foreskin to its natural position to prevent paraphimosis.
- Catheter care: clean the catheter from the meatus outward, about 10 cm, using a clean area of cloth for each stroke.
- Pat skin dry, especially in skin folds; moisture causes maceration and fungal infection.
Oral Care
- Unconscious client or weak gag reflex: place side-lying with the head turned, have suction ready, use a soft toothbrush or swab and minimal fluid. Never place fingers in the mouth.
- Stomatitis (chemotherapy): soft brush, normal saline or bland rinses; avoid alcohol-based mouthwash and lemon-glycerin swabs, which dry and irritate the mucosa.
- Dentures: clean over a basin lined with a towel, store in a labeled cup with water, and inspect the gums.
Foot Care for Clients With Diabetes
| Do | Avoid |
|---|---|
| Inspect feet daily, using a mirror for the soles | Soaking the feet (dries the skin, risks burns) |
| Wash in lukewarm water tested with the elbow or thermometer | Heating pads or hot water bottles |
| Dry thoroughly, especially between the toes | Lotion between the toes |
| Cut nails straight across, or have a podiatrist trim them | Cutting corns or calluses at home |
| Wear well-fitting shoes and clean cotton socks | Going barefoot, even indoors |
Pressure Injuries
A pressure injury is localized damage to skin and underlying tissue over a bony prominence or under a medical device, caused by pressure alone or pressure combined with shear. Common sites are the sacrum, coccyx, heels, greater trochanters, ischial tuberosities, elbows, and occiput.
| Stage | Appearance |
|---|---|
| Stage 1 | Intact skin with nonblanchable redness; may feel warm, firm, or boggy. Darker skin may show color change without visible redness. |
| Stage 2 | Partial-thickness loss of dermis; shallow open wound with a pink-red bed and no slough, or an intact or ruptured serum-filled blister. |
| Stage 3 | Full-thickness skin loss; fat visible; slough or eschar may be present; undermining and tunneling possible. No bone, tendon, or muscle visible. |
| Stage 4 | Full-thickness skin and tissue loss with exposed or palpable bone, tendon, muscle, or cartilage. |
| Unstageable | Full-thickness loss obscured by slough or eschar, so depth cannot be determined. |
| Deep tissue injury | Persistent nonblanchable deep red, maroon, or purple area, or a blood-filled blister, from damage to underlying soft tissue. |
Prevention Priorities
- Assess risk on admission and regularly with the Braden Scale (sensory perception, moisture, activity, mobility, nutrition, friction and shear). Total 6–23: 18 or less = at risk, 13–14 moderate, 10–12 high, 9 or less very high.
- Reposition at least every 2 hours in bed; keep the head of the bed at or below 30 degrees unless contraindicated to reduce shear.
- Float heels off the bed with a pillow under the calves; use pressure-redistribution surfaces.
- Manage moisture from incontinence promptly, and use a lift sheet to reduce friction.
- Never massage reddened bony prominences, and do not use donut-shaped cushions or heat lamps.
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