新编护理学基础-病人的清洁卫生1.pptVIP

病人的清洁卫生(一) 中国医科大学护理学院 吕 岩 Cleanliness and hygiene Functional Levels of Self-Care Totally dependent Moderately dependent Semidependent Types of Hygienic Care Morning Care (AM Care) Hour of Sleep Care (HS Care) As-Needed Care (prn Care) Oral Care Assessing Nursing History Physical assessment Risk factors Assessment of clients with denture Nursing History Oral hygiene practices —determine learning needs and incorporate the client’s needs and preferences Self-care ability —determine the amount and type of nursing assistance to provide Past or current mouth problems —alert the nurse to specific interventions required or referrals Physical Assessment Dental caries（龋齿） Periodontal disease(牙周组织疾病） Gingivitis（牙龈炎） Mucosa ,lip, tongue, odor 龋齿的形成 牙周疾病 Risk Factors Lack of knowledge Inability People with hasogastric tubes or receiving oxygen Oral or jaw surgery Inadequate nutrition Excessive intake of refined sugars Family history Older people Dry mouth Diagnosing Self-Care Deficit Altered Oral Mucous Membrane Knowledge Deficit Planning To maintain or improve oral hygiene practices To maintain or restore the integrity of the oral tissues To prevent associated risks such as dental caries and inflammation or injury of the gums , tongue, or oral mucosa Nursing Interventions Teaching client about good oral hygiene practices and other measures to prevent tooth decay Assisting dependent clients with oral care Providing special oral hygiene for clients who are debilitated, unconscious,or have lesions of the mucosa membrane or other oral tissue Implementing （一）Teaching oral hygiene 1.Brushing the teeth 2.Flossing the teeth 3.Health education （二）Caring for artificial dentures （三）Special oral care Hair Care Assessing Nursing history 1.Hair Care Practices 2.Self-Care Abilities 3.Past or Current Hair Problems Physical assessment Dandruff, hair loss, pediculosis 男性脱发一般进程 Diagnosing Self-Care Deficit Impaired Skin Integrity Risk for Infection Body Image Dis