ESSENTIAL NURSING CARE:

PERSONAL HYGIENE,
EYE CARE, ORAL CARE
Anita Setyawati, S.Kep., Ners., M.Kep.
Department of Critical Care
Faculty of Nursing
Universitas Padjadjaran
 PERSONAL HYGIENE (1)
It is important to provide the critically ill patient with effective personal hygiene as poor
hygiene may increase the risk of bacterial colonisation and subsequent infection, or lead to
surgical infection.
Daily bed-baths are usually provided for most critically ill patients, although their
effectiveness at reducing bacterial colonisation is questionable.
Personal hygiene is also closely related to an individual’s esteem and sense of wellbeing.
It may also influence family members’ perception of the quality of care the patients is
receiving and the confidence they have in the staff’s ability to care for their loved one.
 PERSONAL HYGIENE (2)
• Consideration of the patient’s specific condition may influence the timing and way personal
hygiene is performed. For example, the patient may have to be moved slowly when
changing bed linen because of their cardio- vascular instability, or they may require a
blanket while bathing if they are hypothermic.
• Finally, providing essential care should be timed to promote optimal rest.
 ASSESSMENT OF PERSONAL HYGIENE
Assessment of critical care patients’ personal hygiene should be undertaken on two levels:
1. First, determining what patients are able to do for themselves and what they want.
2. Second, the nurse’s professional assessment of what is required. As with all aspects of
care, the patient has the right to refuse personal hygiene measures. Many critical care
patients are unable to participate in decision making, and in these cases it falls to the nurse
at the bedside to determine what level of care is necessary.
 BASIC HYGIENE (1)
• A daily bed-bath with intermittent washes of the face and hands is standard care, however
patients who are sweat- ing, incontinent, bleeding or with leaking wounds should be washed
and their linen changed as often as necessary.
• Wet, creased sheets may cause pressure on dependent areas, increasing the risk of pressure
ulcer development. For many critically ill patients, being moved is painful and it may be
appropriate to give prophylactic pain relief before commencing a bed-bath.
 BASIC HYGIENE (2)
• A daily bed-bath with intermittent washes of the face and hands is standard care, however
patients who are sweat- ing, incontinent, bleeding or with leaking wounds should be washed
and their linen changed as often as necessary.
• Wet, creased sheets may cause pressure on dependent areas, increasing the risk of pressure
ulcer development. For many critically ill patients, being moved is painful and it may be
appropriate to give prophylactic pain relief before commencing a bed-bath.
 BASIC HYGIENE (3)
• The timing of a bed-bath and personal hygiene is impor- tant.
• When several nurses are required to move the patient, it makes sense to consult with
colleagues to coor- dinate their availability.
• Planning ahead with respect to events such as medical rounds, chest X-ray requirements and
family visits helps avoid unnecessary delays in completing personal hygiene and
interruptions that affect the dignity of the patient.
• Privacy for the patient during personal hygiene should be of paramount concern.
 BASIC HYGIENE (4)
• The length of time taken to wash a patient and the environmental temperature are factors that
affect cooling.
• Water on exposed skin causes rapid heat loss through conduction, convection and radiation,
and for many years tepid sponging was used in critical care as a method of cooling pyrexic
patients.
 BASIC HYGIENE (5)
• Soap can cause dryness of the skin.
• Aqueous cream can be used as a soap substitute.
• Salep pengemulsi.
• Moisturisers.
• Baby care products.
• Specific topical treatments.
• Complete disposable wash kits.
 BASIC HYGIENE (6)
• Personal hygiene involves washing the patient’s hair as necessary, shaving the patient,
management of cerumen in ears and care of finger and toe nails.
• While normal shampoo can be used, hair caps and washing products are available that are
easier to use for bed ridden patients.
• Male facial hair should be managed as per the patient’s normal routine, such as maintaining
a beard or shaving.
• Ears should be gently inspected for debris or injury.
• If assessed as appropriate, wax softening drops may be needed for 3–5 days if cerumen is
present and causing the patient difficulties with their hearing.
• Maintaining clean nails is another aspect of personal hygiene. Care should be taken if nails
require trimming, especially if the patient has brittle nails or is diabetic.
 BASIC
HYGIENE
(6)
 ORAL CARE OR MOUTH CARE (1)
The oral cavity includes mucous membranes, teeth, and lips.
In health, most people maintain oral health and comfort by:
• Drinking
• Salivation
• Brushing teeth/cleaning dentures
And often by additional methods such as:
• Mouthwashes (many of which are antibacterial)
• Flossing
• lipbalm
 ORAL CARE OR MOUTH CARE (2)
Mouth care refers to measures that maintain oral health (mouth hygiene) and or comfort.
Mouth hygiene is effective removal of plaque and debris to ensure the structures and tissues
of the mouth are kept in a healthy condition.
Dental plaque is a film on teeth, usually including bacteria and breakdown products from
food, including acid.
The aims of mouth hygiene:
• Maintain comfort
• Remove plaque and debris
• Prevent damage and complications
 ORAL CARE OR MOUTH CARE (3)
Critically ill patients are vulnerable and often unable to maintain their own hygiene.
While patients rarely require critical care because of oral pathologies, some have problems
on admission, and all are at potential risk of developing complications.
For many people, oral comfort is an important component of psychological wellbeing.
Unfortunatelly, oral care is poorly researched, and sometimes poorly practised.
 ORAL CARE OR MOUTH CARE (4)
Poor oral hygiene can cause or contribute to complications ranging from short-term (e.g.
ventilator associated pneumonia) to long-term (tooth loss).
Oral discomfort from dryness, fungal infection, or other problems, can also cause distress.
 PROBLEMS IN CRITICAL CARE
In addition to general health problems, critical illness may cause or exaserbate :
• Xerostomia (dry mouth)
• Trauma from oral intubation
 XEROSTOMIA (1)
The sensation of dry mouth is usually caused by lack of saliva.
Dryness of the normally moist mucous membranes can lead to ulceration, and colonization
by microbes.
Other factors that contribute to xerostomia in critically ill patients often include:
• Dysphagia
• Absence of oral intake
• Convection
• Side effect of drugs
 TRAUMA FROM ORAL INTUBATION (1)
Intubation is necessarily a quick procedure, and so many cause unintentional trauma.
While trauma may be caused to almost any part of the mouth, the cavity can be easily seen
and the durability of the hard pallet (root of the mouth) usually prevents many potential
problems.
However, loose teeth or crowns may be dislodged.
Any damage from intubation should be recorded as a clinical incident.
Oral endotracheal tubes inevitably place pressure on parts of the oral cavity, including the
tongue.
While oral damage from prolonged pressure is relatively rare, the oral cavity should be
inspected for signs of any problems.
 TRAUMA FROM ORAL INTUBATION (2)
Tapes used to secure endotracheal tubes can cause trauma, sores
and lacerations, especially to the corners of the lips.
Tapes should be changed at least daily, with a slightly different
position in relation to oral tissue with each change.
There are various tube holders and sponge covers marketed that
may reduce trauma from endotracheal tube tape.
Moist tapes, and tissue adjacent to tubes, can encourage microbial
growth.
Frequent mouth care and daily change of tapes reduce this risks.
PROBLEM-SOLVING:
ORAL ASSESSMENT
 ASSESSMENT OF ORAL CAVITY
Equipment: pen torch
Procedure:
• When possible, explain and discuss the procedure with the patient. If the patient lacks the
capacity to make decisions the practitioners must act in the patient’s best interests.
• Follow any oral assessment tool available.
• Ensure sufficient light.
• Ensure head is appropriately supported to precent trauma or discomfort.
• Ensure linen is not touching mucous membrane.
• Document care and report any abnormalities.
 CARE OF THE ORAL CAVITY (1)
Equipment:
• Small headed paediatric toothbrush
• Fluoride toothpaste
• Sterile water
• 5ml syringe
• Rigid OPA suction catheter
 CARE OF THE ORAL CAVITY (2)
Procedure to clean teeth:
• When possible, explain and discuss the procedure with the patient. If the patient lacks the
capacity to make decisions the practitioners must act in the patient’s best interests.
• Sit patient upright (unless contraindicated).
• Brush teeth.
• Clean teeth at least twice a day.
• (unless contraindicated) teeth should be brushed vigorously.
• Brush teeth away from gums.
• Rinse mouth with water during and after cleaning (use 5 ml syringe).
• Suction oral cavity with rigid OPA suction catheter.
• Document care and report any abnormalities.
 CARE OF THE ORAL CAVITY (3)
Procedure to lip care:
• Moisten lips frequently with lubricant.
• Prevent tape securing ETT.
• Document care and report any abnormalities.
 EYE CARE
Eye care of the ventilation patient is important, why?
Many patients In ICU are comatose, sedated, or chemically paralyzed and therefore have lost
the blink reflex or ability to close their eyelids completely  lead to cornea dryness and
ulceration.
Frequent problems occurring in patients’ eyes in critical care include:
• Keratitis (corneal inflammation)
• Blepharitis (inflammation of eyelash follicles and sebaceous glands)
What may appear minor irritations can progress to serious complication such as:
• Microbial keratitis
• Corneal abrasions and or erosions
 KERATITIS AND CORNEAL EROSIONS (1)
Keratitis (inflammation of the cornea) may be caused by any irritant, and is more likely to
occur if eye surface are dry.
Deeply unconscious and or sedated patients often develop dry, red eyes.
Keratitis can also be caused by microbes .
Keratitis can progress to keratopathy (corneal damage).
Exposure keratopathy, from drying or corneal surfaces, occurs relatively frequently (20-
42%) in critically ill patients and can cause permanent damage.
 KERATITIS AND CORNEAL EROSIONS (2)
Keratitis and corneal erosions can lead to blindness, unless corneal transplantation is
available.
Factors that expose eyes to potential damage in critical care may include:
• Inability to protect own eyes
• Impaired tear production
• Intraoculer hypertension
• Drying with oxygen from face mask (unhumidified oxygen or non-invasive ventilation)
• Deep sedation, which impairs blink reflexes and possibly tear production
• Trauma from equipment (e.g. ventilator tubing, tapes to secure endotracheal tube, linen)
 DRY EYE (1)
Dry eye is the most common problem in critically ill patiens.
Patients may have pre-existing problems with dry eye, but tear production may be impaired
by drugs, such as atropine, antihistamines, muscle relaxants, and paralysing agents.
Drying may be caused by:
• Incomplete eyelid closure
• Loss of blink reflexes
 DRY EYE (2)
Dry corneal surfaces lack the antibacterial protection of tears.
Exposure to opportunist organism is therefore more likely to cause infection.
Acute bacterial conjunctivitis (pink eye) is the most common eye disease in the general population
and is highly contagious .
Most mechanically ventilated patients (77%) developed bacterial colonization of eye surfaces after
one week.
Infection may appear as:
• Keratitis (corneal inflammation)
• Red eye
• Stickness
• Discharge
• Crusts (dried mucus)
 DRY EYE (3)
Dry eye surfaces and especially eye surfaces exposed to hardened substances (e.g. crusts),
can cause corneal abrasions.
Abrasions occur in one-fifth of critically ill patients and can develop within 48 hours to one
week.
Intact corneas, like skin, provide a barrier against microbes, but damage corneas can harbour
microbes, progressing to microbial keratitis.
Keratitis can lead to corneal ulceration – an acutely painful condition. It may also cause loss
of vision, unless urgent keratoplasty is performed.
 DRY EYE (4)
Anything touching the eye surface, such as ointment or drops, should therefore be steril.
Excess moisture should be removed with a clean swab.
Gauzed fibre s can damage the corneal surface, so swab should be soft, such as non-woven
or low-linting gauze; available swabs are popularly called ‘gauze swabs’, although seldom
are now made from gauze.
Separate eye drops and pads should be used for each eye, to prevent microorganisms being
transferred between eyes.
 BLURRED VISION
Blurred vision may be caused by critical illness or other factors.
Problems should be recorded, but vision usually normalizes with recovery, so patients and
families should be reassured that this is probably a temporary problem.
 SUSPECTED OCULAR INFECTION
Suspected ocular infection should be recorded and communicated to relevant practitioners.
Swabs may need to be taken and topical antibiotic prescribed.
Prone positioning places eyes at high risk of damage, so prophylactic interventions are
needed to keep eye surfaces clear from bedding or other objects.
 ASSESSMENT AND CARE (1)
Although seldom life threatening, eye problems frequently occur in critically ill patients, so
preventative eye care should be commenced on admission.
Both eyes should be clearly visualized for assessment.
A good light is therefore needed.; ambient light may be sufficient, but if using a torch this
should not be shone directly into the patients’ eyes, as this could cause distress.
If the patients normally uses visual aids (glasses, contact lenses), this should be documented,
together with whether aids are present or absent. If present, but not being used, they should
be stored safely.
Aids should only be used if the patients wishes, if they are conscious and in suitable position
(e.g. upright), as glasses can be broken and contact lenses lost.
 ASSESSMENT AND CARE (2)
Contact lenses can also provide a medium for corneal surface infection, and if patients are
unconscious, they are unable to communicate pain, which would indicate a potential problem.
Aids should be cleaned using one of the options bellow:
• Patient’s own cleaning solution and cloth
• Glasses may be cleaned under running water, then dried with a lint-free cloth or soft tissue
• Hard contact lenses may be cleaned by soaking in 0.9% sodium chloride, then dried with a
tissue
• Sort contact lenses are normally only cleaned weekly. Advise is inconsistent, but manufacturers’
instructions should be followed and lenses stored in a sterile solution to prevent them drying
out. Contact lenses should be rubbed to remove bacteria to reduce the risk of keratitis.
• Gloves whould be worn when handling contact lenses to prevent cross-infection.
 ASSESSING THE EYE
Equipment: pen torch
Procedure:
• When possible, explain and discuss the procedure with the patient. If the patient lacks the
capacity to make decisions the practitioners must act in the patient’s best interests.
• Follow any eye assessment tool available.
• Ensure sufficient light.
• Ensure head is appropriately supported to enable periorbital drainage.
• Ensure any tapes or tubing around the face do not restrict venous drainage.
• Ensure linen and equipment are not in direct contact with either eye.
• Document care and report any abnormalities.
 CLEANSING THE EYES (1)
Equipment:
• Water
• 2 gallipots
 CLEANSING THE EYES (1)
Equipment:
• When possible, explain and discuss the procedure with the patient. If the patient lacks the capacity to make
decisions the practitioners must act in the patient’s best interests.
• Tilt head backwards where possible and lower bottom eyelid.
• With gloved hands, clean along eyelashes using a soft cloth or swab soak in sterile water.
• Gently brush the fornix with new swab moistened in water, removing any crusts.
• Brush moistened steril swab from the fornix very gently across the eyelids, avoiding contact with the cornea.
• Repeat until eyes appears clean
• Remove excess moisture with dry swab.
• Clean other eye in the same way.
• Instill eye drops into fornix of eye.
• Remove excess moisture with dry swab.
• Document care and report any abnormalities.
Thank You