病人的清洁卫生 ( 一 )

病人的清洁卫生( 一 )

中国医科大学护理学院吕 岩

Cleanliness and hygiene

Religion

Environment

Developmentallevel

Health and energy

Personal preferences

Culture

Individual hygiene practice

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

(plaque)

(tartar)

牙垢（牙石）

龋齿的形成

没受酸影响的健康的牙釉柱

受酸影响而脱矿损的牙釉柱

氟与唾液中的矿物质再度矿化及重建牙釉柱

牙周疾病

牙龈炎 牙周炎 严重的牙周炎

地 图 舌

牛肉舌

镜面舌

裂纹舌

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

Goals

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 ProblemsPhysical 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 Disturbance

Planning

Maintain or improve hair care Maintain or improve a sense of

well-being Prevent specific hair and scalp

problems

Goals

Nursing Intervention

Performs hair grooming with assistance

Has clean ,well-groomed ,resilient hair with a healthy sheen

Has reduced or absent scalp lessions or infestations

Describes contributing factors, interventions ,and preventive measures for specific hair problems

Implementing

Brushing and combing hair Shampooing the hair 灭头虱法

Pediculosis （虱病）

30 ％含酸百部酊剂

百部 30g 放在瓶中，加 50％乙醇 100ml （或 65° 白酒100ml ），再加入 纯乙酸 1ml盖严， 48 小时后即制得此药

30 ％百部含酸煎剂 取百部（干品） 30g ，加水 500ml 煎

煮 30min ，以双层纱布过滤，将药渣中的药液挤出。将药渣再加水 500ml 煎30min ，再以双层纱布过滤，挤出药液。将两次煎得的药液合并，浓缩至 100ml ，冷却后加入纯乙酸 1ml ，即制得 30 ％百部含酸煎剂。若无乙酸，可用食醋代替，纯乙酸 1ml 相当于市售食醋 30ml 。