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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 。