病人的清洁卫生
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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. 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.

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病人的清洁卫生 ( 一 )

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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

Cleanliness and hygiene


Functional levels of self care

Functional Levels of Self-Care

  • Totally dependent

  • Moderately dependent

  • Semidependent


Types of hygienic care

Types of Hygienic Care

  • Morning Care (AM Care)

  • Hour of Sleep Care (HS Care)

  • As-Needed Care (prn Care)


Oral care

Oral Care


Assessing

Assessing

  • Nursing History

  • Physical assessment

  • Risk factors

  • Assessment of clients with denture


Nursing history

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

Physical Assessment

  • Dental caries(龋齿)

  • Periodontal disease(牙周组织疾病)

    Gingivitis(牙龈炎)

  • Mucosa ,lip, tongue, odor


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(plaque)

(tartar)


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牙垢(牙石)


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龋齿的形成


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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


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牙周疾病

牙龈炎

严重的牙周炎

牙周炎


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地 图 舌


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牛肉舌

镜面舌

裂纹舌


Risk factors

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

Diagnosing

  • Self-Care Deficit

  • Altered Oral Mucous Membrane

  • Knowledge Deficit


Planning

Planning

Goals

  • 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

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

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

Hair Care


Assessing1

Assessing

  • Nursing history

    1.Hair Care Practices

    2.Self-Care Abilities

    3.Past or Current Hair Problems

  • Physical assessment

    Dandruff, hair loss, pediculosis


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男性脱发一般进程


Diagnosing1

Diagnosing

  • Self-Care Deficit

  • Impaired Skin Integrity

  • Risk for Infection

  • Body Image Disturbance


Planning1

Planning

  • Maintain or improve hair care

  • Maintain or improve a sense of well-being

  • Prevent specific hair and scalp problems

Goals


Nursing intervention

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


Implementing1

Implementing

  • Brushing and combing hair

  • Shampooing the hair

  • 灭头虱法


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Pediculosis(虱病)


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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


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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。


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