Page 127 - JSOM Summer 2018

• Better: Mouth wash, mouth moisturizer, gloves, gauze, 3. Expose body part to be washed, keeping the rest of the
tongue depressor, tape, lip moisturizer patient covered, and place linen-saver pad under the area
• Best: Oral cleansing and suction system, lip moisturizer to absorb water.
4. Take one gauze or washcloth out of the basin and wring
Good oral hygiene reduces oropharyngeal colonization, out excess water. Wash skin a little bit at a time, throwing
which is associated with ventilator-acquired pneumonia. Pa- away used gauze or washcloths until clean. DO NOT place
tients who are conscious and able should brush their teeth a contaminated gauze or washcloths back into basin or bowl.
minimum of every 12 hours. For unconscious patients, per- 5. Wash face first and genitalia last. (Cleaning genitalia is de-
form oral care at least every 4 hours. Ensure some type of tailed under Foley care.)
suction is available (e.g., manual suction device, syringe with 6. Ensure the skin is thoroughly dried, including all skin folds,
IV tubing). and apply lotion.
1. To keep the patient’s mouth open, make a padded tongue
depressor by wrapping gauze around one end of it and se- Caution: If baby wipes or skin wipes are used to wash the
curing with tape. skin, the wipes should be thoroughly rinsed with water first,
2. If available, use swab and chlorhexidine gluconate rinse from because most contain alcohol and residues that can irritate the
oral cleansing and suction system. Make sure not to over- skin.
saturate the swab to avoid aspiration of fluid. Clean teeth
and oral cavity for approximately 1 minute. If the system is Change Intravenous Bag and Tubing
unavailable, use a 2×2 gauze wrapped around pointed gloved Every 72 hours if possible, replace infusing bag of fluids and
finger and hold firmly with the rest of hand. Moisten the tubing with new equipment. If fluids infusing at a to-keep-
gauze with mouthwash (ensuring not to oversaturate) and open rate and a bag has been up for 72 hours, ensure a fresh
gently clean the teeth and mouth cavity. Multiple gauze swabs bag and tubing are hung and marked with new time and date.
may be needed depending on the level of contamination in
the mouth. Follow up with mouth moisturizer if available. Check Blood Glucose Level
3. Apply lip moisturizer. If available, check blood glucose level (BGL) every 8 hours or
more frequently as dictated by patient status. A low BGL (less
Foley Catheter Care than 80 mg/dL) must be treated immediately with oral sugar
• Minimum: Basin, warm water, nonirritating soap, lin- or juice or IV glucose. A high BGL (greater than 200 mg/dL)
en-saver pad, towels is less dangerous than low glucose, but may be treated if the
capability is available.
Perform Foley care once a day or as needed for excessive
drainage. Change Tape
1. Wash hands thoroughly with soap and water, apply gloves, Once a day, change tape on patient’s skin (except for periph-
and place linen-saver pad or dry towels under patient. eral IV sites, which can be changed every 72 hours to avoid
2. Using mild soap and water, clean genital area. exposing puncture site to contaminants). Daily tape changes
o For male patient: retract the foreskin, if needed, and decrease the potential for skin breakdown. This intervention
clean the area, including the penis. may be accomplished after patient’s daily wash.
o For female patient: separate the labia, and clean the area 1. For ETT or cricothyroid tube, gently remove tape. If tape
from front to back. is strongly adhered, use an alcohol swab to moisten the top
3. Clean urethra (urinary opening), where the catheter enters of the tape. As the tape is lifted back, use the alcohol swab
the body. and gently rub across the skin at the junction with tape to
4. Clean the catheter from where it enters the body and then loosen, ensuring not to dislodge tube placement.
down, away from urethra. Hold the catheter at the point it 2. For ETT, after tape is removed, gently move the tube to the
enters the patient so that tension is not placed on it. opposite side of the mouth, again ensuring not to dislodge
5. Rinse the area well, dry gently, and replace linen-saver pad it or rest on lip.
under patient. 3. Apply new tape to a section of skin next to where tape was
previously removed. To give skin a break, do not place over
Wash and Dry Skin, Apply Lotion the same area.
• Minimum: Water, gauze, or well-rinsed “baby” wipes
• Better: Bowl, baby or mild wash, unscented lotion, 2×2 Lower Extremity Massage, DVT Prevention
and 4×4 gauze pads, gloves, tongue depressor, tape If available, compression stockings, or elastic bandages
• Best: Basin, linen-saver pads, disposable wash cloths, (wrapped starting from the toes upward) should be placed
compression stockings, trifold lawn chair, nasal mist, on immobile or unconscious patients, ensuring toes remain
pillows, padding, urine test strips, toothbrush and exposed for capillary refill assessment. Patients who are con-
toothpaste, oral cleansing and suctioning kit, tongue de- scious and able may perform the following exercises, complet-
pressor, gauze, tape ing 10 repetitions of each exercise every hour while awake.
This may be done in burned extremities or in the presence of
At least once per day or as needed, wash, dry, and apply lotion open wounds, but should be avoided when fractures or severe
to skin. Cleaning the skin is an opportunity to evaluate addi- extremity injuries are present.
tional injuries and visualize any new areas of erythema. 1. Foot pumps. Have the patient stretch toes up and back,
1. Prepare basin or bowl with warm water and a small amount flexing feet, and hold for a few seconds. Then point toes
of baby wash. and hold before repeating.
2. Obtain multiple 4×4 gauze pads or clean washcloths and 2. Ankle circles. Have patient raise both feet and trace a circle
place in water. or each letter of the alphabet with their toes.

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