NURSING INTERVENTIONS TO
PROMOTE HEALTHY PHYSIOLOGIC
RESPONSES
Hygiene
Hygiene is the science of health and its maintenance.
It includes self-care activities such as bathing, toileting, grooming, and oral care.
It involves care of the skin, hair, nails, teeth, oral cavity, nose, eyes, ears, and
perineal/genital areas.
Nurses assess a patient’s ability to perform Activities of Daily Living (ADLs) during
hygiene care.
Benefits of Good Hygiene
Promotes medical asepsis.
Prevents growth of pathogenic microorganisms.
Protects individuals from illness.
Prevents spread of disease to others.
Improves self-esteem and body image.
Enhances mood and mental health.
Types of Hygiene Care
Early Morning Care – includes washing face and hands, oral care, and assisting with
elimination.
Morning Care – includes bath or shower, perineal care, oral care, hair care, nail care, and
back massage.
Hour of Sleep Care (PM Care) – includes oral care, washing hands and face, and
promoting relaxation before sleep.
As Needed Care (PRN) – given when required, such as changing linens for a diaphoretic
patient.
Factors Influencing Hygiene Practices
Culture
Religion
Environment
Developmental level
Health status and energy
Personal preferences
Skin Care
The skin is the body’s first line of defense.
It protects underlying tissues and prevents infection.
Moisture on the skin can increase bacterial growth and cause irritation.
Body odor is caused by bacteria acting on body secretions.
Skin Breakdown
Damage to skin and underlying tissue caused by prolonged pressure, friction, shear, or
moisture.
Good skin hygiene helps prevent complications and promotes healing.
Bathing
Removes oil, perspiration, dead skin cells, and bacteria.
Stimulates circulation.
Promotes comfort and well-being.
Allows nurses to assess the patient’s condition.
Types of Baths
Cleaning bath – for hygiene purposes.
Therapeutic bath – used to soothe irritated skin or treat conditions, sometimes with
medication in water.
Ear Care
Clean the pinna with a moist washcloth.
Remove visible cerumen carefully.
Avoid using bobby pins, toothpicks, or cotton swabs inside the ear canal.
Eye Care
Clean from inner canthus to outer canthus.
Use a clean cotton ball for each wipe.
For unconscious patients, cover eyes with sterile moist compresses to prevent dryness.
Nose Care
Blow nose gently using tissue.
Keep both nostrils open when blowing to prevent pressure in the Eustachian tube.
Remove dried secretions using a saline-moistened cotton applicator.
Oral Care
Brush teeth after meals and at bedtime.
Floss daily.
Ensure intake of nutrients important for dental health such as calcium and vitamins.
Oral Care for Unconscious Patient
Position patient in side-lying position.
Use suction if needed.
Clean teeth and gums with soft swabs.
Apply petroleum jelly to lips to prevent cracking.
Hair Care
Stimulates scalp circulation.
Cleans hair and improves patient comfort.
Foot Care
Wash and dry feet daily.
Dry well between toes.
Trim nails straight across.
Avoid soaking feet of diabetic patients.
Perineal Care
Removes secretions and prevents infection.
For females: clean from front to back.
For males: retract foreskin if uncircumcised and clean the glans.
Skin Integrity and Wound Care
The skin is the largest organ of the body.
It protects, regulates temperature, provides sensation, secretes sebum, and produces
vitamin D.
Wound
A break in the continuity of body tissue caused by external force.
Pressure Ulcer
Injury to skin and underlying tissue over a bony prominence caused by prolonged
pressure.
Also called bed sores or decubitus ulcers.
Stages of Pressure Ulcer
Stage I – non-blanchable redness.
Stage II – partial thickness skin loss.
Stage III – full thickness skin loss involving subcutaneous tissue.
Stage IV – full thickness loss with damage to muscle or bone.
Braden Scale
A tool used to assess risk for pressure ulcers.
Maximum score is 23; scores below 18 indicate risk.
Phases of Wound Healing
Inflammatory Phase (3-6 days) – hemostasis and phagocytosis occur.
Proliferative Phase (3-21 days) – collagen and granulation tissue formation.
Remodeling Phase (21 days to 2 years) – scar formation and wound contraction.
Pain
Pain is an unpleasant sensory and emotional experience associated with actual or
potential tissue damage.
Physiologic Process of Pain
Transduction
Transmission
Perception
Modulation
Pain Classification
Based on severity: mild, moderate, severe.
Based on duration: acute and chronic.
Based on location: cutaneous, somatic, visceral, referred pain.
Pain Management
Pharmacologic therapy – medications such as analgesics.
Non-pharmacologic therapy – relaxation, music, breathing exercises, distraction, and
environmental control.
Nursing Responsibilities in Pain Management
Assess pain regularly.
Monitor side effects of medications.
Watch for respiratory depression.
Educate patients about pain management strategies.