HEALTH AND ILLNESS

Introduction:
The primary rolcs of nurse as carc givers are to promole health, to prevent

illness, to restore health and facilitate coping .These activities help maximize the
health of patients at all ages. Health is more than just the absence of illness; it is an
active process in which an individual moves his or her maximum level of well
being. To give holistic care, the nurse must understand and respect each person's
individual definition of health and responses to illness, the nurse knowledge of
health and illness as well as the philosophy of health is even more important to
provide a comprehensive patient care.

Definitions:

Health: can be defined as the general condition of a person's mind, body and
spirit, usually meaning to be free from illness, injury or pain (as in "good health" or
"healthy").

Health: Adynamic state in which the individual adapts to changes in internal

and external environment to maintain a state of well being.

The World Health Organization (WHO):-defincd health as "a state of

complete physical, mental, and social well-being and not merely the absence of
disease or infirmity.

Wellness: Is the condition in which an individual functions at optimal

Levels.

High level wellness: an active process by which an individual progresses

towards maximum potential possible, regardless of current state of health.

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 Biological

Heal

ogical sociological

The maintenance and promotion of health is achieved through different

combination of physical, mental, and social well-being, together sometimes
referred to as the "health triangle"

Positive health behaviors: Are activities related to maintaining, attaining,

regaining good hecalth and preventing illness (such as immunization and adequate
exercise).

Negative health behaviors: Are including activities that are actually or

potentially harmful to health as smoking.

/ Factors Affecting Health and IlnesS::

1-Physical:

Genetic make-up, age, developmental level, race and sex are all part of an
individual's physical dimension and strongly influence health status and health
practices.
For example:-The young woman who has a family history of brcast cancer
and diabetes and therefore is at a higher risk to develop these
conditions.

2-Emotional:

How the mind and body interact to affect body

function and to respond to
body conditions also influences health. Long term stress
affects the body system_
and anxiety affccts health habits; conversely, calm
acceptance and relaxation can
actually change body responses to illness.
 For example:
*Prior to a test, a student always has diarrhea.
"Extremely nervous about a surgery, a man experiences severe pain following his
operation.

3-Intellectual :

The intellectual dimension cncompasses cognitive abilities, educational

background and past expericnces. These influencc a client's responses to teaching
about heaith and reactions to health care during illness. They also play a major role
in health behaviors.

For example:
*An elderly woman who has only a third-grade education who needs teaching
about a complicated diagnostic test.
*A young college student with diabetes who follows a diabetic diet but continues to
drink beer and eat pizza with friends several times a week.

4-Environmental:
The environment has many influences on health and illness. Housing.
sanitation, climate and pollution of air, food and water are aspects of environmental
dimension.
For example:
" Increased incidence of asthma and respiratory problems in large cities
with
smoking.

$-Socio-cultural:
Health practices and beliefs are strongly influenced by a person's economic
level, lifestyle, family and culture. Low-income groups are less likely to seek health
care to prevent or treat illness; high-income groups are more prone to stresS-related
habits and illness. The family and the culture to which the person belongs
determine patterns of livings and values, about health and illness that are often
unalterable.
 For example:
*An adolescent who sces nothing wrong with smoking or drinking because his
parents smoke and drink.

$-Spiritual:
Spiritual and religious beliefs are important components of thc way the
person bchaves in hecalth and illness.

Models ofhealth and illness:

1. Health-llness Continuum Model: The health - illness continuum is onc way to

measure a person's level of health. Continuum is a model of the dynamic state of
health, as a person adapts to changes in the internal and external environment to

maintain state-of wellbeing.

A paticnt with a chronic illness may vicw his-herself at different points on the
Continuum, depending on how well thc patient bclieves he or she is functioning
with the illness.

liness heait High level

Death
nealth wellness

2-Agent -Host environment model: The agent-host environment model of health

and illncss developed by "Clark and Lcavll" (1965) for use in community health, is
useful to examining the causes of disease in an individual. In this model, health and
illness depend on the interaction of three factors:
" Agent - any internal or external factor that disease or illness.
"Host -the person or persons who may be susceptible to aparticular illness or
disease.
"Environment - consists of all factors outside of the host.
 Environment

Host Agent

For cxample: A person(host) who has poor nutritional habits and gets little
slecp(environnent) is at incrcased risk for infection ,eg. influenzalagent) if the
person is immunc deficiency .the risk is even greater.

3-The High- Level Wellness Model: It is oriented toward maximizing the hcalth
potential of an individual. This model requires the individual to maintain a
continuum of balance and purposcful direction within the environment.

4-Basic human needs model (Maslow's hierarchy of needs): basic human needs
are elements necessary for human survival and health (e g food, water, safety,
love), the basic hurman needs are shared by all people and the extenit to which basic
needs are met is amajor factor in deternining aperson's level of health.

Types of illness: - IInesses are classified into acute and chronic.

1- Acue illness:-An acute illness generally has a rapid onset of symptoms and last
only a relatively short
2- chronic illness:-Is a broad tern that encompasses many different physical and
mental alterations in hcalth.

It's characterized by:

-It is a permanent change.
-It cause or is caused by irreversible alteration in normal anatomy and
physiology.
-It requircd-Special patient education and rehabilitation.
-It required a long period of care and support.
 This stage is characterizcd by the patient's decision to accept the diagnosis
and follow the prescribed treatment plan.
The client depends on health care professionals for the relief of symptoms.
The client accepts care, sympathy and protection from the demands and stresses of
life. A client can adopt the dependent role in a health care institution, at home, or in
a community setting. The client must also adjust to the disruption of a daily
schedule.

Stage 5: Recover and rehabilitation

This stage can arrive suddenly, such as when the

symptoms appeared. In the
case of chronic illness, the final stage may
involve in an adjustment to a prolong
reduction in health and functioning.
Chronic illnesses: usually have a slow onset and may have period of remission
(when the discase is present, but the person docs not experience symptoms) and
exacerbation (the symptoms of the disease reappear),To successfully adapt to the
chronic illness, the individual must learn to live as normally as possible and
maintain a positive self concept and sense of hope.

Stages of Illness:

Stare I: Symptoms Experience

How do people define themselves as (sick)? The first indication of an ilness

usually is recognizing one or more symptoms that are incompatible with once
personal definition of health.
Although pain is the most significant symptom indicating illness, other
common symptoms include a rash, fever, bleeding or a cough.
If symptoms last a short time or are relieved by self -care; the person
usually takes no further action. If the symptoms continue, however, the person
enters the next stage.

Stage 2: Assumption of the Sick Role

If symptoms persist and become severe, clients assume the sick role, the
person now defines himsclf or herself as being sick, seeks validation of this
experiance from others.
Athis point, the illness becomes a social phenomenon, and sick people seek
confirmatioh from their families and social groups that they are indecd ill and that
they be excuses from normal duties and role expectations.

Stage 3: Medical Care Contact

If symptoms persist despite the home remedies, become severe or require

emergency care, the person is motivated to seek professional health services. In this
stage the client seeks expert acknowledgement of the illness as well as the

treatmcnt.

Stage 4: Dependent Client Role

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Major areas of risk factors:

Ages school age children are at high risk for communicable discascs.
" Genetic: a family history of cancer or diabetes predisposing factors to
developing disease.
" Physiological: obesity increases the possibility of the heart discase.
" Health habits: smoking increases probability of lung cancer.
" Life style: multiple sexual relationship increases the risk for sexual
transmitted discase.

" Environment: poor sanitation may contribute to the discase.

Impact of lllness on Client and Family

1-Impact on the Body Image

Body image is the subjective concept of physical appearance. Some
illnesses result in changes in physical appearance and client and family react
differently to these changes. The reaction depends on the following:
The type of changes (loss of limb, or an organ)
Their adaptive capacity
The rate at which change take place
Supportive services available

2- Impact on Self Concept

Self-concept is the mental self-image of strengths and weakness in all
aspect of personality. The impact of illness on the self-concept of client and
family may be more complex because it is important in relationships with
other families .so in caring with this problem the nurse should be observe the
klient and family and develop a carc plan to help the client adjust to the
chånges results from illness.
3-lmpact On Family Role
People have many roles in life such as decision making, parent and
profession when an illness occurs the roles of client and his family may
changc.
The clicnt and family often require specific counting and
guidance to assist
them in coping with the role changes.

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4-Impact on Family Dynamic
Family dynamic is the process by which the family functions, make
decisions, give support to individual members and cope with every day
changes.
If a parent in a family become ill, family activities and decision making
change the adult child often assumes many of the parent's responsibilities and
become a parent who lcad to stress and conflict.

Nårsing Care as Preventive Care (Levels of Preventions):

1-primary prevention
Primary prevention care is directed toward promoting health and
preventing the devclopment of discase processes, health-risk assessment are
an important part of primary preventive carc. A hcalth risk asscssment is an
asscssment of the total person, resulting from this assessment indicates arcas
of risk for discase or injury as well as areas that support health.

Primaryprevention includes:
a-Health Promotion
Health cducation.
Good standard of nutrition adjusted to developmental phases of life.
/ Alteration to personality development.
Provision of adequate housing and recreation as well agreeable
working condition.
Marriage counseling and sex education.
/ Genetic screening.
/ Period selective examination.

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 " For purposes of cducation and rescurch, most agencies allow student
and graduate health professionals access to client records. The records
are used in client confercnces, clinics, rounds, clicnt studies, and
written papers. The student or graduate is bound by a strict cthical
code and legal responsibility to hold all information in confidence.
Purpose of record:

1. Communication: the record helps different health professionals who

interact with a client to communicate with cach other.
2. Planning Client Care: cach health professional uses data from the
client's record to plan care for that client.
3. Auditing Health Agencies: an audit is a review of client records for
quality assurance purposes
4. Researeh: the information containcd in a record can be a valuable source
of data for rescarch.
5. Education: students in health disciplines often use client records as
educational tools.
6. Reimbursement: documentation also helps a facility receive
reimbursement from the federal government.
7. Legal Documentation: the client's record is a legal document and is
usually admissible in court as evidence.

8. Health Care Analysis: information from records may assist health care
planners to identify agency needs, such as over utilized and underutilized
hospital services.

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 Record and Report
Introduction:
Effective communication among health professionals is vital to the
quality of client care. Generally, health personnel communicate through
discussion, reports, and records. The proccss of making an entry on a client
record is called recording, charting, or documcnting.
Each health care organization has policies about recording and reporting
client data, and each nurse is accountable for practicing according to these
standards. Agencies also indicate which nursing assessments and
interventions can be recorded by RNs and which can be charted by
unlicensed personnel. In addition, The Joint Commission requires client
record documentation to be timely, complete, accurate, confidential, and
specific to the client.
Definition of record:

A record, also called a chart or client record, is a fomal, legal

document that provides evidence of a client's care and can be written or
computer based.
Ethical and legal consideration
" The nurse has a duty to maintain confidentiality of all patient
information.
The client's record is also protected legally as a private record of the
client's care.
Access to the record is restricted to health professionals involved in
giving care to the client.
The institution or agency is the rightful owner of the client's record.

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 b-Specific Protection
Use ofspecific inmunization.
Attention to personal hygiene.
V Use of environmental situation.
Protection against occupational hazards.
Protection from accident.
Use of specific nutrients.
VProtection from carcinogens.
V Avoidance of allergens.

2-Secendary prevention
It consists of organized, direct screening cfforts or cducation of the public to promote
carly case finding of an individual with disease so that prompt intervention
can be instituted to halt pathologic processes and limit disability.
The goal of secondary preventive care:
is to reserve or reduce the severity of the disease or to provide a cure.
Ex: Direct nursing actions (eg, providing wound care, or exercising arms and legs)

Secondary prevention include

a-Early diagnosis through
b-Disability Limitations

3-Tertiary Prevention
It begins early in the period of recovery from illness and consists of such
activities as consistent and appropriate administration of medications.
Continuing health supervision during rehabilitation to restore an individual
to an optimal level of functioning

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8. Accuracy: the client's name and identifying information should be
stamped or written on cach page of the clinical record. Before
making an cntry, check that the chat is the correct one.
9. Sequence: document events in the order in which they occur; for
example, record assessments, then the nursing interventions, and
then the client's responses.
[Link]: record only information that pertains to the
client's health problems and care.
[Link]: not all data that a nursc obtains abouta clicnt can be
recorded. However, the infomation that is recorded needs to be
complete and helpful to the client and health care professionals.
[Link]: recordings necd to be brief as well as complete to save
time in comunication.

[Link] Prudence: accurate, complete documentation should give

legal protection to the nurse, the client's other caregivers, the health
care facility, and the client. Documentation is usually viewed by
juries and attorneys as the best evidence of what really happened to
the client.

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 Types of records:
DOCUMENTING NURSING
ACTIVITIES
The client record should describe the client's ongoing status and reflect
the full range of the nursing process. The nurses document evidence of the
nursing process on a variety of forms throughout the clinical record.
1. Admission Nursing Assessment

A comprehensive admission assessment, or an initial database or nursing

assessment, is completed when the client is admitted to the nursing unit. It
can be organized according to health patterns, body systems, functional
abilities, health problems and risks.
2. Nursing Care Plans
The clinical record includes evidence of client assessmcnts, nursing

diagnoses or client necds, nursing interventions, client outcomes, and

evidence of a current nursing care plan. Depending on the records system
being used, the nursing care plan may be separate from the client's chart,
recorded in progress notes.
3. Kardexes

The Kardex is a widely used, concise method of organizing and recording

data about a client, making information quickly accessible to all health
professionals.
4. Flow Sheets
A flow sheet enables nurses to record nursing data quickly and concisely
and provides an easy-to-read record of the client's condition over time. Such
as

" Graphic record: Include body temperature, pulse, respiratory rate,

blood pressure and weight.

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HOME GARE DOCUMENTATION
Two records are required: (a) a home health certification and plan
of treatment form and (b) a medical update and client information form.
The nurse assigned to the home care client usually completes the forms,
which must be signed by both the nurse and the attending primary care
provider.
General guideline for recording:
1. Date and Time: essential not only for legal reasons but also for
client safety.
2. Timing: follow the agency's policy about the frequency of
documenting, and adjust the frequency as a client's condition
indicates.

3. Legibility: all entries must be legible and easy to read to prevent

interpretation errors.
4. Permanence: all entries on the client's record are made in dark ink
so that the record is permanent and changes can be identified.
5. Accepted Terminology: abbreviations are used because they are
short, convenient, and easy to use. It is important to use only
commonly accepted abbreviations, symbols, and terms that are
specified by the agency.
6. Correct Spelling: correct spelling is essential for accuracy in
recording. Incorrect spelling gives a negative impression to the
reader.
7. Signature: each recording on the nursing notes is signed by the
nurse making it.

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 blete tmn nt REPORTING
Definition:

A report is oral, written, or computer-based communication intended to

convey information to others. For instance, nurses always report on clients at
the end ofa hospital work shift.
The purpose of reporting:
To communicate specific information to a person or group of people.
" To show the kind and quantity of service delivered over to a specific period.
" To show the progress in reaching goals.
" As an aid in studyíng health conditions.
As an aid in planning.
" To interpret the services to the public and to other interested agencies.
Types of report:
Change-of-Shift Reports
Defined as a process in which infomation about patient/client/resident
care is communicated in a consistent manner including an opportunity to
ask and respond to questions. It is given to all nurses on the next shift.
Telephone Reports
Health professionals frequently report about a client by telephone. Nurses
inform primary care providers about a change in a client's condition; a
radiologist reports the results of an x-ray study; a nurse may report to a
nurse on another unit about a transferred client.

Telephone Orders
Primary care providers often order a therapy (e.g., a medication) for a
client by telephone.

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 Medical and Surgical Asepsis
INTRODUCTION

Nurses are directly involved in providing a biologically safe environment.

Microorganisms exist everywhere: in water, in soil, and on body surfaces such as the
skin, intestinal tract, and other arcas open to the outside (e.g., mouth, upper
respiratory tract, vagina, and lower urinary tract). Most microorganisms are
harmless, and some are even beneficial in that they perform essential functions in the
body.
Some microorganisms found in the intestines (e.g., enterobacteria) produce
substances called bacteriocins, which are lethal to related strains of bacteria. Others
produce substances that repress the growth of other microorganisms. Some
microorganisms are normal resident flora in one part of the body. yet produce
infection in another. For example, Escherichia coli, commonly referred to as E. coli,
is a normal inhabitant of the large intestine but a common cause of infection of the
urinary tract.
An infection is the growth of microorganisms in body tissue where they are
not usually found. Such a microorganism is called an infectious agent.

Definition of:
" Disease: is a detectable
alteration in normal tissue function.
" Pathogenicity is the ability to produce disease
" Pathogen is a microorganism that causes disease.
" Asepsis is the freedom from disease-causing
microorganisms. The two basic
types of asepsis are medical and surgical.
Medical asepsi includes all practices intended to confine a
specific
microorganism to a specific area, limiting the number, growth, and

41
Nurses responsibility for record keeping and reporting
Kecp under safe custody of nurses.
No individual sheet should be separated.
" Not accessible to patients and visitors.
Strangers is not permitted to read records.
" Records are not handed over to the legal advisors
without written
permission of the administration.
Handed carefully, not destroycd.
Identified with bio-data of the patients such as name, age,
admission
number, diagnosis, etc.
Never sent outside of the hospital without the
written administrative
permission.
 While the primary Care provider gives the order:
1. Write the complete order down on the physician's order form and read it
back to the primary care provider to cnsurc accuracy.
2. Question the primary care provider about any order that is ambiguous,
unusual or contraindicated by the client's condition.
3. Indicate on the physician's order form that it is a verbal order (VO) or
telephone order (TO).
Care Plan Conference

A care plan conference is a meeting of a group of nurses to discuss

possiblc solutions to certain problems of a client, such as lack of

progress toward goal attainment.

Nursing Rounds
Nursing rounds are procedures in which two or more nurses visit
selected clients at each client's bedside to:
1. Obtain information that will help plan nursing care.
2. Provide clients the opportunity to discuss their care.
3. Evaluate the nursing care the client has received.
Criteria for a good report
" Can be made promptly
" Clear, concise and complete
All pertinent, identifying data included

. Mention all people concerncd, situation and signature of person making report
" Easily understood

" Important points are cmphasized

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 . Intake and output record
" Medication administration record
" Skin assessment record

5. Progress Notes
Progress notes made by nurses provide information about the progress a
client is making toward achieving desired outcomes.
6. Nursing Discharge/Referral Summaries
Adischarge note and referral summary are completed when the client is
being discharged and transferred to another institution or to a home setting
where a visit by a community health nurse is required.
LONG-TERM CARE DOCUMENTATION
Long-term facilities usually provide two types of eare: skilled or
intermediate._Clients nccding skilled care require more extensive nursing
care and specialized nursing skills. Ia contrast, an intermediate care focus is
nceded for clients who usually have chronic illnesses and only need
assistance with activities of daily living.
Example:
Mental status

"Activitics of daily living lat

Hydration and nutrition status
"Safcty measures neededb olle
" Medicationslg
Treatments

" Preventive measures

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 slerild iclds) and coven tract.

the mouth and nose

when coughing and
sneezing.
Method of (Cleanse hands between Hand hygiene is an important
transmission client contacts, after means of controlling and

touching body preventing the transmission of

substances, and before microorganisms.
Sbdeogi o performing invasive Hand hygiene helps prevent
procedures or touching transfer of microorganisms
open wounds. from one person to another.
Instruct clients and
support people to

cleanse hands before

bandling food or
eating, after

eliminating, and after

touching infectious
material.

Wear gloves when Gloves prevent soiling of the

handling secretions and hands.
excretions

Wear gowns if there is" Gowns prevent soiling of the

danger of soiling clothing.
clothing with body
substances.

47
Reservoir Change dressings andMoist dressings are idcal
(source) bandages when they cnvironments for

2 3 t art soiledpr(vct) allo microorganisms to grow and

" Assist clients to carry multiply.
out appropriate skin Hygicnic measures reduce the
and oral hygiene. numbers of resident and

Dispose of damp, transient microorganisms and

soiled linens the chance of infection.
" Damp, soiled linens harbor
appropriately. J
Dispose of (feces )and more microorganisms than dry
Jurine) in appropriate Jinens.
receptacles. " Urine and feces in particulat
" Ensure that all fluid contain many microorganisms.
containers, such as Prolonged exposure increases
suction and drainage the risk of contamination and

bottles, are(covered or promotes microbial growth.

capped. " Drainage harbors
" Empty suction and microorganisms that, if left for
drainage bottles at the long periods, proliferate and
end of each shift or can be transmitted to others.
before they become
full, or accordingto
agency policy.
Portal of exit Avoid talking, " These measures limit the
from coughing, or sneezing number of microorganisms that
the reservoir over open wounds)or escape from the respiratory

46
" Place discarded soiled Moisturc-proof bags prevent
materials in moisture the spread of microorganisms
proof refuse bags. to others.
Hold used bedpans
steadily to " Feces in particular contain
prevent

spillage, and dispose of many microorganisms.

urine and feces in

appropriate receptacles.
Initiate and implement
infection prevention
strategies for all All clients may harbor
clients. potentially infectious
Wear mask and eye microorganisms that can be
protection when in transmitted to others.
close contact with Masks and eyewcar reduce the
clients who have spread of droplet transmitted
infections transmitted microorganisms.
by droplets from the
respiratory tract.
Wear mask and eye
protection when sprays
of body fluid are Masks and eye protection
possible (c.g., during provide protection from
irrigation procedures). microorganisms in clients
body substances.

48
 transmission of microorganisms. In medical ascpsis, objects are referred to as
Aeanwhich
cl means the Dall microorganisms.
absenceshose nractices that kecpP
" Surgical asepsis, or sterile technique, an
arca or object free of all microorganisms; it includes practices that destroy all
microorganisms. Surgical asepsis is used for all procedures involving the
(sterile yreas of the body.
" Sepsis is the condition in which acute organ dysfunction)occuré secondary to
nfection
TYPES OF MICROORGANISMS THAT CAUSE INFECTIONS:
V1. Bacteria: the most common infection-causing microorganisms. Several hundred
species can cause discase in humans and can live and be transported through air,
P,0, soil, body tissues and fluids,'and inanimate objects.
water, food,
[Link] consist primarily of nucleic acid and therefore must enter living cells in
order to reproduce. Common virus families include the rhinovirus (causes the
common cold), hepatitis, herpes, and human immunodeficiency vinus.
Eungi inelude yeasts and molds. Candida albicans is yeast considered to be
normal flora in the human vagina.
4. Parasites: live on other living organisms. They include protozoa such as the one
that causcs malaria, helminthes (worms).
TYPES OF INFECTIONSe
Infection occurs when newly introduced or resident microorganisms succeed
in invading a part of the body where the host's defense mechanisms are ineffective
and the pathogen causes tissue damage.
A local infection is limited to the specific part of the body where the
microorganisms remain.
" Systemic infection If the microorganisms spread and damage different paris

42
leave the reservoir. Portal of exit include: Sputum, Emesis, Stool and Blood.
4- Method of Transmission
There are three mechanisms:

1. Dircct transmission: transfer of microorganisms from person to person through

touching, biting, kissing.
2. Indirect transmission. Indirect transmission may be either vehicle borne or
vector borne:
a. Vehicle-borne transmission. A vehicle is any substance that serves as an
intermediate means to transport and introduce an infectious agent into a susceptible
host through a suitable portal of entry. such as toys, soiled clothes, cooking and
surgical instruments or dressings.
b. Vector-borne transmission. A vector is an animal or crawling insect that serves as
an intermediate means of transporting the infectious agent. Transmission may occur
by injecting salivary fluid during biting or by depositing feces or other materials on
the skin through the bite wound ora traumatized skin area.
3. Airborne transmission. Airborme transmission may involve droplets or dust.
5- Portal of Entry to the Susceptible Host
Before a person can become infected, microorganisms must enter the body.
Portal of Entry include: Mucous membranes, Nonintact skin, GI tract, GU tract and
Respiratory tract.
6- Susceptible Host
A susceptible host is any person who is at risk for infection.
Immunosuppressed elderly, chronically ill, Surgery and Trauma patients are
nereased of risk.

44
 of the body
" Acute infections: generally, appear suddenly òr last a(short time
A chronic infection may occuf slowly) over a verý long period and may last
months or years.
NOSOCOMIAL AND HEALTH CARE-ASSOCIATED INFECTIONS
" Nosocomial infections are classified as infections that originate in the
hospital. Nosocomial infections can either develop during a client's stay in a
facility or manifest after discharge.
" Nosocomial microorganisms may also be acquired by personnel working in
the facility and can cause significant illness and time lost from work.
Factors contribute to nosocomial infections:

latrogenic: infections are the direct result of diagnostic or therapeutic

procedures. One example of an iatrogenic infection is bacteremia that results
from an intravascular infusion line.

The patient normal defenses have been lowered by treatments or illness.

Insufficient hand hygiene is important factor contributing to the spread of
nosocomial microorganisms.
CHAIN OF INFECTION
1- Etiologic Agent
" Any microorganism is capable of producing an infectious process.
2- Reservoirs:
The sources of organisms, also called reservoirs, there are
many sources of
microorganisms. Common sources are humans, plants, animals, or the general
environment.
3- Portal of Exit from Reservoir
Before an infection can establish itself in a host, the
microorganisms must

43
 StandardPrecautions
Standard precautions are used in the care of all hospitalized individuals
regardless of their diagnosis or possible infection status.
They are used in any situations involving blood, all body fluids, excretions, and
secretions, non-intact skin, and mucous membrancs.
Standard Precautions inchude:
1. Hand hygiene V
2. Use of personal protective equipment PPE){ which includes 7loves,towns,
[cyeweat) and (nasksjda
3. Safe injection practices
4. Safe handling ofpotentiallj eontaminated gquipment ar surfaces in the client
environment

5. Respiratory hygiene.
6. Place used qeedles>and other "sharps" directly into puncture-resistant
containers as soon as their use is completed. Do not 'attempt to recap needles
Disposal of Soiled Equipment and Supplies
1. Place garbage and soiled disposable equipment, including dressings and tissues,
in the plastic bag that lines the waste container and tie the bag. If the bag
waterproof or solid enough to prevent organisms from moving through it even
when wet a single bag is adequate. If not, place the first bag inside another
impermeable bag.

2. Place non disposable or reusable equipment that is visibly soiled in a labeled bag
before removing it from the client's room and send it to a central processing arca
for decontamination.
3. Disassemble special procedure trays into component parts. Some components
are disposable; others need to be sent to the laundry central services for
cleaning and decontaminating.

52
 I n f e e t l s ngens

NNeptitsle ReNervoir

rtal o e n t y
Portal ofuxit

Mole oftransmisNion

Nursing Interventions That Break the Chain of Infection

CHAIN OF Interventions Rationale
INFECTION

Etiologie agent Ensure that articles are Correct cleaning, disinfecting,

(microorganism) correctly cleaned and and sterilizing reduce or
disinfected or sterilized eliminate microorgan1sms.
before use. " Knowledge of ways to reduce
" Educate clients and or eliminate microorganisms
support people about reduces the chance of
appropriate methods transmission
for cleaning,
disinfecting. and
sterilizing articles.

45
 "Encourage deep. slow. infectious discascs.
full breathing, These actions enhance

ambulation, and ventilation and circulation

movement. throughout the body.
Offer stress

management strategies Tap into the nind-body

and encourage healthy connection to enhance healing
relationships.

FACTORS INCREASING SUSCEPTIBILITY TO INFECTION

1. Age
2. Heredity
3. Level of stress stressors elevates blood cortisone. Prolonged elevation of
blood cortisol decreases anti-inflammatory responses, depletes energy stores,
leads to a state of exhaustion, and decreases resistance to infectio.
4. Nutritional status
5. Current medical therapy
6. Preexisting disease processes.
Supporting Defenses of a Susceptible Host:
The following measures can reduce a person's susceptibility:
Hvgiene Intact skin and mucous membranes are one barrier against
microorganisms entering the body In addition, good oral care, reduces of an
oral infection. Regular and thorough bathing and shampooing remove
microorganisms and dirt that can result in an infection
Portal of entry Use aseptic technique Invasive proccdures penctrate
to the for invasive proccdures the body's natural protective
susceptible host (c.g. njections barriers to microorganisms.
catheterizations).
Use sterile technique Open wounds are vulnerable to
when exposing open microbial infection.

wounds or handling Injuries from needles

dressings. contaminated by blood or body

" Place used disposable fluids from an infected client or
needles and syringes in carrier are a primary cause of
puncture resistant HBV and HIV transmission t¡
containers for disposal. health care workers.

Provide all clients with People have less resistance to

their own personal care another person's
items. microorganisms than to their
OWn.

Susceptible host " Maintain the integrity Intact skin and mucous
of the client's skin and membranes protect against
mucous membranes. invasion by microorganisms.
Ensure that the client A balanced diet supplies
receives a balanced proteins and vitamins necessary
diet. to build or maintain body
" Educate the tissues
public
about the importance of Certain immunizations may
immunizations protect people against vinulent

49
 Nutrition A balanced dict enhances the health of all body tissues, Adequate
nutrition enables tissucs to maintain and rcbuild thcmselves and helps keep the
immune system functioning well..
Fluid. Fluid intake permits fluid output that flushes out the bladder and
urethra, removing microorganisms that could cause an infection
Sleep. Adequate sleep is essential to health and to renewing cnergy.
Stress reducing techniques Excessive stress predisposes people to infections.
Nurses can assist clients to learn stress-reducing techniques.
Immunizations. The use of immunizations has dramatically decrcased the
incidence of infectious discases.

DISINFECTION
Disinfection refers to chemical or physical processes used to reduce the
number of pathogens on an object's surface.
A
chemical used on lifeless objects is called a disinfectant.
A chemical used on living objects is called an antiseptic.
STERILIZATION
Sterilization refers to the complete destruction of all microorganisms,
including spores. Any process used to sterilize equipment must be effective in
killing organisms but not destructive to the equipment.
Methods of sterilization:
|Moist Heat (such as with an autoclave) stcam under pressure
Gas
BoilingWater Boilingla minimum of 15 minutes.
"Radiation

SI
4. Bag soiled clothing before sending it home or to the agency laundry.
5. Linens: Handle soiled linen as little as possible and with the least agitation
possible before placing it in the laundry hamper. This prevents gross microbial
contamination of the air and individuals handling the linen. Close the bag before
scnding it to the laundry in accordance with agency practice
6. Laboratory Specimens: Laboratory specimens, if placed in a leak-proof
containcer with a secure lid with a biohazard label. Use care when collecting

specimens to avoid contaminating the outside of the container. Containers that

are visibly contaminated on the outside should be placed inside a sealable
plastic bag before sending them to the laboratory. This prevents personnel from
having hand contact with potentially infective material.
7. Dishes: Dishes require no special precautions. agerncies use paper dishes
for
convenience, which are disposed.
8. Disposable Needles, Syringes, and Sharps Place needles,
syringes, and "sharps'"
(e.g., scalpels, and broken glass) into a
puncture-resistant container. To avoid
puncture wounds, use approved safety or needlelcss systems and do not
detach
needles from the syringe or recap the ncedle before disposal.
 TRANSMISSION-BASED PRECAUTIONS
Airborne Precautions

Use standard precautions as well as the following:

1. Place client in an airborne infection isolation room (AIR). An AlIR is a
private room that has negative air pressure, 6 to 12 air changes per hour, and
cither discharge of air to the outside or a filtration system for the room air.
2. If a private room is not available, place client with another client who is
infected with the same microorganism.
3. Wear an N95 respirator mask when entering the room of a clicnt.
4. Limit movement of client outside the room to essential purposes.
5. Place a surgical mask on the client during transport.
Droplet Precautions
Use standard precautions as well as the following:
1. Place client in private [Link] b l a e
If a private room is not available, place client with another client who is
infected with the same microorganism.
3. Wear a mask if working within I m (3 ft) of the client.
4. Limit movement of client outside the room to essential purposes.
5. Place a surgical mask on the client while outside the room.
Contact Precautions
Use standard precautions as well as the following:
1. Place client in private room.
2. If a private room is not available, place client with another client who is
infected with the same microorganism.
3. Wear gloves as described in standard precautions.
Change gloves after contact with infectious material.

S4
 b. Remove gloves before leaving clicnt s room.
c. Cleanse hands immediately after removing gloves. Use an antimicrobial
it is not
agent. Note: do not use an alcohol-based hand rub because
effective on these spores. Use soap and water.
d. After hand hygiene, do not touch possibly contaminated surfaces or items
in the room.
4. Wear a gown when entering a room if there is a possibility of contact with
infected surfaces or items, or if the client has diarrhea, a colostomy, or wound

drainage.
a. Remove gown in the client s room.

b. Make sure uniform does not contact possible contaminated surfaces.

5. Limit movement of client outside the room.
Principles and Practices of Surgical Asepsis
1. All objects used in a sterile field must be sterile.
2. Sterile objects become unsterile when touched by unsterile objects.
3. Sterile objects that are out of sight or below the waist or table level are
considered unsterile

4. Open, unused sterile articles are no longer sterile after the proccdure.
5. Always face the sterile field.
6. Sterile objects can become unsterile by prolonged exposure to airborne
microorganisms.
7. When working over a sterile field, keep talking to a minimum.
8. Fluids flow in the direction of gravity.
9. Always place sterile objects on a dry surface and avoid splashing liquids when
pouring; moisture causes contamination.
 [Link] edges of asterile ficld are considered unsterile. A 2.5-cm (1-in.) margin at
cach cdge of an opencd drapc is considercd unsterile because the cdges are in
wcontact with unsterile surfaces.
[Link] skin cannot be sterilized and is unsterile.
[Link], alertness, and honesty are essential qualities in
maintaining surgical asepsis.
Infection Prevention for Health Care Workers
There are three major modes of transmission of infectious materials in the clinical
setting:
1. Puncture wounds from contaminated needles or other sharps
2. Skin contact, which allows infectious fluids to enter through wounds and
broken or damaged skin

3. Mucous membrane contact, which allows infectious fluids to enter through

mucous membranes of the eyes, mouth, or nose.

Using proper precautions with general medical asepsis, appropriately using PPE
(gloves, masks, gowns, goggles, special resuscitative cquipment), and avoiding
carelessness in the clinical area will place the caregiver at significantly less risk
for injury.
"\Prevention remains the primary goal. the hepatitis B vaccine and vaccination
Series available to all employees.
Stepsyo Follow After Exposure to Blood borne Pathogens
1.\Report the incident immediately to appropriate personnel within the agency.
2. Seek appropriate evaluation and follow-up.
3. Ideytification and documentation of the source individual when feasible and
legal.

S6
 4. Testing of the source for hepatitis B, hepatitis C, and HIV when fcasible and
consent is given.
5. Making results of the test available to the source individual's hcalth care

provider.
6. Testing of blood of exposed nurse (with conscnt) for hepatitis B, hepatitis C,
and HIV antibodies.
7. Post exposure prophylaxis if medically indicated.
Medical and psychological counseling regarding personal risk of infection
or risk of infecting others.
"For a puncture/laceration:
1. Allow some bleeding to drain the site but do not squccze the tissues.
2. Wash/clcan the area with soap and water.
3. For a mucous membrane exposure (eyes, nose, mouth), saline or water flush
for 5 to 10 minutes.

POSTEXPOSURE PROTOCOL (PEP)

HIV
" Treatment should be started as soon as possible, preferably within hours after
exposure. Treatment may be less effective when started more than 24 hours
after exposure. Starting treatment after a longer period (e.g., I week) should be
considered for high-risk exposures previously untreated.
HIV antibody tests should be done shortly after exposure (baseline), and 6
weeks, 3 months, and 6 months afterward.
|Hepatitis B
Anti-HBs testing after last vaccine dose.
HBIG and/or hepatitis B vaccine within 1 to 7 days following cxposure for
non-immune workers.
Hepatitis C: Anti-HCV and ALT at baseline and 4 to 6 months after exposure.

57
 Hygienic care 2p) o

Introduction:

Self-care refers to aa person's ability to perform primary care functions in the

following four arcas: bathing, fecding, toileting, and dressing without the help of
others. Hygiene is the observance of health rules relating to these self-care activities.
The ability to independently perform appropriate self-care and hygiene practices
greatly enhances a persan's health status and emotional well-being. Nurses can play
a crucial role in helping patients learn or relearn self-care techniques. Because nurses
focus on patients' responses to health and illness rather than on disease itself,
helping patients gain or regain independence in self-care is one of the most
important goals of nursing. When illness or injury interferes with the ability to
perform self-care, nurses assist or perform tasks that patients cannot manage, or
offer support to family members or other caregivers. The main focus, however, is to
heip patients achieve as much independence in sclf-care as possible.
Definition:
Hygiene is the science of health and its maintenance.
> Hygiene is a highly personal matter determined by individual values and
practices. It involves care of the skin, feet, nails, oral and nasal cavities, teeth,
hair, eyes, ears, and perineal-genital areas.
Personal hygiene is the self-care by which people attend to such functions as
bathing, toileting, general body hygiene, and grooming

Function of skin: s
The skin is the largest organ of the body. It serves five major functions:

96
1. It protects underlying tissucs from injury by preventing the passage of
microorganisms.
2. It regulates the body temperature.
3. It'secretes sebum) an oily substance that (a) softens and lubricates the hair and
skin, (b) prevents the hair from becoming brittle, and (c) decreases water loss
from the skin (d) lessens the amount of heat lost from the skin (e) a bactericidal
(bacteria-killing) action.
4. It transmits sensations through nerve receptors, which are
sensitive to pain,
temperature, touch, and pressure.
5. It produces and absorbs vitamin D in conjunction with ultraviolet rays from
the
sun, which activate a vitamin D precursor present in the skin.

General Guidelines for Skin Care:

1. Intact, healthy skin is the body's first line of

defense. Nurses need to ensure that
all skin care measures prevent injury and irritation.
2. The degree of the skin to protect the
underlying tissues from injury depends on
the general health of the cells, the amount of
subcutancous tissue, and the dryness
of the skin. When the skin is dry, lotions or
creams with lanolin çan be applied,
and bathing is limited to once or twice a
week because frequent bathing removes
the natural oils of the skin and causes
dryness.
3. Moisture in contact with the
skin for more than a short time can
result in
increased bacterial growth and iritation.
4. Body odors are caused by
resident skin bacteria acting on body secretions.
Cleanliness is the best deodorant. Commercial deodorants and
be applied only after the skin is cleaned.
antiperspirants can

97
5. Skin sensitivity to irritation and injury varies among individuals and in
accordance with thcir hcalth. Skin sensitivity is greater in infants, very young
children, and older people, emaciated and obese pcople

Factors affecting on self-care:

" CulturesaJI

" Religion.
" Environment finances may affect the availability of bathing facilities.
" Developmental level. Practices vary according to the individual's age,
Health and energy Ill people may not have the motivation or energy to attend
to hygiene.
Personal preferences some people prefer a shower to atub [Link]

Etiologies of Self-Care Deficits oll s

- Decreased or lack of motivation

- Pain or discomfort
- Neuromuscular or musculoskeletal impairment
- Medically imposed restriction
Therapeutic procedure restraining mobility (intravenous infusion, cast)
- Severe anxiety
Environmental bariers
- Immobility or limited use of an extremity
- Mental confusion or decreased mental alertness
- Decreased visual acuity or other sensory deficits
Decreased energy levels or fatigue
Definitions and Descriptors for Functional Level:

" (0) Completely Independent

" (+1) Requires Use of Equipment or Device
" (+2) Semi dependent Requires Help from Another Person for Assistancc,
Supervision, or Teaching
+3) Moderately Dependent Requires Help from Another Person and
Equipment or Device
" (+4) Totally Dependent Does Not Participate in Activity
Scheduling Hygiene Care
Early Morning Care Comfort Measures and
Preparation for the Day
Bedpan, urinal, or assistance to bathroom
" Preparation for diagnostic tests or early surgery
Washing hands and face
Oral care

Preparation for breakfast

Morning Care (AM Care) Hygiene and Grooming

" Bedpan, urinal., or assistance to bathroom
" Bath, shower, or bathing - Back massage
Hair care and shaving -Oral care
Care for feet and nails - Dressing
Bed linen change
-Positioning (bed or chair)

99
Afternoon Care after Tests, After [Link], and Before Visitors
Bedpan, urinal, or assistance to bathroom
Washing hands and face
Oral care

" Bed linens and repositioning if necded

Hour-of-Sleep (HS) Care Comfort Measures and Bedtine

" Bedpan, urinal, or assistance to bathroom
" Washing hands and face
. Oral care
. Back massage

" Bed linens (change soiled linens, pull out wrinkles)

Bedelothes
" Straightening unit (place nceded night objccts within reach)

Nursing management: Assessment

Nursing History
Data about the client's skin care practices
Assessment of the client's self-care abilities determines the amount of nursing
assistance and the type of bath
nCognition and motivation.
The presence of past or current skin problems alerts the nurse to specific nursing
interventions or referrals the client may require.

100
" Physlcal Assessnient of the skin, which involves inspcction and palpation, skin
color, turgor, temperature, intactness, and lesions.

Diagnosing
V Self-Care Deficit diagnoses are used for clients who have problems performing
hygiene care such as Bathing Self-Care Deficit, Dressing Self-Care Deficit,
Toileting Self-Care Deficit, Feeding Sclf-Care Deficit.
KDeficient Knowledge rlated to: Lack of experience with skin condition, new
herapeutic regimen to manage skin problems, Unfamiliarity with devices
available to facilitate sitting on or rising from toilet.
V Low Self-Estcem related to: Visible skin problem (e.g., acne or alopecia) or Body
odor.
Risk for Impaired Skin Integrity and Impaired Skin Integrity.

Planning
In planning care, the nurse, the client and family set outcomes for cach
nursing
diagnosis.
The nurse then performs nursing interventions and activities to achieve the client
outcomes.

SkirProblems and Care

Dry skin:
. Use cleansing creams to clean the skin rather than
soap
" Bathe less frequently.
" Increase fluid intake.

101
 Two Bathing: " Acne:
" rashes:
" 1. Categories "" " Skin
Complete scarr1ng. Never
follicles. Avoid Avoid Wash
[Link] rash.
[Link] Todry. itKecp Use
categories
relieve
squeeze using using face the moisturizing
frequently
clothing scratching area
bed baths
of itching,
cosmetics oily
bath. baths or clecan
are pick creams. carcfully. creams
the try
The given are at with by
that rash a
given the soak. washing
nurse soap that
chiefly lesions. block Too to
to and prevent contain
washes clients: the much it
102
for This hot with
hygiene ducts lanolin.
the cleaning increases water inflammation,
can a
of
mild
entire cause
the to
purposes remove soap.
body and the sebaceous perspiration Rinse
therapeutic. potential infection,
of and oil
a and the
dependentinclude glands
for dirt. and and skin
infection and well,
these aggravate further
client the and
types: hair
and skin
in pat
a
with 12
ordiscomfort
area, The
back.
and to
wash require skin water. be excretions,
and
dead
themselves 10 solution. to irritated may
contains casier and the
minutes.
46°C
towels. facilities soothein full.
cause cleanser
bathe is placedhalf 30 to
fect. mightperineal that regularit
because to 37.7°C
to one 20
to the product
rinse [Link] as be secretions
and
able perhaps that axillae, uses suchmay orthirdoftenorder;
bathstherapeutic
are body prepared no use Medicationstime,the
but effects,
bed and hands, contain bath bed to one
designated
in
client' s able
to back to
bag preferred physical tub included transient
microorganisms,
body
confined face, commercially
that for are nurse.
a
in
ato used clients perineum). 103
the the microwave. taken
washing the washcloths
similar also the for a
for generally skin well-being
Clients ofpartswashed: often from given generally
bath the
ais are ambulatory the
for the a is are are (e.g., the is to
in bath Tubs
assistance
Self-help are bath disposable temperature circulation
bath.
bed nurse Only baths baths is in of
neglected, warmed This tub. area bath remains for adults.
ordered sense
This Tub Many
the bath. a minimal Therapeutic bath:
of
Purpose
fronm is bath. in
bath. presoaked bath.
an therapeutic
treat clientbath
remove stimulate apromote
Partialif package rinse Shower. skin
cells
odor, Towel
help Bag Tub and only to The The To
or " A To To
" 2.
" "
 |
problem:
Commonfoot Identifying Foot: " " "
impairment
Visual
V / V dryness,Inspcct
ComparePalpatePalpate care.
foot
psychosocial
illness. While Offers To To
circulation) diabetes
clients
Impaired peripheral
PoorlyarterialAltered with preventproduce
Assessment: an
Clients dorsalisanterior all Learning
necds, assisting
fitting skin inflammation, excellent
tissue hand skin and
relaxation
vascular temperature nccds,
shoe coordination at pedis and surfaces, aeliminate
perfusion: Risk posterior opportunity
clicnt
disease pulse swelling, such and
such unpleasantcomfort
of on particularly aswith
peripheral both dorsalsurfaces as
orientation a for
abrasions, the
104
feet. bath, the
nced body
surface of between nurse
ankles the
(associated or clientfor atimande to odors
of other nurse to
foot and assess
the
feet
lesions. toes, can
with
for
whohas ability alsoclients
edema for
edema, assess
cleanliness,
diabetes
lcarnto to
cope
inadequate the
h
witclient's
odor,
the
 Mouth: " To " Purpose > > > >
To To TO absorb
antifungal
between warm Calluses
bony
exacerbated
foot inflammatory
Footagents. nail moisture.
wearing Ingrown Ringworm,
maintain
assesspreventprevent
problem
Pastoral Mouthcare powders, trimming, water
prominenceltight
of odor
orfoot foot foot well-fitted Flattened
monitor the nails toes/Fungus,
powder and
Assessment: Excessive
by tinca
odors
infections care:
skin 100% hot, poorly
Inflammation, abrade
foot integrity or pedis thickening
cotton moist Surgicalshoes/
foul fitting ointment. with shoes
problems worsened
(athlete's
environment/Decrease
socks,
of odor pumice or of
the removal Pain shoe_swelling, Change inadequate
problem
Current - Last - epidermis,
fect well-ventilated of foot)
by
andPrevent stone.
105 feet
dental of
Possibly
inflammation
nail Pre and socks moist,
Redness
by
tissue padding often
examination may trimming daily;
unventilated
shoesexcess and on
from be pain in
bottom
required. wear cracking shocs
moisture; fungal are nails at
edge 100% |Soften or
treated
straight environment
of side
foot of cotton
use nail skin by of
infections;
deodorant withacross
Improper especially soaking foot
socks/Apply
over
anti and
to in a
 comatose,
confused, ventilator devclop a regular a
produces permits.
see cleaning.
hygiene
hygiene to
to provide client
to likcly medications. health
lead [Link] regular
oral oral Advise
are or as
may dental
intake regular
Teach intake provide
ill, oxygen regular
seriously that and hygiene. painful
for fluid bleeding
complications insurance anxiety, provide
provide fluid or
receiving poor
older, oral be
Increase Teach
or intake, or or and
regular may
as impairments are adults
and/or mucosa. TeachTeachspongy mucosa
such surgery arcas;
mucosa
cxperiencewho moneyolder
salt treatnents
provide
gums
tongue 06
hygiene or oral high appear darkened oral
jaw
physical tubesmembranes. in the or the the buccal the
or of productionuse,
Risk oral dehydrated.
depressed,
or can nasogastric oral lack of radiation
alcohol
Teach of Gums of
thinning \[Link]
mouth
problem: of Inflammation the have inflammation
at
maintain or clientsassociated
pneumonia. had nutrition, Inflammation
visual, breath disease of Tecth
Clients mucoushave saliva smoking, dryness
and reccived
to ill with Bad caries
ldentifying Cognitive,
who Inadequate Periodontal
oral
hygiene
Inability Critically Decreased
mouth Gingivitis Stomatitis
Peopleoral Clients Halitosis
Glossitis Excessive
Heavy
Clients Dentaldentist.
dry dry
V V V " .
 Problems
hair:of abilities /Hair:
UseChemotherapeutic Self-care Purpose "
hair
Hypothyroidism loss). History hygiene.
oral
Parotitis
>
lincns debris Pediculosis Dandruff c> Maintain ToTo To To
thoroughScabies: to
IpaLossHair become of Assessment: prevent
of
some
promoteremoveremove oralof
and from hair Inflammation
a hydrated, care
clothing cleansing
contagious (Lice) dry hair or sores
crusts, may the dental food
and dyes agents scalp andclient's particles
cause intact plaque.
should and of brittle. and problems, infection of
the skin and feelings the
then curling the oral from
body
be infestation hair radiation parotid
washed an conditions mucosa. of
107
application with or to the of around
straightening be well-being
oral salivary
in soap by thin, of and
very theknown tissues,
the dry, between
teeththe
hot of
and head glands
itch and/or
or a
water preparations to
scabicide
boiling mite. may affect Teach
to brittle.
Treatment cause the
water. remove or
lotion. provide
can alopecia hair.
scales cause
All involves
bed (hair regular
and the
Ears: Assessment
V Determine if the client has experienced any problems with the hearing aid and
hearing aid practices.
Assess for the presence of inflammation, excessive wax, drainage, or
discomfort in the external ear.
Risk factor:
/ Clients who have excessivecerumen (earwax)
V Dependent clients who have hearing aids may require assistance from the nurse.
Purpose: To maintain proper hearing aid function
Nose:
" Nurses usually need not provide spccial care for the nose,
because clients can
ordinarily clear nasal secretions by blowing gently into a soft tissue.
" When the external nares are encrusted with
dricd secretions, they should be
cleancd with a cotton-tipped applicator or moistened with saline or
water.
The applicator should not be inserted beyond the length of the cotton tip:
nserting it further may cause injury to the mucosa.

109
 > > Teach General
Care
Eye Eves: Purpose
Schedåle
such maintaining Take If
immediately. Eye VAny
dirt "
as the drainage, Recent increase
To theTo To To Hirsutism
measures or All Eveglasses
Assessment
cataracts imitationspatient external stimulate of
assess distribute
regular dust eyehistory
hair
examination
adequate gets specific encrustations, or
and or care:
eye to or of contact monitor hair the
into
glaucoma. guard injuries structuresare eye comfort
client's
examinations, lighting the information problems oils blood
by
lenses, hair and
against eyes, or an circulation
for at ophthalmologist,
other orprovide
clean and scalp
10s eycstrain
any about inspected
particularly reading them
obvious related
age problems a to
care healthy
sheen the
and with should for
[Link]. scalp
and of
atter obtaining clean the signs (e.g.,
to beeyes.
age of matted
protect tepid
40,
shatterproof treated Such inflammation,
excessive
water. hair
to as:
detect vision,
medically or
dandruff)
problems lenses such

for as and