NURSING DIAGNOSIS

Self-Care Deficit (Hygiene) related to:

× Decreased or lack of motivation

× Weakness or tiredness

× Pain or discomfort

× Perceptual or cognitive impairment

× Inability to perceive body part or spatial relationship

× Neuromuscular or musculoskeletal impairment

× Medically imposed restriction

× Therapeutic procedure restraining mobility (e.g., intravenous infusion, cast)

× Severe anxiety

× Environmental barriers

Assess presence of:

× Irritation, excoriation, inflammation, swelling

× Excessive discharge

× Odor; pain or discomfort

× Urinary or fecal incontinence

× Recent rectal or perineal surgery

× Indwelling catheter

Determine:

× Perineal-genital hygiene practices

× Self-care abilities
Equipments:

1. Washcloth (6) and bath towels (2)

2.Bath blanket

3.Soap and soap dish

4.Toiletry items

5.Toilet tissue or diaper wipes

6.Water proof pad or bed pan

7.Disposable gloves

8.Laundry bag

9.Solution bottle or prescribed rinsing solution

10.Cotton balls or swabs

11.Perineal pad

12.Bath basin with warm water at 43°C to 46°C (110°F to 115°F)

13.Urinals

NURSING ASSESSMENT:

1. Introduce self and identify patient using two identifiers (e.g. Name and birthday; name and medical
record number, according to agency policy).

1.1 Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate,
being particularly sensitive to any embarrassment felt by the patient.

Rationale: Ensure correct patient. Complies with the Joint Commission Standards and improve patient
safety. (TJC, 2016)

2. Assess client's tolerance for perineal care: activity tolerance, comfort level during movement,
cognitive ability, musculoskeletal function, presence of shortness of breath.
Rationale: Determines client's ability to perform perineal care

3. Assess client's visual status, ability to sit without support, hand grasp, ROM of extremities.

Rationale: Determines degree of assistance patient needs for bathing, ROM may be delegated to
assistive personnel.

4. Assess for presence of equipment (e.g. Foley Catheter, Condom Catheter)

Rationale: Affects how you plan bathing activities and positioning. Helps determine how to set up
supplies.

5. Assess for allergy or sensitivity to Chlorhexidine gluconate (CHG)

Rationale: When allergy or sensitivity is present, select another cleansing solution

6. Ask if patient has noticed any problems related to condition of genitalia, excess moisture,
inflammation, drainage or excretions from lesions

Rationale: Provides you with information to direct physical assessment of genitalia. Also influences
selection of skin care products.

7. Assess patient's knowledge of perineal hygiene in terms of its importance, preventive measures to
take, and common problems.

Rationale: Determine patient's learning needs.

8. If patient is able to maneuver and handle washcloth, allow them to clean perineum on their own.

Rationale: Maintain patient's dignity and self-care ability

NURSING PLANNING:
 1. Review orders for specific precautions concerning patient's movement or positioning.

Rationale: Prevents injury to patient during bathing activities. Determine level of assistance required by
the patient.

2. Explain procedure and ask patient for suggestions on how to prepare supplies. If using CHG, explain
benefit of reducing infection and that solution leaves a sticky feeling.

Rationale: Promotes cooperation and participation. Patients who prefer using own perineal hygiene
solutions may need to discuss benefits of CHG.

3. Prepare equipment and supplies. If it is necessary to leave room, be sure that call light is within
patient's reach.

Rationale: Avoids interrupting procedure or leaving patient unattended to retrieve missing equipment