Patients have individual desires and preferences about when to perform hygiene and grooming care. Some patients prefer to shower, whereas others prefer to bathe. Patients select different hygiene and grooming products according to personal preferences. Knowing patients’ personal preferences promotes individualized care. Help the patient develop new hygiene practices when indicated by an illness or condition. For example, you need to teach a patient with diabetes proper foot hygiene. Safe and effective patient-centered nursing care elicits individual preferences, allows patients to make personal choices whenever possible, and promotes patient involvement and independence (Cronenwett et al., 2007).

Body image is a person’s subjective concept of his or her body, including physical appearance, structure, or function (see Chapter 33). Body image affects the way in which individuals maintain personal hygiene. If a patient maintains a neatly groomed appearance, be sure to consider the details of grooming when planning care and consult with the patient before making decisions about how to provide hygiene care. Patients who appear unkempt or uninterested in hygiene sometimes need education about its importance or further assessment regarding their ability to participate with daily hygiene.

Surgery, illness, or a change in emotional or functional status often affects a patient’s body image. Discomfort and pain, emotional stress, or fatigue diminish the ability or desire to perform hygiene self-care and require extra effort to promote hygiene and grooming.

Knowledge about the importance of hygiene and its implications for well-being influences hygiene practices. However, knowledge alone is not enough. Motivation also plays a key role in a patient’s hygiene practices. Patient teaching is often needed to foster hygiene self-care. Provide information that focuses on a patient’s health-related issues relevant to the desired hygiene care behaviors. Patient perceptions of the benefits of hygiene care and the susceptibility to and seriousness of developing a problem affect the motivation to change behavior (Pender, Murdaugh, and Parsons, 2011). For example, do patients perceive that they are at risk for dental disease, that dental disease is serious, and that brushing and flossing are effective in reducing risk? When they recognize that there is a risk and that they can take reasonable action without negative consequences, they are more likely to be receptive to nurses’ counseling and teaching efforts.

Cultural beliefs and personal values influence hygiene care (Box 39-1). People from diverse cultural backgrounds frequently follow different self-care practices (see Chapter 9). Maintaining cleanliness does not hold the same importance for some ethnic or social groups as it does for others (Galanti, 2008). In North America it is common to bathe or shower daily and use deodorant to prevent body odors. However, people from some cultures are not sensitive to body odors, prefer to bathe less frequently, and do not use deodorant. Some homeless people believe that a layer of dirt helps protect them from becoming sick (Galanti, 2008). Do not express disapproval when caring for patients whose hygiene practices differ from yours. Avoid forcing changes in hygiene practices unless the practices affect the patient’s health. In these situations use tact, provide information, and allow choices. Religious beliefs associated with culture sometimes influence hygiene practices. Facilitate a patient’s religious practices whenever possible. For example, Muslim patients often remove their shoes and assume different positions for prayer. This increases the risk of developing foot pathology such as calluses on the toes and lateral ankles. When caring for Muslim patients who have diabetes mellitus, you need to be supportive of religious practices while also stressing the need to be diligent in inspecting the feet after prayer sessions for any blisters or calluses.

Acute and chronic cognitive impairments such as stroke, brain injury, psychoses, and dementia often result in the inability to perform self-care independently. When people with cognitive impairments are unaware of their hygiene and grooming needs, they become fearful and agitated during hygiene care, resulting in aggressive behavior (Hoeffer et al., 2006). Safe, effective patient care takes the effect of cognitive impairment on hygiene care into consideration and allows for appropriate modifications.

Explore the patient’s viewpoint regarding hygiene care by asking him or her about preferred personal hygiene and grooming practices. Ask about personal care products desired and preferences such as frequency, time of day, and amount of assistance needed. Also ask questions such as “To make you most comfortable and feel at home, how can I best perform your bath and personal care?” Determine the patient’s awareness of any hygiene-related problems and his or her knowledge and ability to perform hygiene care measures (Box 39-2). Learning a patient’s expectations and applying them in practice fosters a caring relationship. Fully individualizing hygiene care shows the nurse’s respect for the patient’s needs. As you learn what the patient expects, you incorporate this information into a plan of care.

Assess a patient’s physical status as it relates to ability to perform or assist with hygiene care safely and efficiently; include assessment of the patient’s muscle strength, flexibility, balance, visual acuity, and ability to detect thermal and tactile stimuli. Determine your patient’s mental status, including orientation and cognitive function (see Chapter 30). The patient with impaired cognitive function may be unaware of hygiene care needs or less able to follow instructions and assist with care. Observe the patient performing hygiene care, noting complaints or physical manifestations that suggest activity intolerance. Assess respiratory rate and effort, skin color, and pulse rate. Ask questions to assess the patient for dizziness, weakness, or fatigue. To determine the amount of assistance the patient needs, observe him or her performing care activities such as brushing teeth or combing hair (Fig. 39-2). Patients who have limited upper-extremity mobility, reduced vision, fatigue, or inability to grasp small objects require assistance. For example, current evidence shows that older adults who have poor hand function have more dental plaque when they perform their own oral care (Padilha et al., 2007). Also note the presence of equipment such as IV lines or urinary catheters. When patients have self-care limitations, family may assist with care. Determine how the family can help the patient, how often they can provide this assistance, and what their feelings are about being caregivers. In addition, assess the home environment and its influence on the patient’s hygiene practices. Are there barriers in the home that affect his or her self-care abilities? Water faucets that are too tight to adjust easily, bathtubs with high sides, and a bathroom too small to fit a chair in front of a sink are a few examples.

Perform an assessment of the skin (see Chapter 30), noting color, texture, thickness, turgor, temperature, and hydration. In the healthy person the skin is smooth, warm, and supple with good turgor. Pay special attention to the presence and condition of any lesions. Note dryness of the skin indicated by flaking, redness, scaling, and cracking. Discovering manifestations of common skin problems influences how you administer hygiene care (Table 39-2).

Be attentive to characteristics of skin problems most influenced by hygiene measures. Is the skin dry from too much bathing or from use of hot water or irritating soap? Does the patient have a rash caused by an allergic reaction to a skin care product? Certain conditions place patients at risk for impaired skin integrity (Box 39-3). Because of increased risk be particularly alert when assessing patients with reduced sensation, impaired circulation, nutrition or hydration alterations, body secretions, incontinence, altered cognition, external devices, and decreased mobility. Patients may be unaware of skin problems because they are unable to feel pain or pressure or see their skin in some places (e.g., the back or the feet). Carefully assess the skin under orthopedic devices (braces, splints, casts) and beneath items such as antiembolic stockings and tape. Assess the condition and cleanliness of the perineal and anal areas during hygiene care and when the patient requires toileting assistance. When prolonged contact of urine or feces occurs such as with diarrhea or incontinence, skin breakdown often results. Most people consider these areas to be private. Use sensitivity in your approach.

When caring for patients with dark skin pigmentation, be aware of assessment techniques and skin characteristics unique to highly pigmented skin (see Chapter 30). Carefully assess the skin in dark-skinned patients at risk for pressure ulcers (see Chapter 48).

People are often unaware of foot or nail problems until pain or discomfort occurs. Assess patients with diseases that affect peripheral circulation and sensation for the adequacy of circulation and sensation of the feet. Foot ulceration is the most common single precursor to lower-extremity amputations among people with diabetes (Frykberg et al., 2006). Daily inspection and preventive foot care help maintain ulcer-free feet. Palpate the dorsalis pedis and posterior tibial pulses and assess for intact sensation to light touch, pinprick, and temperature (see Chapter 30).

Observe the patient’s gait. Painful foot disorders or decreased sensation cause limping or an unnatural gait. Ask whether the patient has foot discomfort and determine factors that aggravate the pain. Foot problems sometimes result from bone or muscular alterations or wearing poorly fitting footwear.

Inspect the condition of the fingernails and toenails, looking for lesions, dryness, inflammation, or cracking, which are often associated with a variety of common nail problems (Table 39-3). The cuticle that surrounds the nail can grow over it and become inflamed if nail care is not performed correctly and periodically. Ask women whether they frequently polish their nails and use polish remover because chemicals in these products cause excessive nail dryness. Disease changes the shape and curvature of the nails (see Chapter 30). Inflammatory lesions and fungus of the nail bed cause thickened, horny nails that separate from the nail bed.

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