Knowledge from the physical sciences is explored in relation to the skin, mouth, eyes, hair, nails and perineum. In each section the focus is on the applied knowledge needed to make decisions about hygiene care. The psychosocial knowledge base integrates these specific body parts in order to outline issues in hygiene care related to development and individuality. Historical and social dimensions of hygiene care and cultural and spiritual norms are explored.

There is a particular focus on the reflective experiences of students in the delivery of care that is intimate and private (Evolve 14.5). Case studies are used to help consolidate knowledge gained from practice and the chapter content.

On page 333 there are four case studies, each one relating to one of the branch programmes. You may find it helpful to read one of them before you start the chapter and use it as a focus for your reflections while reading.

Eccrine (found throughout the body) and apocrine glands (responsible for odour and found at specific sites such as the pubis, genitalia, axillae) are two types of sweat (sudoriferous) glands; they are distributed throughout the skin and assist in temperature control. They produce sweat when the skin temperature rises above 35°C. Approximately 500 mL of sweat is produced each day in temperate climates. Secretion of sweat also occurs in response to stress and anxiety as well as to certain spicy foods. Both the production of sweat and its evaporation from the skin assist in heat loss from the body, and the rate of evaporation is particularly important in the patient with pyrexia (raised body temperature) (see Ch. 7, ‘Homeostasis’).

Sweat left on the skin, especially if from the apocrine glands of the axilla and genital areas, is responsible for body odour through the process of bacterial decomposition. The apocrine glands are dormant during childhood, but begin actively to secrete sweat during puberty and continue to do so throughout adult life. The widespread use of deodorants in developed countries is based on the principle that these solutions will kill the bacteria and mask any odour produced. Antiperspirant sprays block the openings of the ducts to the sweat glands with metal salts such as aluminium (Montague et al 2005).

Sebaceous glands secrete sebum into the hair follicles. This sebum is an oily odourless fluid, containing cholesterol, triglycerides, waxes and paraffins, that lubricates the skin and keeps it supple and pliant. Sebum also has a role in waterproofing the skin and is inhibitory to many microorganisms. Sebaceous glands are found in highest numbers over the scalp and face, the middle of the back, the genitalia and in the auditory canal.

Babies and young children have relatively fewer and less active sebaceous glands and are therefore more prone to skin redness and excoriation in damp conditions, while the loss of sebaceous glands in old age also makes the skin of the elderly more vulnerable to damp conditions, redness and to breakdown. During the menarche (puberty in females), however, the secretion from sebaceous glands increases in response to an increase in adrenocortical hormones. The increasing output of sebum during the teenage years combined with hereditary factors can contribute to the development of acne vulgaris (common acne) (Hockenberry & Wilson 2007).

The hair follicle is situated in the dermis and is surrounded by its own nerve and blood supply. Sebaceous glands and sweat gland ducts open directly into the hair follicle causing the scalp to become moist and oily, particularly in a hot environment. The cycle of hair growth comprises a period of growth for up to 2 years followed by a rest period and then atrophy. About 70–100 scalp hairs are normally lost each day.

Certain factors affect the rate of normal hair growth and loss. These include:

Most of the body is covered by hair, but it varies in type. Lanugo is the fine silky hair found on the fetus in utero and on premature babies, and which is lost from the body soon after birth. Vellus is colourless hair found on the female face. Terminal hair is found on the adult head and pubis and is the subject of hygiene care in relation to maintaining healthy hair covered later in this chapter.

Nails are keratinized plates resting on the highly vascular and sensitive nail bed. The external appearance of the nail bed is often used to indicate general health status as the shape, colour and condition of fingernails are easily observed. Toenails cause more problems for individuals than fingernails. Debilitated adults may have difficulties in maintaining adequate care and hygiene for their feet which will lead to their toenails becoming thick, brittle and prone to fungal infections. Children may have problems with ingrowing toenails because of difficulties in maintaining well-fitting shoes, especially in times of rapid growth such as during adolescence.

The perineum is the area located between the thighs, extending from the anus (posterior) through to the top of the pubic bone (anterior). Anatomical structures in this area are concerned with the expression of sexuality, reproduction and elimination (see Ch. 16, ‘Sexuality’, and Ch. 18, ‘Continence’).

In the female, the external genitalia (vulva) consists of the mons pubis, clitoris, urethral and vaginal orifices, and the labia majora and minora. The normal moist environment around the vaginal orifice is maintained by secretions from Bartholin’s glands, which are mucus-secreting glands in the lateral wall of the vagina. The slightly acid secretion varies in amount during the ovulation cycle, has a slight odour and helps to inhibit bacterial growth.

In the male, the perineal area includes the penis, the scrotum and the anus. The end of the penis (glans penis) through which the urethra opens in the centre is covered with a skin flap or foreskin in the uncircumcised male. Because the skin of both the penis and the scrotum is thin and hairless it is more easily irritated and injured than skin elsewhere.

The perineal areas of both men and women are prone to infections because they contain openings into the body and are also warm and moist environments. In both sexes, the urethral orifices lead to sterile bladders, but are in close proximity to the anus, which opens into the ‘unclean’ rectum. The main aim for hygiene care in this area is to prevent or eliminate infection. Prevention of odour is closely linked to the prevention of infection and is a cultural preoccupation in developed countries.

The mouth has many physical and psychosocial functions that are important in supporting the health and well-being of an individual (Box 14.1). The mouth or oral cavity forms the first part of the gastrointestinal tract (Fig. 14.2). It is lined by mucous membrane, which along with the three pairs of salivary glands – the parotid, sublingual and submandibular – secretes mucus and saliva to aid the mastication and digestion of food. The tongue is a large muscular organ involved in taste, speech and swallowing. There are numerous papillae and taste buds on the upper surface of the tongue. The teeth masticate food, help to shape the mouth and are involved in the formation of speech sounds. The deciduous teeth begin to erupt at between 5 and 8 months of age. In childhood there are normally 20 deciduous teeth. Gradual exfoliation of the deciduous teeth begins approximately from the age of 6. These teeth are replaced by 32 permanent teeth by the age of 18–25 years. A full complement of teeth has 16 in the lower and 16 in the upper jaw. Knowledge of the natural loss of teeth in childhood is important to the nurse caring for a child going for surgery under a general anaesthetic, as loose teeth may fall out and be inhaled during induction of anaesthesia.

The structure of the adult tooth contains three parts: the exposed section of the tooth is the crown (enamel), the root (dentine) which is held in place in the jaw bone by cementum, and the pulp cavity, which contains the blood vessels and nerves (Fig. 14.3).

The two major types of oral problems in the normally healthy individual are periodontal disease and dental caries (cavities). Dental caries involve the calcified structures of the tooth. Bacterial enzymes combined with dental plaque produce organic acids, which decalcify both enamel and dentine. Cavities or caries begin to develop once the bacteria have access to the central matrix of the tooth.

Gingivitis is a reversible prevalent disease of the gingivae (gums) and in some cases can lead on to periodontal disease. Clinical features of gingivitis include red, swollen, bleeding gums. Periodontal disease is a chronic irreversible disease of the gingivae and supporting tissues of the tooth, i.e. the cementum, periodontal ligaments and underlying jawbone. Clinical features of periodontal disease (periodontitis) include chronic and/or acute gingivitis, gingival recession, leading to the root (dentine) becoming exposed in the oral cavity, severe bone loss, tooth mobility and ultimately premature tooth loss.

Saliva plays an essential role in maintaining a healthy mouth. Thin watery saliva flushes away some debris from around the gums and teeth and buffers any acids in the mouth. Thick sticky saliva will aid the formation of plaque and therefore increases the risk of periodontal disease and dental caries (Griffiths & Boyle 2005).

Halitosis (‘bad breath’), also known as oral malodour or foetor oris, is a common complaint and has many causative factors which include strong spicy foods, coffee, smoking, alcohol, certain drugs and xerostomia (dry mouth). However, dental plaque is also a primary factor of halitosis due to its metabolic activity. Poor oral hygiene activity can lead to halitosis. People who stop cleaning their mouths will soon develop halitosis. Any form of oral sepsis such as gingivitis or periodontitis will produce a degree of halitosis. Rarer causes include diabetic ketoacidosis and severe renal or hepatic problems (Griffiths & Boyle 2005).

The prevention of peridontal disease and dental caries is necessary to control premature tooth loss throughout the lifespan. Particularly vulnerable times for tooth loss are during childhood and teenage years and the third age (over 50 years old). Pregnant women have a higher susceptibility to gum disease (pregnancy gingivitis) due to the increase of hormonal activity which exaggerates the way the gum tissues react to the bacteria in plaque. This results in an increased vulnerability to gum disease if there is not good control of plaque formation. It is important to note that it is the plaque and not the increased hormone levels that is the major cause of pregnancy gingivitis.

Health promotion strategies addressed to all ages must take into account the interaction between the oral environment of the individual and dental plaque. As soon as food and drink are ingested, the acidity in the mouth increases. The pH is lowered considerably by foods containing sugar and until the acidity is buffered by saliva there is a risk of demineralization of the teeth with subsequent decay. The mouth contains many varieties of bacteria, which do not cause problems if suspended in saliva. However, once these organisms attach themselves to the teeth, gums or tongue surfaces via a mucopolysaccharide glue they become insoluble in water and problems begin. The bacterial deposits cannot be rinsed away and dental plaque forms. Plaque takes 24 hours to develop. It causes periodontal disease and dental caries, which may eventually lead to systemic disease.

Beliefs and attitudes to personal hygiene are developed during childhood and are strongly influenced by social and cultural norms. Nurses, aware of the scientific principles on which they base their beliefs about hygiene care, need to be sensitive to the family and cultural influences on their clients.

Historically, hygiene practices have been influenced by:

Hygiene maintenance is a normal daily occupation and promotes a feeling of security and stability alongside well-being and self-esteem. An important stage in the development of independence in hygiene self-care in childhood occurs during the toddler and preschool phase (i.e. at 1–6 years of age). During this time children develop physically, learn to gain self-control and mastery over body functions, and become increasingly aware of their own dependence and independence (Hockenberry & Wilson 2007). The social and cultural beliefs of the family are of great importance in this preschool period in influencing attitudes and practices in hygiene care, and health promotion is usually directed through the parents/carers of the child. Peer influences become increasingly important through the school years and hygiene habits for both sexes may be influenced more by advertising, peer support and the wish to conform to group and sexual norms. Health promotion strategies by healthcare professionals during this phase of development need to consider these predominant social influences. During the late teenage years, values and attitudes become internalized and each individual justifies for themselves their choices in hygiene care. For adults, the influence of advertising which directs its message of responsibility to the family unit, particularly the mother, has an effect on patterns of hygiene practice in society (Aiello & Larson 2001). Anxiety in an individual can lead to an obsession with hygiene care expressed through frequent hand-washing and cleaning. Obsessive compulsive disorder (OCD) is relatively common within the general population and specialist help is needed to deal with the problem.

There are many different ways of delivering body hygiene care (Box 14.2 and Evolve 14.2). Although nurses in multiple contexts use some or all of these methods on a daily basis, textbooks generally concentrate on the techniques of bed bathing the highly dependent patient (Nicol et al 2008). There has been a major shift in conventions around decision making in this area of total body hygiene as the emphasis is placed on patient independence in maintaining his or her own hygiene care.