Question

During a home visit, the nurse determines that a client would benefit from teaching to promote tissue integrity. What did the nurse assess in order to come to this conclusion?

1) The client does not wash her hands after using the commode.
2) The client washes her hair every day.
3) The client washes her hands with soap and running water before eating.
4) The client showers once a week.
5) The client does not apply moisturizer after bathing.

Answer 1

The nurse determined that the client would benefit from teaching to promote tissue integrity due to a lack of proper handwashing and skin care noticed during the visit, such as not washing hands after using the commode and not moisturizing after bathing.

Step-by-step explanation:

During a home visit, the nurse likely assessed the client's hygiene practices and condition of skin to determine that the client would benefit from teaching to promote tissue integrity. Specifically, the nurse may have noticed that the client does not wash her hands after using the commode, which is crucial for preventing the spread of pathogens and maintaining tissue integrity. Additionally, not applying moisturizer after bathing can contribute to skin dryness and compromise tissue integrity. Following the CDC guidelines for proper hand hygiene, such as washing hands thoroughly with soap and warm water and drying them properly, are essential practices to maintain healthy skin and prevent infections.

Proper handwashing is a fundamental part of maintaining tissue integrity. It involves the use of soap, warm running water, and thorough cleaning, including under the fingernails, before food preparation, after using the toilet, and whenever hands become soiled. Emphasizing the correct technique and frequency of handwashing can significantly reduce the risk of infectious diseases and maintain skin health.