Nursing Procedure 4.8
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
Sample desired outcomes include the following:
Special Considerations in Planning and Implementation
If the client is taking an anticoagulant, check the agency's policy about the need to obtain a special doctor's order before shaving. When assessing drug profile, note drugs that contain aspirin or drugs that are not classified as anticoagulants but may cause bleeding. Obtain doctor's order or note agency's policy concerning shaving these clients.
If shaving is ordered before a procedure, maintain control of razor and child to avoid accidental cutting.
Be gentle when shaving. Shave only as often as necessary. The elderly client's skin is often thin, dry, and fragile, and the hair is brittle.
Include shaving as part of a client's grooming as indicated. Doing so contributes to a sense of well-being and peace. It also portrays to family members a sense of caring.
When in doubt about a client's shaving practices, consult the client or a family member. For shaving not related to preparation for a procedure, clients of different ethnic and cultural origins may have objections to shaving hair, as this may be the cultural norm.
Encourage a family member to perform shaving when acceptable to client.
Action | Rationale | |
---|---|---|
1 | Explain procedure to client. | Reduces anxiety; promotes cooperation |
2 | Allow 510 min of uninterrupted time for shaving. | Avoids rushing and possible injury to client |
3 | Perform hand hygiene and organize equipment. | Reduces microorganism transfer; promotes efficiency |
4 | Lower side rail. | Allows easier access to client |
5 | Assist client into appropriate position: supine position, with head of bed elevated or semi-Fowlers (for facial shave). | Provides access to shaving area |
6 | Don gloves. | Prevents contamination of hands; reduces risk of infection transmission |
7 | Place towel across clients chest. | Prevents client from getting wet |
8 | Moisten face with warm, damp washcloth. | Softens area to avoid cuts |
9 | Apply generous amount of shaving cream or lathered soap. | Softens area to avoid cuts and facilitates movement of razor |
10 | Pull the skin taut. | Eliminates excessive skin folding to avoid cuts |
11 | Shave in direction of hair growth, using short, smooth strokes. | Follows natural hair direction to avoid nicks, cuts, or bruises; avoids irritation |
12 | For manual disposable razors, dip razor into water periodically and shake off excess water. | Removes hair debris and excessive cream or soap to facilitate smooth strokes |
13 | Allow client to rinse face or use washcloth to clean area. | Removes cream or soap and debris |
14 | Pat area dry and apply aftershave moisturizer as desired. | Provides comfort and reduces the risk of skin irritation from rubbing |
15 | Reposition client and raise side rails. | Provides for comfort and safety |
16 | Discard equipment appropriately, remove and discard gloves, and perform hand hygiene. | Reduces microorganism transfer |
Were desired outcomes achieved? Examples of evaluation include: