Hygiene
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| what is the overall goal of pt hygiene? | promote eventual self care
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| How do you assess self care abilities? | conduct an initial interview and obtain a health history, assess the pt's cognitive ability and physical functioning, identify other factors (cultural or religious), assess for sensory disturbances, determine preferences and practices
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| What are nursing diagnoses related to self care? | bathing/hygiene self care deficit, dressing/grooming self care deficit, toileting self care deficit, total self care deficit, feeding self care deficit,
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| How should you classify the patient's functional level in self care deficits? | from 0-4, 0 is completely dependent, 1 requires use of equipment, 2 requires help from another person for assistance or teaching , 3 requires help from another person or equipment/device, 4 is totally dependent
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| what does a 0 classification of self care ability mean? | completely independent
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| what does a 1 classification of self care ability mean? | requires use of equipment or device
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| what does a 2 classification of self care ability mean? | requires help from another person for assistance, supervision or teaching
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| what does a 3 classification of self care ability mean? | requires help from another person and equipment/device
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| what does a 4 classification of self care ability mean? | TOTALLY DEPENDENT and does not participate in any activity
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| when does A.M morning care occur? | after breakfast
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| When does early morning care occur? | soon after pt awakens
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| What is PM afternoon care? | consists of preparing pt's to receive visitors or afternoon rest
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| What is H.S. | Hour of sleep
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| When does H.S. occur? | care provided before pt sleeps
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| What should you tell the UAP regarding a bath, shower or toileting? | pt's limitations and restrictions, use of any assistive devices, specific safety precautions, any obstacles present such as tubes and to make observations and why observations are important
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| desquanmates | shedding of the skin
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| what does the dermis contain? | blood and lymphatic vessels, nerves, bases of hair follicles and sebaceous and sweat glands
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| What are the functions of the skin? | protection, sensation, regulation, secretion/excretion, vit D formation
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| What causes the loss of skin integrity | dampness, dehydration, insufficient circulation, low nutritional status, skin diseases, jaundice
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| impetigo | bacterial infection of the skin
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| Jaundice | yellow discoloration caused by accumulation of bile pigments in the skin
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| How does jaundice affect the skin? | causes it to be itchy and dry
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| When assessing the pt's skin what should you obtain? | Subjective and Objective data
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| What is subjective data? | what the pt describes
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| what is objective data? | your observations but not inferences
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| How should a nurse inspect the skin? | from a orderly head to toe manner
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| what should the nurse note when gathering objective data of a pt's skin | overall cleanliness, condition, color, texture, turgor, hydration, temp. Also look for rashes, lumps, lesions and cracking
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| What are the four significant color changes in skin that should be observed for? | Pallor, erythema, jaundice, cyanosis
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| What is pallor | is when a light skinned person may appear pale without any underlying pink tones or when a dark person is gray or yellow color
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| What is erythema? | redness in the skin related to vasodilation and inflammation, in dark people its hard to see so palpate for warm areas
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| Where is the best place to see jaundice? | in the sclera of the eyes
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| What is cyanosis | blusish coloring of the skin, caused by decreased peripheral circulation or decreased oxygenation of the blood
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| How do you assess for cyanosis in dark skinned people? | examining the conjunctivae, tongue, buccal mucosa, palms and soles for dark color
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| Pruritus | itching which may lead to scratching and breaks in the skin
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| dry skin | tends to crack
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| maceration | softening of the kin from prolonged moisture making epidermis more susceptible to injury
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| excoriation | is loss of the superficial layers of the skin caused by digestive enzymes in feces
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| pressure ulcers | lesions caused by tissue compression and inadequate perfusion
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| abrasion | rubbing away of the epidermal layer of the skin especially over bony prominences, often caused by friction or shearing forces when pt moves in bed
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| Acne | inflammation of the sebaceous glands
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| Define the risk for impaired skin integrity? | at risk for skin being adversely altered
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| what are risk factors for risk for impaired skin integrity? | obesity, radiation, dampness, dehydration, insufficient circulation
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| impaired skin integrity | altered epidermis or dermis
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| What is the rationale for bathing? | bathing removes perspiration and bacteria from skin surfaces
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| Help Bath | when the nurse helps the pt with areas that may be difficult to reach and is a functional level of 2
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| partial bath | is provided when baths are stressful and is when you clean only the areas that cause odor or discomfort
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| bed bath | for pt's that must remain in bed but who are able to bathe themselves
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| complete bed bath | you will wash the pt's entire body without assistance from the pt
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| How do you perform a complete bed bath | clean the cleanest are to the most soiled area
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| WHAT IS THE PERINEUM? | the area between the anus and vulva/scrotum
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| When cleaning extremities what should you do? | clean from distal to proximal
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| When inspecting the foot what should you be observing for? | skin integrity, circulation and edema
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| When providing denture care which denture should be removed or replaced first? | The top denture
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| In providing denture care what should you do to avoid breaking the dentures? | place a towel in the sink
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| What is a towel bath? | modification of a bed bath, in which you put a large towel and bath blanket in a plastic bag and saturate them with a commercially prepared mixture of moisturizer, disinfectant, non rinse cleaning agent and water
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| Does a towel bath require towel drying? | no as the solution dries quickly
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| Bag Bath | modification of a towel bath in which you use 8-10 washcloths instead of a towel or bath blanket
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| therapeutic bath | bath with specific instructions for the type of bath and solution to be used, area of the body to be treated and water temp
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| what are contraindications of a massage? | fractured ribs, burns, recent heart surgery
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| When are feet fully grown? | 20 years of age
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| What diseases cause decrease circulation? | arteriosclerosis and peripheral vascular insufficiency
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| Corns | cone shaped thickening of the epidermis caused by continuous pressure typically over joints
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| calluses | Not painful and similar to corns and found on bony prominences in the weight bearing part of the foot (heal, soles)
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| tinea pedis | athletes foot a fungal infection and is aggravated by moisture in unventilated shoes associated with burning skin with blisters, scaling and cracking,
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| ingrown toenail | toenail grows inward into the soft tissue around it
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| foot odor | microbes growing on the feet interacts with sweat to produce foot odor
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| plantar wart | painful growth caused by a virus
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| pressure ulcers | lesions caused by unrelieved pressure that impairs circulation
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| nail nursing diagnoses | risk for impaired tissue integrity related to ingrown nails secondary to trimming to close to the cuticle, risk for infection related to loss of skin integrity secondary to hangnails
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| How can one maintain good oral hygiene | routine dental checkups, adequate nutrition, daily mouth care or oral hygiene
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| What are the first set of teeth we develop? | deciduous teeth
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| Wisdom teeth | are the very back molars on either side of the jawbone
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| What can poorly fitted dentures lead to? | nutritional deficiencies or difficulty in chewing
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| What are the risk factors for oral problems | history of periodontal disease, lack of money for dental care, pregnancy
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| hyperplasia | excessive growth of cells
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| halitosis | bad breath from poor oral hygiene, eating certain foods, tobacco use, dental caries, infections or even systemic disease
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| dental caries | cavities due to failure to remove plaque
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| gingivitis | inflammation of the gum tissue
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| periodontal disease | major cause of tooth loss, inflammation characterized by bleeding and receding gums and destruction of the surrounding bony structures
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| what is the cause of tooth lost | untreated plaque
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| Tartar | dead bacteria forms hard deposits at the gum line, deteriorating supporting structures
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| stomatitis | inflammation of oral mucosa
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| glossitis | inflammation of the tongue due to deficiencies of vit B12, folic acid and iron
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| cheilosis | cracking or ulceration of the lips due to vit B complex deficiencies
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| oral malignancies | lumps, ulcers, white or red patches, bleeding, pain persistent sores or numbness
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| bridge | one or more artifical teeth
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| vellus hair | short fine hair present over the body
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| terminal hair | darker, coarser and longer hair found on the scalp, eyebrows, axillae, perineum and legs
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| dandruff | excessive shedding of the epidermal layer of the scalp may be caused by fungal infection
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| pediculosis | head lice
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| alopecia | hair loss
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| How should one clean the eyes? | from the inner to the outer canthus with a moistened washcloth with no soap
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| cerumen | ear wax
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| cerumenolytic drops | used to remove excess ear wax buildup
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| What are side rails classified as? | passive restraints
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Created by:
lydia.koo
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