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Information for Fundamentals of Nursing Test #3

What are the functions of the skin? *Protection *Secretion *Excretion *Temperature *Regulation *Sensation
What are the two layers of the skin? *Epidermis *Dermis
What layer of skin shields underlying tissue? Epidermis
What layer of skin contains bundle of collagen, nerve, fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles? Dermis
What tissue lies just beneath the skin? Subcutaneous
What part of the body requires special attention to prevent infection, odor, and injury? Feet, Nails, & Hands
The ___ in contrast to the _____ is used for ____ rather than for _______, 1) Hand 2) Foot 3) Manipulation 4) Support
What influences a patient's capability to perform hygiene care? condition of patient's hands & feet
What are the characteristics of a normal nail? transparent, smooth, and convex, with a pink nail bed and a white tip
Why are HCP not supposed to wear artificial nails? They harbor bacteria & become invaded by fungus
How do nails grow? From the root of the nail bed (a layer of epithelium).
Any condition that interferes with movement of the hand _____ a patient's self-care abilities. impairs
--- often changes the patient's gait, causing strain on different joints and muscle groups. Discomfort while standing or walking limits self-care abilities. Foot Pain
The _____ is located in the skin @ the nail groove. Nail Bed
The nail is hidden by the fold of skin called the ______. Cuticle
A crescent-shaped white area of the nail known as the _____. Lunula
What causes changes in the shape, thickness, and curvature of the nail? Disease
What is lined with mucous membranes? Cavity
What does the oral cavity consist of? Lips, Cheeks running along the sidewalls of the cavity, the tongue and its muscles, and the hard & soft palate.
What are the functions of saliva? Saliva cleanses the mouth, dissolves food chemicals to promote taste, moistens food to facilitate bolus formation, and contains enzymes that start the breakdown of starchy foods.
What helps to prevent gingivitis and dental caries? Regular oral hygiene
What part of the tooth extends above the gingiva or gum? Enamel-covered crown
What is the constricted portion of the tooth, which is connected to the crown & the root? Neck
What lies just below the gum margins, surrounds a tooth, and holds it firmly in place? Peridontal Membrane
The _____ is embedded in the jawbone. Root
What three things impairs salivary secretion? 1) Medications 2)Exposure to Radiation 3) Mouth Breathing
What is Xerostoma? Dry Mouth
What is Gingivitis? Inflammation of the Gums
What causes dental caries? Tooth Decay
What are the characteristics of a normal oral mucosa? Light pink, soft, moist, smooth, and w/o lesions.
(True/False) Two individuals perform hygiene in the same manner. False; No two individuals perform hygiene in the same manner. Patient care is individualized on the basis of of learning about his/her hygiene practices & preferences.
During hygiene, what are three areas the nurse should assess? 1) Emotional Status 2) Health Promotion Practices 3) Healthcare Ed Needs
How do social groups influence hygiene? *The types of hygiene products used and the nature and frequency of personal care practices. *Ethnic, social, and family influences on hygiene patterns.
How does knowing the patient's personal preferences influence hygiene? *Promotes individualized care. *Dictate hygiene practices
How does body image influence hygiene? *Surgery, illness, or a change in emotional or functional status. *Discomfort and pain, emotional stress, and fatigue diminish the ability or desire to perform hygiene self-care and require extra effort to promote hygiene and grooming.
How does socioeconomic status influence hygiene? It becomes difficult to participate and take a responsible role in HP activities, for example - basic hygiene. Influences the type and extent of hygiene practices used
How does health beliefs influence hygiene? Patients’ health beliefs predict the likelihood of assuming health promotion behavior such as maintaining good hygiene. Knowledge about the importance of hygiene and its implications for well-being influences hygiene practices, but motivation is key.
Hoes does cultural variables influence good hygiene? People from diverse cultures practice different hygiene rituals.
The skin reflects changes in physical condition caused by ____________. alteration in color, thickness, texture, turgor, temperature, and hydration.
Where does bacteria lie? outer epidermis
What layer of the epidermis generates new cells to replace the dead cells that the outer surface of the skin continuously sheds? innermost layer
What does the resident normal flora on the skin do? The inhibit the multiplication of disease-causing microorganisms.
What kind of action does sebum have? bactericidal
What runs through the dermal layers of the skin? nerve fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles.
What do sebaceous glands secrete? Sebum
What is sebum? An oily, odorous fluid, into the hair follicles.
What softens and lubricates the skin and slows water loss from the skin when the humidity is low? Sebum
The ____________ functions as a heat insulator for the body. Subcutaneous fatty tissue layer
___________ also supports upper skin layers to withstand stresses and pressure without injury and anchors the skin loosely to underlying structures such as muscle. Subcutaneous tissue
As long as the skin remains intact and healthy,its physiological function remains _________. Optimal
__________ frequently influence skin status and can have both beneficial and negative effects on the skin. Hygiene Practices
(True/ False) The skin reflects changes in physical condition caused by alteration in color, thickness, texture, turgor, temperature, and hydration. True
A scalelike modification of the epidermis forms the visible part of the nail _______ . Nail body
What does a normal tooth consists of ______? Crown, Neck, & Root
What do healthy teeth look like? white, smooth, shiny, & properly aligned
(True/False) Growth, distribution, and pattern indicate general health status of hair. True
What affects hair? Hormonal changes, nutrition, emotional stress, physical stress, aging, infection, and other illnesses.
(True/False) When hygiene care is provided, the eyes, ears, and nose require careful attention. True
How does the developmental stages affect hygiene? A patient’s developmental stage affects the ability of the patient to perform hygiene care and the type of care needed.
How does physical condition affect hygiene? Patients with certain types of physical limitations or disabilities associated with disease and injury lack the physical energy and dexterity to perform hygiene self-care safely.
During the developmental stage, how does skin affect hygiene? Any break in the skin can result in an infection. Sebaceous glands become more active in puberty, predisposing adolescents to acne (i.e., active inflammation of the sebaceous glands accompanied by pimples).
During the developmental stage, how does skin affect hygiene? (continued) The condition of the adult’s skin depends on hygiene practices and exposure to environmental irritants.
During the developmental stage, how does feet & nails affect hygiene? Older adults do not always have the strength, flexibility, visual acuity, or manual dexterity to care for their feet and nails. Older adults often have dry feet because of a decrease in sebaceous gland secretion and dehydration of epidermal cells.
During the developmental stage, how does feet & nails affect hygiene? (continued) Common problems of the feet affecting older adults include corns, calluses, bunions, hammer toe, and fungal infections.
During the developmental stage, how does the mouth affect hygiene? From adolescence, when all of the permanent teeth are in place, through middle adulthood, the teeth and gums remain healthy if a person follows healthy eating patterns and dental care.
During the developmental stage, how does the mouth affect hygiene? (continued) Regular brushing and flossing help to prevent caries and periodontal disease
During the developmental stage, how does the mouth affect hygiene? (continued) Gums lose vascularity and tissue elasticity, and this causes dentures to fit poorly. If the older adult becomes edentulous (i.e., without teeth) and wears complete or partial dentures, include assessment of underlying gums and palate.
During the developmental stage, how does the mouth affect hygiene? (continued) As a person ages, numerous factors result in poor oral health. These include age-related changes of the mouth, chronic disease such as diabetes, physical disabilities involving hand grasp or strength affecting the ability to perform hygiene.
During the developmental stage, how does hair affect hygiene? Throughout life, changes in growth, distribution, and condition of the hair influence hair hygiene. With aging, as scalp hair becomes thinner and drier, shampooing is usually performed less frequently.
When the nurse is using critical thinking, what should she do? 1) Integrate his/her nursing knowledge. -Consider developmental & cultural influences -Think creatively. 2) Be nonjudgmental and confident. - Draw on your own experiences -Rely on professional standards
Assessment of a patient's hygiene status and self-care abilities requires the nurse to do what ______? A nursing history & perform a physical assessment.
What are the characteristics of the skin on a healthy person? Smooth, warm, & supple with good turgor.
What are some common diagnoses associated with hygiene? Activity intolerance Bathing self-care deficit Dressing self-care deficit Impaired physical mobility Impaired oral mucous membrane Ineffective health maintenance Risk for infection
Hygiene care should be ____________; know when to learn more about the patient’s preferences. patient-centered
When performing the skills in this chapter, remember the following points to ensure safe, individualized patient care: Always perform hygiene measures moving from the cleanest to less clean or dirty areas. Use clean gloves. Test the water to prevent injury. Use principles of body mechanics & safe patient handling. Be sensitive to invasion of privacy. Communicate.
When doing hygiene care, the nurse should assess the patient's : *Self-care ability *Skin *Feet & Nails *Oral Cavity *Hair *EEN *Use of sensory aids *Hygiene care practices *Cultural influences
(True/False) The nurse should assess the patients physical and cognitive ability to perform basic hygiene measures. True
What should the nurse note when doing the assessment of the skin? Note the color, texture, thickness, turgor, temperature, and hydration. Be attentive to characteristics of skin problems most influenced by hygiene measures.
What are the common cavity problems of teeth? Receding gum tissue, inflamed gums (gingivitis), a coated tongue, glossitis (inflamed tongue), discolored teeth (particularly along gum margins), dental caries, missing teeth, and halitosis (foul-smelling breath).
What places a patient at greater risk for impaired skin integrity? Reduced sensation, vascular insufficiency, and immobility
What should the nurse do when he/she suspects a patient with pediculosis capitis (Head Lice) ? He/she should guard against self-infestation by handwashing and using gloves or tongue blades to inspect the patient’s hair. Note any loss of hair (alopecia).
What are the characteristics of a normal eye? It is not inflamed and is without drainage.
What should the nurse observe for in the ear? Observe for the presence of accumulated cerumen (earwax) or drainage in the ear.
During the nursing process, the nurse will assess _________. assess the skin, feet, nails, oral cavity, hair, eyes, ears, and nose. You will need to assess normal dvlpmntl changes that occur throughout the life span. Hygiene practices and any cultural factors that influence them should be identified at this time.
What is mucositis? Painful inflammation of oral mucous membranes
What is important in planning hygiene care? Timing
The evaluation of hygiene care is based on ________. a patient’s sense of comfort, relaxation, and well-being, and understanding of hygiene techniques.
What does critical thinking ensure _______. that the nurse considers the patient’s perspectives and applies what is known about hygiene to the patient’s unique situation.
Regardless of the type of bath the patient receives, use the following guidelines: 1)Provide privacy 2) Maintain safety. 3) Maintain warmth. 4) Promote independence. 5) Anticipate needs.