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FONDATION OF NURSING
exam 2 chapter 31
| Question | Answer | |
|---|---|---|
| what is HYGIENE AND how does impact a pt care? | Skin first line of defense. HYGIENIC PRACTICE INCLUDES CLEANING HAIR, NAIL EYES , NOSE, MOUTH AND PERINEAL AREA. IT JUST CARING FOR THE SKIN. | IT speeds the recovery process, make a difference in pt care. CONSIDER USING NONPHARMACOTHERAPEUTIC METHODS I.E MUSIC |
| unique hygiene practice◦Respect & observe cultural needs | IDENTIFY CULTURAL VARIATION THAT AFFECT A PT'S HYGINE PREFERENCE. Different bathing practices based on cultureand behaviors. Also use of hygiene-related products. | |
| HOW Socioeconomic class define a good HYGIENE? | A lack of funds to obtain toiletries or clean clothing may contribute to an inability to maintain personal hygiene needs. I.E Homeless people | |
| Spiritual practices | Including religious beliefs, may dictate ceremonial washings and purifications, sometimes as a prelude to prayer or eating. i.e Muslims men bathing after an intercourse | |
| Developmental level◦Young & older adults | Modeling-Moralizing : Family practices often dictate hygiene habits, such as morning or evening baths; the frequency of shampooing, tooth brushing, and clothing changes; feelings about nudity; and so on. i.e (Olde.r adults may experience an increase in | Gender can affect hygiene practices |
| Health state-tolerability◦Personal preferences | Disease, surgery, or injury may reduce a person’s ability to perform hygiene measures or motivation to follow usual hygiene habits. Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash the low | Impairment of the musculoskeletal system can interfere with a patient’s ability to perform tasks related to personal hygiene. |
| describe a good skin care benefits | IT contributes to maintaining skin condition and integrity,. An important first line of defense, preventing the entry of pathogens, minimizing absorption of harmful substances, and preventing excessive water loss. | |
| Hair care | Illness affects the hair, especially when endocrine abnormalities, increased body temperature, poor nutrition, or anxiety and worry are present. Changes in the color or condition of the hair shaft are related to changes in hormonal activity or to changes | |
| Nails care | Epithelial tissue. Healthy nail beds are pink, convex, and evenly curved. With certain pathologic conditions, and to some extent with aging, the nails become ridged and areas become concave. Hygienic care includes keeping the nails of fingers and fee | DIABETES AND PERIPHERAL NEUROPATHY COULD LEAD TO AMPUTATION = PT CAN'T FELL ANYTHING =NAILS SHOULDNT BE CUT OR CUT STRAIGH ACROSS COUNSEL A WOUND CARE NURSE- PODIATRIST |
| Oral care | Relationship between healthy teeth and a diet sufficient in calcium and phosphorus, along with vitamin D, which is necessary for the body to make use of these minerals. | NP0-NG TUBE oral airways in place, and those who have had oral surgery are also at increased risk. GLLITIS-INFLAMMED TONGUE |
| Good dental hygiene leads to : | Intact body image tasting pleasure(diges sys.) It contributes to decreased incidence of aspiration pneumonia. It promotes the patient’s sense of well-being. It prevents deterioration of the oral cavity. | |
| Poor oral hygiene leads to : | oral tissues may signal the presence of disease, disease progression, or exposure to risk factors for disease diabetes, cardiovascular disease, and metabolic syndrome | |
| what questions should be ask prior to bathing a PT? | How do you normally proceed with bathing and skin care?◦Skin problems? How long have you had this problem?◦Any alterations in oral cavity?◦Nails & foot care; Diabetic? Peripheral vascular disease?◦Perineal or vaginal issues? | |
| Personal preferences? | showering or in tub, bar or liquid soap. Ask pt about preferences | |
| Head to toe assessment of skin | Systematic approach-head to toe front to back *daylight or good light(turn on over light on) *Standard terminology in recording *Identify Variables causing problems Perform the appropriate skin assessment when risk factors are identified. | CHECK TO SEE IF LESSIONS, VASCULARITY-SENSATION OR NO SENSATION- MOISTURE *cleanliness of skin= mental problem * Pale skin=no O2 *Warm=inflammation *COLD=NO BLOOD FLOW-NERVE PROBLEM |
| Questions about Skin assessment | How long have you had this problem? Does it bother you? How does it bother you? Does it itch? Have you found anything that helps relieve these symptoms? | |
| RISK ASSESSMENT FOR FOOT AND NAIL PROBLEMS, PT AT HIGHER RISK ARE? | A patient diagnosed with type II diabetes A patient who has a nervous habit of biting his nails A patient whose job involves frequent handwashing A patient who is obese | DIABETICCOLER WOMEN WEARING KNEE-HIGH HOSE W/ DEEP INDENTATION OBSTRUCT LOWER EXTREMTIES CIRCULATION. |
| Oral cavity ASSESSMENT | Identify variables to cause oral problems *deficient self-care abilities, poor nutrition or excessive intake of refined sugars. *family history of periodontal disease(PAINFUL RED, SWALLOEN-BLEED GUN TISSSUE) or ingestion of chemotherapeutic agents that p | PT at increased risk of oral problem are seriously ill, comatose, dehydrated, confused, depressed or paralyze. With mental health problems wit mouth brethers, NPO, NGO TUBES , ORAL AIRWAYS IN PLACE ORAL SURGERY=DRY MOUTH=ULCERATION |
| EYES, EARS AND NOSE ASSESSMENT | Ask the patient to identify any special eye, ear, or nose care that the patient performs | Identify Visual aids or prosthetics (glasses, contact lenses, artificial eye) and hearing aids. Inquire about any history of eye, ear, and nose problems, and related treatments. |
| Hair assessment | Pt style preference; scalp problems causes in the texture, amount of hair and related treatment. ALOPECIA-DANDRUF-PEDICULOSIS-INFESATION WITH LICE | require special care such as deficient self-care abilities, immobility, malnutrition and treatment known to treat hair loss |
| HOW DO YOU CLEAN PERINEAL AND VAGINAL AREAS? | IDENTIFY ANY CULTURE FACTORS PRIOR TO BATHING-VARIALES CAUSING PROBLEMS OR CRETE NEED FOR INDWELLING FOLAY, URINARY OR FECAL INCONTINENCE, CHILDBIRTH wash groin-spread labia-use clean portion of washcloth for each stroke-clean tip of penis- circular moti | DOUCHING, RECTAL OR GENITAL SURGERY AND DISEASE. I.E UTI, DIABETES, STIS. ASK WHAT PT PREFERENCE- CULTURAL WISE MATTER-OF-FACT= DO IT AS QUICK AS POSSIBLE-RETRAT AFTER CLEANING WIPE LEAST TO MORE CONTINATED- |
| AM CARE COULD BE: | INDEPENDENT: PT IS INDEPENDENT- NURSES GATHER SUPPLY AND SHOWER HIMSELF PARTIAL: Nurse set up everything and assist PT on hard part to reach (back extremities) promote independence. DONE AT SINK OR BED | TOTAL : Doing Total care. Always do it with another student. |
| PM (PRN ) CARE : | Bath patient. If refuse, document. When family comes in, say :YOU SURE YOU DONT WANT A BATH, I ASK YOU EARLIER? ASK WHY. IF PT,. HAS A DISCHARGE ORDER, YOU DONT HAVE TO. | Patients who are diaphoretic (sweating profusely) may need their clothing and bed linens changed several times a shift. |
| PROPER HYGIENE: | DECREASE BREAK CYCLE OF TRANSMISSION-PROMTE CIRCULATION AND COMFORT | |
| SAFETY LROR-PRT-INFORM PATIENT OF WHAT ILL BE DONE | CHECK TEMPERATURE OF ROOM AND WATER-ASK IF RESTROOM IS NEEDED AND PAIN MEDICATION IF IN PAIN LOCK BED, RAISE BED, OPPOSITE RAIL SIDE UP | LEAVING THE ROOM, NURSE SHOULD: LEAVE BED LOCKED-LOWEST POSITION-RAIL SIDE UP- LINENS IN DESIGNATED AREAS(NEVER FALL ON GROUND) |
| FEMALES? | SHOULD NOT DOUCH- TO NOT DISRUPT NORMAL FLORAL PAY SPECIAL ATTENTION UNDERNEATH BREAST AND BETWEEN SKIN FOLDS | PIERCINGS new and crusted and slightly inflamed: Rinse the sites with warm water and remove crusts with a cotton swab. |
| DENTURE CARE? | WEAR GLOVES-HAVE PT PUT IT IN A CUP- HAVE COLD L WATER- HOLD IT ABOVE THE SINK WITH A TABLECLOTH UNDER-USE DENTAL CLEANSER INSTED OTHER TOOTHPASTE | HAVE PT WASH GUN AND RINSE OUT |
| EYE CARE? EAR CARE | DO IT FIRST-WIPE IN TO OUT WITH A DIFFERENT SIDE OF THE MITTEN W/ NS The nurse notices that one of the lenses(STORE IN NORMAL SALINE) is not centered over the cornea: Apply gentle pressure on the lower eyelid to center the lens prior to removing it. | NEVER CLEAN IT WITH A COTTON SWAP-USE FINGER +WATER |
| HAIR CARE? SHAVING | ASK PREFERENCE- SHAVE MALE UP DOWN; FEMALES DOWN UP, PEDICULOSIS | USE ELECTRIC RAZORS W/ PT ON ANTICOAGULANT =CUTTING WILL CAUSE BLEEDING |
| FACE CARE? | for an adolescent with severe acne: *Wash the skin twice a day with a mild cleanser and warm water. *Keep hair off the face and wash hair daily. Avoid sun-tanning booth exposure and use sunscreen. | |
| FOOT CARE ? | Bathe the feet thoroughly in a mild soap and tepid water solution. Dry feet thoroughly, including the area between the toes. Use an antifungal foot powder if necessary to prevent fungal infections. | |
| CARING FOR PATIENT WHO CAN'T SWALLOW? | ARRANGE FOR SUCTIONING TO REMOVE MUCUS ASSIST PT. TO A LATERAL POSITION [PROVDE FREQUENT MOUTH CARE | INCONTINENT PT? USE SPECIAL PERINEAL SKIN CEANERS AND MOSITURE BARRIERS TO PREVENT SKIN BREAKDOWN AND EXCORIATION |
Created by:
Seka_nurse
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