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NURS 106 Exam 2


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