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NURS 106 Exam 2
Hygiene
| Question | Answer |
|---|---|
| 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
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