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Chapter 19 Blueprint
| Question | Answer |
|---|---|
| When talking with patients remember that they may not have the same hygiene practices as the ______ | Nurse |
| What type of patient may you see personal care modifications made in? | Limited mobility, vision problems, etc. |
| What is the largest organ in the body? | Skin |
| Name the 3 layers of the skin | Epidermis Dermis Subcutaneous |
| What are some of the functions of the skin? | Temp regulation secretion & sensory information maintain fluid & chemical balance Converting precursors to Vitamin D |
| What are the 4 main functions of the skin? | Sensation Excretion Secretion Protection |
| List some changes that occur to our skin as we age. | Skin is more fragile because of loss of collagen fibers. Skin wrinkles & sags. Sebaceous gland activity is decreased. |
| Can our skin ever be sterile? | NO |
| When you are making an assessment & you notice something abnormal what are you going to do? | Report it to the charge nurse & make sure that it is documented |
| You are assessing your patient's skin. List what you are going to observe for. | Color Texture Thickness Turgor Temperature Hydration |
| What is our primary goal when it comes to skin care? | To prevent skin breakdown |
| You find during skin assessment that there is a break in the skin. What does this increase the patient's risk for? | Infection |
| What is the factor that will most likely result in a decubitus ulcer? | Prolonged pressure |
| List patients that are at an increased risk for skin breakdown | Chronically ill Debilitated Unconscious Older (decreased skin elasticity) Disabled Underweight or Overweight Incontinent Spinal cord injury Limited Mobility Poor overall Nutrition |
| Define Necrosis. | Death of tissue |
| List some bony prominences where patients are more prone for skin breakdown. | Sacrum Ischial Tuberosities hips heels malleoli of the ankles ears head |
| When turning a patient what do you want to make sure of in relation to the skin breakdown? | Keep them off the area where the skin is broken |
| Describe Stage 1 pressure ulcers | The skin is red & intact. It doesn't blanch |
| Describe Stage 2 pressure ulcers | Partial Thickness, involves epidermis, dermis, or both. The ulcer is superficial. Abrasion, blister, or shallow crater. |
| Describe Stage 3 Pressure ulcers | Full thickness. Necrosis of the subcutaneous that may extend deep down but not through underlying fascia, deep crater with drainage. |
| Describe Stage 4 pressure ulcers | Full thickness, extensive destruction, tissue necrosis, damage to muscle, bone, or supporting structures. |
| What is reactive hyperemia? | The process in which the blood rushes to a place where there was a decrease in circulation |
| What is eschar? | Necrotic tissue which is black, tough, & hard |
| Decubitus ulcers cannot be staged if _______ is present. | Eschar |
| What is the initial care if a decubitus ulcer? | Debridement |
| List the guidelines for care of pressure ulcers. | Use surgical asepsis Don't message red area Nutritional support Observe hydration Turn client every 2 hrs Reassess redness after 30 to 45 mins Reposition chairbound client every hr Pressure relieving matress Document & report abnormal findings & d |
| How do you chart for abnormal findings? | document a description of a pressure ulcer & be specific. Give a visual picture of the are. Document drainage & be specific. |
| What are some things that determine what type of bath a patient will get? | patient's diagnosis patient's condition movement in their condition limits on movement |
| Besides bathing what are some other hygiene interventions we can do? | Use deodorant/antiperspirants wear cologne wear clean undergarments |
| What are some benefits you can receive from a bath? | Reduce chance of infection Stimulate circulation Cuts down on odor Feel refreshed Relaxing Improve self esteem Allow exercise Good time to do an assessment |
| Describe the hygiene care of the elderly. | They may get a bath only every other day and you should warm the room before bathing to prevent chilling |
| You are bathing your patient when they become short of breath. What would you do? | Stop, let the patient rest, & resume later if possible |
| You have readied your supplies for a bath. What part of the body do you begin bathing first? | Eyes |
| Describe full bed baths and who would receive one | you must was the entire body while the patient is in bed. The patient isn't able to wash anything. This would be for a patient that is unable to move or cooperate in their bathing |
| Describe Partial bed bath | bed bath were the nurse will assist the patient by washing any areas that the patient can't reach. This type of bath is for patients with limited use of hands and arms |
| Describe the shower or tub bath | a bath in a shower or tub. For a patient that can get out of bath |
| Describe a sitz bath and what type of patient would use this | Bath where buttocks and peri area are submerged in water. For patients with hemorrhoid surgeries or vaginal deliveries. |
| Describe a cool water/tepid bath | A bath in cool water for 25-30 minutes. It is used to reduce fever or for patients with dermatitis. |
| Describe a medicated bath | bath with additives such as oatmeal, cornstarch, or Barrow's solution. For patients with tension, itching, or with certain skin problems. |
| Describe a whirlpool bath | immersion of the body or body part in a tank of water agitated by a jet of equally hot water or air. It is for patients that need the skin cleaned, peripheral circulation, comfort, & debridement |
| What type of patient may not tolerate the heat from a sitz bath? | patient with broken skin older patients patient with decreased sensation |
| Your patient is receiving a sitz bath. What are you going to observe them for? | Faintness/weakness Syncope Dizziness Vertigo Pressure to the back of the legs Increased pulse Chilling |
| You have a patient that comes in with dermatitis and has dry, itchy skin. What type of bath and additives might you see ordered? | medicated bath with oatmeal or cornstarch additives. Notes also say a tepid bath may be used for a patient with dermatitis |
| Describe peri care for a female | Clean labia majora & labia minora Clean from front to back |
| Describe peri care for a male | Retract foreskin & cleanse underneath it Replace the foreskin Clean from the end of the penis down the shaft |
| What might happen if the retracted foreskin is not replaced? | Discomfort, contricture, & edema |
| What is a complication if peri care is not done correctly on a female? | UTI |
| What should you do before shaving your patient? | Determine the type of razor to be used Check area for moles, skin tags, sores Check to see if patient is on anticoagulant meds Check for low platelet count Check to see if patient is receiving chemotherapy |
| When might you see an electric razor used instead of a safety razor? | if the patient: is on anticoagulant meds has a low platelet count is undergoing chemotherapy |
| What could happen to a patient if you remove their IV from the IVAC and forget to adjust the flow or hook it back up? | Overload |
| Define sordes | dried crust containing mucus, microorganisms, & epithelial cells shed from the mucus membranes. Common on the lips & teeth of an unconscious patient |
| If you patients gums bleed what adjustments would you implement? | Use extra care Use soft bristle toothbrush, toothette, gauze, or wash cloth |
| Describe how to do denture care | place washcloth/towel in the sink DO NOT use hot water place them in water or denture cleaner Label the container Do not place on the food tray |
| What do you need to do after you have gathered supplies for oral care and right before beginning the procedure? | Raise the bed to a comfortable position |
| What position would you place the unconscious patient in and why? | laying flat on his/her side with the head slightly lowered. This is to prevent aspiration. |
| What might you see used on an unconscious patient to prevent fluids from collecting in their mouth and being aspirated? | Suction |
| How often should oral care be done on an unconscious patient? | Every 8 hours |
| How often should oral care be done on an unconscious patient that is NPO? | Every 2 hours |
| When doing hair care for your patient. What do you need to assess for? | sores scratches marks pressure areas lice nits |
| What is pediculosis & where can you find it? | Infestation of lice. It can be found on head skin body eyelids eyelashes pubic region |
| What is alopecia & what may cause it? | loss of hair. May be caused by lack of hair care, illness, or medications |
| You have a patient that has really bad tangles, can you cut their hair to remove them? If no, what can you do? | Use alcohol & a comb |
| What type of patient should you teach proper care of the hands, feet, & nails? | Diabetic patients & patients with circulatory problems |
| What do you want to do to the patient's feet before beginning nail care? | Soak |
| What do you clean under the nails with? | Orange stick |
| How would you cut nails? | straight across |
| What type of patient would you have to have a doctor's order to cut their nails? | diabetic patient |
| What does care of the eyes include? | washing/drying the eyes applying meds compresses protecting the eye from injury |
| Discuss how you would clean someone's glasses. | Wash with tepid water (not hot) Wash with mild soap rinse dry with a cloth store in a safe place |
| If your patient couldn't remove their own contact lenses. How could you safely remove them? | Open eyes with non dominant hand Place dominant hand on lower lid Gently grasp contact lense Use saline solution if needed |
| In an emergency situation when you cannot remove contacts, what can you do? | You can use a suction device or ask a nurse that is familiar with contacts. |
| Do prosthetic eyes restore vision? | No they are just for cosmetic purposes |
| If you use cotton swabs to clean the ear canal what could this lead to? | infection & injury to the ear canal |
| Describe the patient teaching for blowing their nose. | Blow gently & do not block both nostrils |
| What could happen if you block both nostrils while blowing the nose? | It could force debris into the Eustachian tube causing an ear infection or damage to the ear drum. |
| How would you clean the nose? | The best way is by blowing it gently. If dry secretions are present then clean with soap and water. |
| Describe the care of a hearing aide. | Clean with water (Do not immerse) Do not use alcohol Dry thoroughly Mark L/R & store properly |
| What is feedback and what would you do to correct it? | The noise causes by the hearing aid not being positioned correctly in the patients ear. Adjust & reposition the hearing aid to correct this problem. |
Created by:
Jacksonville VNE
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