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Found in Nurs Ch. 18

Hygiene and Care of the Patients Environment

Axilla Underarm area or Armpit
Bedpan Device for receiving feces or urine from the patients confined bed.
Canthus Angle at the medial and lateral margins of the eyelid. (INNER AND OUTER CORNER OF THE EYE).
Cerumen EARWAX; Yellowish or brownish waxy secretion produces by vestigial apocrine sweat glands IN THE EXTERNAL EAR CANAL.
Circumorbital Around the orbit; often referreing to the eye.
Dentures Artificial teeth not permanently fixed or implanted.
Febrile Body temperature above normal
Hygiene The science of health and its maintenance; system of principles for preserving health and preventing disease.
Labia majora Lip; two large folds of tissue extending from the mons pubis to the perineal floor.
Labia Minora Lip; Smaller fold of tissue covered by the labia majora
Medical Asepsis A group of techniques that inhibit the growth and spread of pathogenic microorganisms. "CLEAN TECHNIQUE"
Oral Hygiene (MOUTH CARE) Care of the oral cavity.
Pathogenic Capable of causing disease.
Perineal Care Care given to the genetalia
Personal Hygiene Self-care measures that people use to maintain their health.
Prone Lying face down on the abdomen
Range of Motion (ROM) Normal movement that any given joint is capable of making.
Sim's Position Lying on the left side with the right knee and thigh drawn upward toward the chest; the chest and abdomen are allowed to fall forward.
Supine Being in the horizontal position, lying face upward.
Syncope FAINTING; A transient loss of conciousness due to inadequate blood flow to the brain.
Umbilicus Point on the abdomen at which the umbilical cord joined the fetus.
Urinal A device for receiving urine; may be used with males or females; May be used for specimen collection.
Vertigo The sensation that the outer world is revolving about oneself or that one is moving in space.
When preparing for patient care, a student nurse lears that microorganisms are spread by placing linens where? On the floor
Why is a patient covered with a bath barrier during a bed bath? To prevent chilling
A patient with severe, crippling rheumatoid arthritis is confined to bed for extended periods. an erythematous and edematous area over the coccyx that has potential to become an open lesion is noted. This is referred to as what? A pressure ulcer
A 64-old patient with terminal cancer is too weak to perform her own perineal care. The student nurse will include bathing which areas as part of perineal care? Uppler thighs, genetalia, and anal area.
A child placed on bed rest is not at a great risk for a skin impairment. True or False False, they are at greatest risk for a skin impairment.
When giving a female patient a bed bath and caring for her face, what should the nurse do? ASK THE PATIENT for her preference of soap, cleasing cream, or plain water.
It is okay to use the same section of washcloth as part of the proper eye care for a patient when cleaning the face. True or false False, use should use a different section of the washcloth for each eye.
What is the correct temperature of water when filling a bathtub? 109.4* F
What is the purpose of a tepid sponge bath? To reduce the temperature in febrile patients.
It is okay to use the same section of washcloth as part of the proper eye care for a patient when cleaning the face. True or false False, use should use a different section of the washcloth for each eye.
What is the correct temperature of water when filling a bathtub? 109.4* F
What is the purpose of a tepid sponge bath? To reduce the temperature in febrile patients.
When performing perineal care on an uncircumsised man, what should the the nurse retract to cleanse the penis? The foreskin
When performing perineal care on a female patient, the nurse should cleanse from the ______ to the _______. Pubis to the Rectum
What is the optimal position for providing oral hygiene to a patient that is unconcious? side-lying with the head facing to the side as this will prevent choking.
It is ok to use a hard toothbrush when performing denture care for a patient? No, this may scratch the dentures. Brush the dentures with a soft brush.
Stage II pressure ulcers are identified as: full thickness skin loss extending but not through the fascia.
In addition to bathing, what intervention is likely to promote patient comfort? back rub
patients will experience conditions that threaten the integrity of oral mucosa; therefore ________ __________mouth care is needed. more frequent
What is the goal of meticulous foot care for patients? Prevent injury to the toes and feet.
What tissues are most vulnerable to pressure? Skin and muscle tissue.
Topical moisture barriers protect the skin from breakdown and impairment. True or False True
What color is eschar? tan, brown, or black
What kind of light should the nurse use when assessing a patient with dark skin? Fluorescent
Staging a pressure ulcer is not possible if the skin is intact with a blood-filled blister present that is cool to the touch. True or False. True.
What does the nurse need to do to create a therapeutic hospital room environment? Control the room temperature, ventilation, noise, and odors.
What is the recommended room temperature for an adult patient? 68* F to 74* F (20* to 23* C)
What should a nurse keep in mind regarding room temperature for older adults and infants? They are more likely to need warmer temperatures.
Different types of care are performed at various types of the day. What are the four times (general not specific) of the day this hygiene may be performed. 1. Early morning care (NOC Care) - Night Shift performs to get patient ready for breakfast. 2. Morning Care - After breakfast 3. Afternoon care - After diagnostic tests and procedures. Evening Care (HS) Hour before sleep - bedtime
What (7) factors may influence a patients personal hygiene? 1) Social practices 2) Body Image 3) Socioeconomic status 4) Knowledge 5) Personal preferencce 6) Physical Condition 7) Cultural Variables
To perform a back rub, the nurse will begin at the patients _____. The ypes of strokes to use are __________. Sacral area firm,smooth strokes
Patients on anticoagulants or that may have a bleeding disorder need to use what type of razor? Electric razor
What type of coordinated care is not appropriate to delegate to assistive personnel? Skin and Range of Motion (ROM) assessment as they require critical thinking and knowledge application unique to the nurse.
When a patient receives oxygen per nasal cannula, how often should the nurse clease the nares with a cotton-tipped applicator moistened with saline? Every 8 hours.
The patient in the hospital requires foot care, the nurse should include what in the care provided? Filing the toenails straight across.
What are the two mechanical factors that play a role in the devlopment of pressure ulcers? 1) shearing force - tissue layers of the skin slide on each other. 2) Friction - rubbing of the skin against another surface.
What are some possible risk factors for developing pressure ulcers? 1) patient stays in one position; especially, over bony prominences. 2)Patients that are chronically Ill patients, debilitated, older disabled, incontinent, limited mobility, spinal cord injury, or poor overall nutrition.
What are some general guidelines for the care of pressure ulcers? 1) Practice Surgical Asepsis 2) Never Massage reddened areas 3) Nutritional support 4)Hydration 5)Turn and reposition 6) pressure relief mattress 7) some topical agents
Stage I Pressure Ulcer ulcer is in a localized area of the skin, typically over bony prominence, intact with nonblanchable redness.
Stage II Pressure Ulcer Partial thickness loss of dermis
Stage III Pressure Ulcer Full thickness tissue loss in which subcutaneous fat is sometimes visible, but bone, tendon, and muscle are not exposed.
Stage IV Pressure Ulcer Full thickness tissue loss in which bone, tendon, and muscle are exposed.
Unstageable Pressure Ulcer full thickness tissue loss, a wound base that is covered by slough and/or eschar in the wound bed.
granulation tissue pink/red healthy skin that is reginerating tissue. No slough or eschar is present.
friable delicate
What are the 5 principles of medical asepsis for bedmaking? 1) keep soiled linens away from uniform 2) place soiled linens in hamper/bag 3) never fan linens in the air 4) Never place soiled linens on the floor 5) Remove all unecessary equipment and maintain a neat work area.
What are some possible nursing diagnosis for a patients ability to maintain personal hygiene? * Impaired oral mucous membranes * Impaired physical Mobility * Impaires Skin Integrity * Self-care deficit: bathing/hygiene * Self-care Deficit: dressing/grooming
Created by: losmica