Hygiene, Rest & Sleep, Nutrition & Oral Hydration Flashcards

You may prefer our related Brainscape-certified flashcards:
1
Q

Bathing

A

Bathing clients is often delegated to AP
nurse is responsible for data collection and client care.

Give a complete bath to clients who can tolerate it and whose hygiene needs warrant it.

Allow rest periods for clients who become tired during bathing.
Partial baths are useful when clients cannot tolerate a complete bath

-those who cant stand long enough, if they are in pain, have a medical procedure (surgery)
Watch for skin issues

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2
Q

Eyes and Ears

A

Use a clean, moist washcloth without any soap to wipe gently across the eyelids from the inner to the outer canthus.
-inside out

Rotate the end of a clean, moist washcloth gently into the ear canal
-never jam anything

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3
Q

Oral Care

A

Proper oral hygiene helps decrease the risk of infection in LTC especially pneumonia.

Other populations who require meticulous oral hygiene include those who are seriously ill, injured, unconscious, dehydrated, o have an altered mental status or limited upper body mobility

-those with dysphagia, ventilator patients, and intubated patients (lung infections)

-oral care before and after eating for dysphagia pt

-helps prevent pneumonia,

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4
Q

Foot care

A

Foot care prevents skin breakdown, pain, and infection.

Foot care is extremely important for clients who have diabetes mellitus, and a qualified professional must perform it.
-doctors (podiatry),
Nurses can wash the feet but cannot clip the toenails unless they have undergone specific training
Foot care: watch for any tingling/numbness

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5
Q

Peri care

A

Perineal care helps maintain skin integrity, relieve discomfort, and prevent transmission of micro‑organisms (catheter care).
Prevent infections
Catheter care 2-3 times a day
4 inches away, not tugging at the meatus
Front to back

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6
Q

Culture and social practice

A

Culture also plays an important role, because some cultures have unique hygiene practices. Be sure to be respectful and observant of each client’s specific cultural needs

Socioeconomic status can affect clients’ hygiene status. If a client is homeless, alter discharge instructions and follow‑up care accordingly

Some cultures may feel uncomfortable, men cant complete certain cares on women, homelessness/impoverty should be given resources for follow-up care

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7
Q

Safety

A

Adjust the bed to a comfortable working height.
Don gloves.
Roll the bottom linens up in the bottom sheet or mattress pad under the client who is turned to one side, facing the opposite direction. For safety purposes, adjust and lower side rails accordingly.
Apply clean bottom linens to the bed (draw sheets are optional), and extend them to the middle of the bed with the remainder of the linen fan‑folded underneath the client.
Have the client roll over the linens and face the opposite direction, then remove the used linens (keep them away from your uniform) and apply the clean linens. Make sure the linens are free from wrinkles.
Apply the upper sheet and blanket.
To remove the pillowcase, insert one hand into the opening, grab the pillow, and turn the pillowcase inside‑out.
Apply the clean pillowcase by grasping the center of the closed end, turning the case inside‑out, fitting the pillow into the corner of the case, and pulling the case until it is right‑side out over the pillow

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8
Q

Foot care considerations

A

It is important to prevent any infection or pain that can interfere with gait.

A qualified professional should perform foot care for clients who have diabetes mellitus, peripheral vascular disease**, or immunosuppression to evaluate the feet and prevent injury

Inspect the feet daily, paying specific attention to the area between the toes.

Use lukewarm water, and dry the feet thoroughly.*
Apply moisturizer to the feet, but avoid applying it between the toes.***
Avoid over‑the‑counter products that contain alcohol or other strong chemicals.

Wear clean cotton socks daily.**
Check shoes for any objects, rough seams, or edges that can cause injury.**
Cut the nails straight across, and use an emery board to file nail edges.**
Avoid self‑treating corns or calluses.

Wear comfortable shoes that do not restrict circulation.

Do not apply heat unless prescribed.****

Contact the provider if any indications of infection or inflammation appear**

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9
Q

Nsg Peri Care

A

It is important to maintain skin integrity to relieve discomfort and prevent transmission of infection (catheter care).

PRINCIPLES OF PERINEAL CARE
Provide privacy.
Maintain a professional demeanor.
Remove any fecal material from the skin.
Cleanse the perineal area from front to back (perineum to rectum).
Dry thoroughly.

Retract the foreskin of male clients to wash the tip of the penis, clean from the meatus outward in a circular motion, then replace the foreskin.

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10
Q

Nsg oral care

A

Check for aspiration risk, impaired swallowing, and a decreased gag reflex.

Clients who have fragile oral mucosa require gentle brushing and flossing.

Have suction apparatus ready at the bedside when providing oral** hygiene to clients who are unconscious to help prevent aspiration.****

Do not place your fingers into an unconscious client’s mouth because the client could bite down on your fingers.

Position the client on one side with the head turned toward you in either a semi‑Fowler’s position, or with the head of the bed flat.

This will allow fluid and oral secretions to collect in the dependent side of the client’s mouth and drain out

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11
Q

Nsg shaving

A

Safety is important. Clients who are prone to bleeding, are receiving anticoagulants, or have low platelet counts should use an electric razor.***

Soften the skin with warm water
.
Apply liquid soap or shaving cream.

Hold the skin taut.

Move the razor over the skin in the direction of hair growth using long strokes on large areas of the face and short strokes around the chin and lips.**

Be sure to communicate with clients about personal shaving preferences

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12
Q

NREM 1

A

transition from wakeness to sleep 5-10

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13
Q

NREM 2

A

body temp drops
heart rate slows
brain forms sleep spindles
20 mins

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14
Q

NREM 3

A

muscles relax
BP and breathing slow drop
Deepest sleep

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15
Q

REM

A

Rapid Eye Movement
brain activity occurs
body is relaxed and immobilized
dreams occur

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16
Q

Sleep Duration

A

Infants and toddlers averaging 9 to 15 hr/day
Adolescents averaging 9 to 10 hr/day
Adults 7 to 8 hr/day

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17
Q

Insomnia
acute v chronic

A

The most common sleep disorder,
Inability to get an adequate amount of sleep and to feel rested. It might mean difficulty falling asleep, difficulty staying asleep, awakening too early, or not getting refreshing sleep.

Acute insomnia lasts a few days possibly due to personal or situational stressors.

Chronic insomnia lasts a month or more.**

Some people have intermittent insomnia, sleeping well for a few days and then having insomnia for a few days.

Women and older adults are more prone to insomnia
Acute insomnia due to stress

18
Q

Sleep Apnea
Central V obstructive

A

More than five breathing cessations lasting longer than 10 *****seconds per hour during sleep, resulting in decreased arterial oxygen saturation levels.

Sleep apnea can be a single disorder or a mixture of the following

Central: Central nervous system dysfunction in the respiratory control center of the brain that fails to trigger breathing during sleep.

Obstructive: Structures in the mouth and throat relax during sleep and occlude the upper airway.

19
Q

Narcolepsy

A

Sudden attacks of sleep that are often uncontrollable
Often happens at inappropriate times and increases the risk for injury
Falling and head injuries

20
Q

Hypersomnalence

A

Excessive daytime sleepiness lasting at least 3 months for Dx
Impairs social and vocational activities**
Increased risk for accident or injury related to sleepiness

21
Q

sleep assessment

A

Ask about sleep patterns, history, and any recent changes.
Identify the usual sleep requirements.

Ask about sleep problems (type, manifestations, timing, seriousness, related factors, aftereffects).

Use a linear or visual scale with “best sleep” on one end and “worst sleep” on the opposite end and ask for asleep rating on a 0 to 10 scale.**

Check for common factors that interfere with sleep.

22
Q

What can interfere with sleep

A

Physiologic disorders: Can require more sleep or disrupt sleep (sleep apnea, nocturia)

Current life events: Traveling more, change in work hours

Emotional stress or mental illness: Anxiety, fear, grief

Diet: Caffeine consumption, heavy meals before bedtime

Exercise: Promotes sleep if at least 2 hr before bedtime, otherwise can disrupt sleep

Fatigue: Exhausting or stressful work makes falling asleep difficult.

Sleep environment: Too light, the wrong temperature, or too noisy (children, pets, loud noise, snoring partner)

Medications: Some can induce sleep but interfere with restorative sleep. Others (bronchodilators, antihypertensives) cause insomnia.

Substance use: Nicotine and caffeine are stimulants. Caffeine and alcohol tend to cause night awakenings

23
Q

Nursing actions for sleep

A

Help clients establish and follow a bedtime routine.

Limit waking clients during the night.
Promote a quiet hospital environment.

Help with personal hygiene needs or a back rub prior to sleep to increase comfort.

Consider continuous positive airway pressure (CPAP) devices for clients who have sleep apnea.
Consult the provider about trying sleep‑promoting over‑the‑counter products (melatonin, valerian, chamomile).

As a last resort, suggest that the provider prescribe a pharmacological agent. Medications of choice for insomnia are benzodiazepine‑like medications, which include the sedative‑hypnotics zolpidem, eszopiclone, and zaleplon.

Adjust inpatient routines when possible to conform with clients’ home routines (bathing, bedtime).

24
Q

pt education for sleep

A

Exercise regularly at least 2 hr before bedtime.

Establish a bedtime routine and a regular sleep pattern.

Arrange the sleep environment for comfort.

Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime**

Limit fluids 2 to 4 hr before bedtime.**

Engage in muscle relaxation if anxious or stressed

25
Q

Nutrients
Macros

A

Carbohydrates provide most of the body’s energy and fiber. Each gram produces 4 kcal. They provide glucose, which burns completely and efficiently without end products to excrete.

Fats provide energy and vitamins. No more than **35% of caloric intake should be from fat. Each gram produces 9 kcal
.
Proteins contribute to the growth, maintenance, and repair of body tissues. Each gram produces 4 kcal.

26
Q

Nutrients
micro

A

Vitamins are necessary for metabolism. The fat‑soluble vitamins are A, D, E, and K. The water‑soluble vitamins include C and the B complex (eight vitamins).

Minerals complete essential biochemical reactions in the body (calcium, potassium, sodium, iron).

Water is critical for cell function and replaces fluids the body loses through perspiration, elimination, and respiration

27
Q

Nutrition and Metabolism Factors

A

Religious and cultural practices guide food preparation and choices.

Financial issues prevent some clients from buying foods that are high in protein, vitamins, and minerals.

Appetite decreases with illness, medications, pain, depression, and unpleasant environmental stimuli.

Negative experiences with certain foods or familiarity with foods clients like help determine preferences.

Environmental factors (sedentary lifestyles, work schedules, and widespread access to less healthy foods) contribute to obesity.

Disease and illness can affect the functional ability to prepare and eat food.

Medications can alter taste and appetite and can interfere with the absorption of certain nutrients.

Age affects nutritional requirements

28
Q

Nutrition for newborns and infants

A

Newborns and infants (birth to 1 year)
High energy requirements
Breast milk (ideally) or formula to provide:
Solid food starting at 4 to 6 months of age**
No cow’s milk or honey for the first year
**

29
Q

Toddlers nutritional

A

Toddlers (12 months to 3 years) and preschoolers 3 to 6 years)
Toddlers and preschoolers need fewer calories per kg of weight than infants do.**
Toddlers and preschoolers need increased protein from sources other than milk.
*
Calcium and phosphorus are important for bone health.
Nutrient density is more important than quantity

30
Q

School ages 6-12 nutritional needs

A

School‑age children need supervision to consume adequate protein and vitamins C and A.

They tend to eat foods high in carbohydrates, fats, and salt.

They grow at a slower and steadier rate, with a gradual decline in energy requirements.

31
Q

Adolescents (12 to 20 years) nutritional needs

A

Metabolic demands are high and require more energy.
Protein, calcium, iron, iodine, folic acid, and vitamin B needs are high.
One‑fourth of dietary intake comes from snacks.
Increased water consumption is important for active adolescents.
Body image and appearance, fast foods, peer pressure, and fad diets influence adolescents’ diet

32
Q

Young adults (20 to 35 years) and middle adults (35 to 65 years)

A

There is a decreased need for most nutrients (except during pregnancy).

Calcium and iron are essential minerals for women.**
Good oral health is important

33
Q

Older adults (over 65 years) nutritional needs

A

A slower metabolic rate requires fewer calories.

Thirst sensations diminish, increasing the risk for dehydration.

Older adults need the same amount of most vitamins and minerals as younger adults.

Calcium is important for both men and women.

Many older adults require carbohydrates that provide fiber and bulk to enhance gastrointestinal function.*****

34
Q

Bullimia and anorexia nervousa

A

Anorexia nervosa
Significantly low body weight for gender, age, developmental level, and physical health.
Fear of being fat
Self‑perception of being fat
Consistent restriction of food intake or repeated behavior that prevents weight gain

Bulimia nervosa: a cycle of binge eating followed by purging (vomiting, using diuretics or laxatives, exercising excessively, fasting)
Lack of control during binges
Average at least one cycle of binge eating and purging per week for at least 3 months
Esophageal burns, knuckles, going to the bathroom after eating

35
Q

Binge-eating

A

Binge‑eating disorder: repeated episodes of binge eating
Feels a loss of control when binge eating, followed by an emotional response (guilt, shame, or depression)
Does not use compensatory behaviors (purging)
Binge‑eating episodes can range from one to multiple times per week.
Clients are often overweight or obese.

36
Q

BMI levels

A

A BMI of 25 is the upper boundary of a healthy weight
25 to 29.9 is overweight
30 to 34.9 is obesity class 1
35 to 39.9 is obesity class 2
40 and above is obesity class 3.

37
Q

nutritinal assessment

A

Number of meals per day
Fluid intake
Food preferences, amounts
Food preparation, purchasing practices, access
History of indigestion, heartburn, gas
Allergies
Taste
Chewing, swallowing
Appetite
Elimination patterns
Medication use
Activity levels
Religious, cultural food preferences and restrictions
Nutritional screening tools

38
Q

I&O

A

Record I&O.
Monitor I&O for clients who have fluid or electrolyte imbalances.
Measure and calculate all intake and output in mL (1 oz = 30 mL).

Intake includes all liquids (oral fluids, food that liquefy at room temperature, IV fluids, IV flushes, IV medications, enteral feedings, fluid instillations, catheter irrigants, tube irrigants).

Output includes all liquids (urine, blood, emesis, diarrhea, tube drainage, wound drainage, fistula drainage).

Weigh clients each day at the same time, after voiding, and while wearing the same type of clothes.

If using bed scales, use the same amount of linen each day, and reset the scale to zero if possible.

39
Q

nutritional assessment of poor intake

A

Nausea, vomiting, diarrhea, constipation
Flaccid muscles
Mental status changes
Loss of appetite
Change in bowel pattern
Spleen, liver enlargement
Dry, brittle hair and nails
Loss of subcutaneous fat
Dry, scaly skin
Inflammation, bleeding of gums
Poor dental health
Dry, dull eyes
Enlarged thyroid
Prominent protrusions in bony areas
Weakness, fatigue
Change in weight
Poor posture

40
Q

interventions

A

Assist with preventing aspiration.
Position in Fowler’s position or in a chair.
Support the upper back, neck, and head.
Have clients tuck their chin when swallowing to help propel food down the esophagus.*
Avoid the use of a straw. -risk
*
Observe for aspiration and pocketing of food in the cheeks or other areas of the mouth.*
Observe for indications of dysphagia (coughing, choking, gagging, and drooling of food).
Keep clients in semi‑Fowler’s position for at least 1 hr after meals.

Provide oral hygiene after meals and snacks.

41
Q

Therapetuic diet

A

Provide therapeutic diets
NPO: no food or fluid at all by mouth, not even ice chips, requiring a provider’s prescription before resuming oral intake

Clear liquid: liquids that leave little residue (clear fruit juices, gelatin, broth)

Full liquid: clear liquids plus liquid dairy products, all juices. Some facilities include pureed vegetables in a full liquid diet. Cant see
Avoid red jell-o

Pureed: clear and full liquids plus pureed meats, fruits, and scrambled eggs (no teeth, stroke)

Mechanical soft: clear and full liquids plus diced or ground foods
Soft/low‑residue: foods that are low in fiber and easy to digest (dairy products, eggs, ripe bananas)

High‑fiber: whole grains, raw and dried fruits

Low sodium: no added salt or 1 to 2 g sodium (cardiac pt)

Low cholesterol: no more than 300 mg/day of dietary cholesterol (cardiac pt)

Diabetic: balanced intake of protein, fats, and carbohydrates of about 1,800 calories

Dysphagia: pureed food and thickened liquids (honey, nectar, pudding)

Regular: no restrictions

42
Q

nsg interventions

A

Maintain fluid balance.
Administer IV fluids.
Restrict oral fluid intake (maintaining strict I&O).
Remove the water pitcher from the bedside.
Inform the dietary staff of the amount of fluid to serve with each meal tray.
Inform the staff of each shift of the amount of fluid clients may have in addition to what they receive with each meal tray.
Record all oral intake, and inform the family of the restriction.
Encourage oral intake of fluids.
Provide fresh drinking water.
Remind and encourage a consistent fluid intake.
Ask about beverage preferences.