Ch. 22 Facilitating hygiene

Question 1

______ _______ promotes comfort, improves self image, decreases infection and disease

Answer 1

Personal hygiene

Question 2

What is the nurses role in patient hygiene?

Answer 2

Assess self care abilities

Provide assistance w/ ADLs

Promote self care in ADLs

Delegate appropriate parts of hygiene care

Activities of daily living (ADLs) : 
Bathing
Complete = head to toe
Showering
Combing hair

Question 3

Which factor influence hygiene and self care?

Answer 3

Psychosocial/physical factors

Personal preferences (showers vs baths)

Culture and religion (Beliefs about hygiene and cleanliness)

Economic status/living environment (homeless, etc.)

Developmental level (parents bathe children, depending on age children dislike baths, then puberty comes and showering becomes more frequent)

knowledge level (does a woman know to wipe front to back? does pt understand flossing importance)

Physical factors:

1. Pain: limits mobility and energy.if pain give medication, wait a half hour to see pain level then give bath
2. Limited mobility: decreased range of motion, weakness, bedrest
3. Sensory deficits: decreased independence and increased safety concerns (example: loss of eyessight, cannot find supplies w/out asst; pt with hearing loss on anticoagulant needs electric razor to avoid cutting himself)
4. Cognitive impairment - doesn’t udnestand need for hygiene, cannot problem-solve, forgetful,
5. emotional or mental disturbances - Patients suffering from depression often report a profound lack of energy or motivation and may neglect their grooming and hygiene practices because of thi

Question 4

What is the importance of maintenance of personal hygiene?

Answer 4

Promotes comfort (hair style)
Improves self-image
Decreases infection and disease
Contributes to physical and psychological well-being
Fosters activity and movement
Provides comfort

Question 5

Which factor would be most likely to influence the hygiene practice of the homeless client?

a. The client’s degree of mental illness
b. The client’s cultural beliefs
c. The client’s living environment
d. The client’s knowledge level

Answer 5

Correct answer: C

The homeless client may have no access to facilities in which to perform routine hygiene measures.

Question 6

Why should you respect and accommodate your patients’ hygiene preferences?

Answer 6

Respecting the patient’s hygiene preferences promotes maximum participation and independence with ADLs and reflects caring. Nothing turns someone off more than being forced to do anything!

Question 7

T or F: In a study of ICU unit, 48% of hygienes performed resulted in “adverse event.” Therefore, in ICU you should avoid hygiene care.

Answer 7

False! Modification should be made to decrease the chances of an adverse event. You could provide care in small segments, allowing rest periods.

p.467

Question 8

Why asess pt willingness and ability to perform ADLs?

Answer 8

enables us to determine the type of help needed and to encourage self care. p467

Question 9

What are the steps in assessing self-care abilities?

Answer 9

1. Obtain health history - identify self care deficits and tolerance for hygiene care
2. assess cognitive and physical ability - level of consciousness, memory function, ability to follow instructions, mobility, energy level
3. Identify other factors influencing - religion/culture/etc/
4. Assess for sensory disturbances - senses in tact? ex. no tactile sensation for heat may burn themself.
5. determine preferences - FOcus on ability to perform self care and the need for assistance (in what capacity)

Question 10

T or F: Hospitals have standard routines for hygiene care and you should not deviate from them.

Answer 10

False. You must tailor to the patient preferences, needs and tolerance, etc.

Question 11

What is the purpose or hourly rounding?

Answer 11

offer help with self-care needs such as pain relief, positioning and toileting

also called safety and comfort rounds

Question 12

What are typical things we do during:

1. early morning care
2. a.m. care
3. p.m. care
4. H.S. care

Answer 12

1. Early morning care: on awakening – wash face and hands, mouth care
2. A.M. care: after breakfast – bathing, toileting, hair, skin, bedmaking
3. P.M. care: afternoon – toileting, hand washing, oral care, readying for visitors
4. H.S. care: prior to sleep – relaxation activities, readying environment to facilitate sleep, back massage. lights and tv off, close the door!

Question 13

You may delegate hygiene care to a NAP. It is your responsibilty to assess pt to ensure it is safe to do so. If the pt is unstable or the NAP is inexperienced or unfamliar, what do you do?

Answer 13

Assist or perform the care yourself!

Question 14

Before turning hygiene care over to the NAP what should you do?

Answer 14

Assess prior to delegating
 Instruct NAP regarding
Client’s limitations
Amount of assistance needed
Use of assistive devices
Presence and care of tubes
Observations to make during hygiene care (look for lesions, skin over bony prominence, ulcers, 

p.469

Question 15

A)What are the layers of our skin? .

B)What are the main functions of the skin?

Answer 15

A:

1. epidermis - replaced every 3-4 weeks
2. melanin - protects against UV rays
3. dermis - contains blood/lymphatic vessels/nerves/sweat and sebaceous glands.

B:

1. protection
2. sensation - heat cold pressure pain
3. REgulation - maintain f&e balance; sweat cools
4. secretion/excretion-perspiration of waste products
5. vitamin d formation - sun + form of cholesterol = vitamin d

Question 16

Factors affecting the skin:

Answer 16

1. dampness
2. dehydration - can lead to dry cracked skin
3. nutritional status - morbidly obese may not be able to reach areas and develop odors/fungal infections
4. insufficient circulation - can lead to tissue death
5. skin disease
   6 jaundice
6. lifestyle person choices - tanning, tattooing

Question 17

When bathing a client, you have opportunity to asess the skin. Look for:

Answer 17

OBJECTIVE DATA:

Color: pallor, erythema, jaundice, cyanosis
Conditions that affect the skin: maceration (softening of skin from prolonged moisture: urinary incontinence)
pruritus (itching), excoriation (loss of superficial layers due to scratching and enzymes in feces; acne;
Alterations in skin integrity: abrasions, pressure ulcers
Take picture of anything dr needs to assess
Document every single wound/bruise etc upon arrival, this will keep you from being blamed

SUBJECTIVE DATA:

1. ask about usual pref
2. past or current skin problems? effects on pt?
3. Prescription meds, OTC etc, that is being used to treat skin
4. allergies
5. history of disease of the skin

Question 18

Bathing serves three purposes: health, social interaction, and pleasure or relaxation. What other benefits can you think of?

Answer 18

1. bath water and friction of bathing dilate the blood vessels increasing circulation
2. stimulates depth of resp and provide sensory input
3. bonding time with pt

Question 19

When giving a bed bath to a patient, what supplies do you need?

Answer 19

1. Basin of water (105 degrees)
2. bath linens
3. clean gown
4. bathing supplies - soap etc

Question 20

What is the difference between a complete and partial bed bath?

Answer 20

Complete is from head to toe while partial is on a focused area. Both are performed by the RN or NAP.

Partial is given when the pt is experiencing stress from the activity.

Question 21

If a patient has miled to moderate impaired skin integrity or activity tolerance, you can give them a ____ bath. p.473

Answer 21

towel

Question 22

What is an “assist bath”?

Answer 22

When RN bathe areas hard to reach

Question 23

The confused client becomes distressed and agitated when the NAP attempts to give the morning bath. The nurse instructs the NAP to complete a

a. partial bath
b. help bath
c. bed bath
d. complete bath

Answer 23

Correct answer: A

The intent of the partial bath is to cleanse only the areas in most need of hygienic care. The nurse would continue to monitor the client’s emotional/cognitive status and alter the type of bath accordingly.

Question 24

When is a tub bath preferable?

Answer 24

when client is ambulatory but requires assistance due to pain and stiffness in hand and arms. Immersion helps soak crusty, scaly, soiled;relaxes stiff sore muscles.p475

Question 25

The PCP may prescribe a _____ _____ . The prescription will include spec instructions for type of bath, solution to be used, areaa to be treated, and water temp.

Answer 25

therapeutic bath

oatmeal bath, coal tar bath, sitz bath, etc

Question 26

How often should you give perineal care?

Answer 26

When you give a complete bed bath; more frequently if the pt is incontinent of urine or feces or has drainage from the area.

Question 27

Regardless of which type of bath used, when possible end with a _____ ______ to provide relaxation and stimulate circulation. CHECK FOR CONTRAINDICATION!

Answer 27

back massage

Question 28

Pts with dementia commonly become combative when told its time to bathe. THe reason is because they experience pain, cold, fear and loss of control. What can you do to reduce this behavior?

Answer 28

Meet pt comfort needs, adjust water temp, take special care with joints, etc. Educate family on towel baths/partial baths.

Question 29

When bathing obeses and morbidly obese pts, pay special attention to _______

Answer 29

skinfolds

Question 30

List common foot problems

Answer 30

1. corns - look like a piece of corn, are painful
2. calluses - like corn, over bony prom. and caused by rubbing BUT calluses dont hurt
3. Tinea Pedia - Athlete’s foot (tough actin tinactin); caused by fungi; commonly cracked skin between toes
4. ingrown toenail - improper fitting shoes or improper cutting of nails causes this
5. foot odor - wash dem stank feet
6. plantar warts - soles and heels get them
7. pressure ulcers - heels and ankles from being bed ridden
8. bunions - look up a picture, you will never forget it; caused by tight shoes and genetics such as arthritis

Question 31

When assessing feet look for:

Answer 31

cleanliness, odor, skin integrity, redness, drainage, swelling, edems, cracks between toes, temp, capillary refill.

Question 32

why are diabetic pts at high risk for foot disease?

Answer 32

neuropathy

Question 33

Oral care facilitates:

Answer 33

Removal of food particles and secretions
Improved appetite
Reduces incidence of HCA pneumonia (teeth may be important reservoir for pneumonia causing bacteria, esp in ventillated pts.
Assessment of client’s oral status
Care of dentures
Assessment of the oral cavity: Condition of the teeth, cavities, gingivitis; Conditions affecting the mouth: stomatitis, glossitis, oral lesions/malignancies

p482-3

Question 34

The structures pertinent to oral hygiene include the ____, _____ and ____.

Answer 34

tongue, gingiva, and teeth

Question 35

Normal stages of tooth development:
First set of teeth erupt at age _____

By _____, children have about 20 teeth.

Around _____, they loosen and fall out and are replaced with adult teeth

Answer 35

6month - 2 years

age 2

6-12

Question 36

Poorly fitted or loose dentures can lead to …

Answer 36

chewing difficulties and even nutritional deficiencies

Question 37

When providing oral care for the unconscious patient, the nurse should

a. Place the patient on his side with the head of the bed in a lowered position.
b. Skip brushing the teeth as the patient could aspirate.
c. Swab the patient’s lips and oral cavity with lemon glycerin swabs at least hourly.
d. Place the patient in an upright position and brush his teeth with a sponge brush

Answer 37

Correct answer: A

To facilitate oral hygiene and protect the patient's airway, the nurse should keep the patient on his side with his head lower than his stomach.

minimal amt of solution required.

Question 38

Risk factors for oral problems:

Answer 38

1. hist of peridontal disease
2. lack of money or insruance for care
3. pregnancy - increases gum bleeding (on menstrual cycle you will notice this, I never schedule cleanings within a week prior or after Aunt Flo)
4. poor nutrition or eating habits (baby bottle tooth decay is an example).
5. medications/treatments (diuretics, dilantin, cyclosporine, …jaw surgery, radiation, etc.)
6. dry mouth
7. compromised self care ability

Question 39

Common mouth problems include dental caries and periodontal disease. What are some addl problems?

Answer 39

Halitosis - many causes p.483

Gingivitis - can progress to periodontal disease

Tartar build up - LACK OF FLOSSING!!! can lead to tooth loss

Stomatitis - inflam. of oral mucosa

glossitis - inflammatin of the tongue

cheilosis - cracking /ulceraction of lips

oral malignancies

geographic tongue - looks like a map

Question 40

What is the purpose of the padded tongue blade?

Answer 40

unconscious pt often responds to oral stimulation by biting down. Use tongue blade instead of fingers to hold mouth open.

Question 41

Why should you avoid lemon glycerin swabs?

Answer 41

they are drying to oral mucosa and may cause changes in enamel. Avoid hydrogen peroxide too because it irritates and alters balance of normal flora

Question 42

What is pediculosis?

Answer 42

head lice.

Question 43

What is an alternative to shaving with a razor that can be used for pt on anticoagulants? Men with curly facial hair?

Answer 43

electric razor

depilatory

Question 44

How do you remove the artificial eye?

Answer 44

using your dominant hand, raise the upper eyelid and depress lower lid. Apply slight pressure below the eye to RELEASE THE SUCTION HOLDING IT IN PLACE.

If you want to really see some stuff, look at volume 2 :-|
It’s a cartoon but it is still terrifying (even beyond dentures, Des)

Question 45

Which change in hygiene practices may be necessary as the patient ages?

1) Brushing teeth twice a day
2) Bathing every other day
3) Decreasing moisturizer use
4) Increasing soap use

Answer 45

Answer:
2) Bathing every other day

Rationale:
As a person ages, sebaceous glands become less active, causing skin to dry. Older people may find it necessary to bathe every 2 days, increase the use of moisturizers, and decrease soap use to prevent further drying of skin. Older adults should brush their teeth after every meal and at bedtime to prevent tooth decay. It is recommended that people of all ages brush their teeth at least twice a day, so that option does not represent a change in an older adult’s hygiene practices.

Question 46

A woman of Orthodox Jewish faith who underwent a hysterectomy for cancer is being cared for on the surgical floor. Which healthcare team member(s) could be assigned to bathe this patient? Choose all correct answers.

1) Male nursing assistant
2) Male licensed practical nurse
3) Female graduate nurse
4) Female registered nurse

Answer 46

Answer:

3) Female graduate nurse
4) Female registered nurse

Rationale:
Orthodox Judaism prohibits personal care being provided by a member of the opposite sex. The patient who underwent a hysterectomy is female; therefore, out of respect for her religious beliefs, she should not be bathed by the male licensed practical nurse or nursing assistant.

Question 47

A 75-year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with dehydration. A nursing diagnosis of Risk for Impaired Skin Integrity is identified for this patient. Which factor places the client at Risk for Impaired Skin Integrity?
______________

Answer 47

Answer:
Dehydration

Rationale:
Dehydration places the patient at risk for impaired skin integrity. Dehydration, caused by fluid volume deficit, causes the skin to become dry and crack easily, impairing skin integrity. People who are very thin or very obese are more likely to experience impaired skin integrity. This patient is of normal height and weight; therefore, his body stature does not place him at risk. There is nothing to suggest that this patient has an impaired nutritional status.

Question 48

The nurse notes a lesion that appears to be caused by tissue compression on the right hip of a patient who suffered a stroke 5 days ago. How should the nurse document this finding?

1) Maceration
2) Abrasion
3) Excoriation
4) Pressure ulcer

Answer 48

Answer:
4) Pressure ulcer

Rationale:
The nurse should document a lesion caused by tissue compression and inadequate perfusion as a pressure ulcer. Abrasion, a rubbing away of the epidermal layer of skin, is commonly caused by shearing forces that occur when a patient moves or is moved in bed. Maceration is a softening of skin from prolonged moisture. Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces.

Question 49

The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed?

1) Bathe the patient’s entire body using 8 to 10 washcloths.
2) Assist the patient to a chair and provide bathing supplies.
3) Saturate a towel and blanket in a plastic bag, and then bathe the patient.
4) Assist the patient to the bathtub and provide a bath chair.

Answer 49

Answer:
1) Bathe the patient’s entire body using 8 to 10 washcloths.

Rationale:
A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water; warms in them in a microwave, and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient’s body is bathed with a fresh cloth. A bag bath is not given in a chair or in the tub.

Question 50

For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds?

1) Cover the mattress with a sheepskin.
2) Keep the linens wrinkle free.
3) Separate the skin folds with towels.
4) Apply petrolatum barrier creams.

Answer 50

Answer:
2) Keep the linens wrinkle free.

Rationale:
Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Sheepskins are not recommended for use at all. Petrolatum barrier creams are used to minimize moisture caused by incontinence.