Chapter 40: Hygiene (IRAT/GRAT #1) Flashcards Preview

NURS 305 > Chapter 40: Hygiene (IRAT/GRAT #1) > Flashcards

Flashcards in Chapter 40: Hygiene (IRAT/GRAT #1) Deck (59)
Loading flashcards...
1
Q

Personal hygiene affects patients comfort, safety and well-being by

A
  • promoting comfort and relaxation
  • fostering a positive self-image
  • promoting healthy skin
  • helping to prevent infection and diseases
2
Q

Close contact provided by administering hygiene also promotes

A
  • the nurse-patient therapeutic relationship
  • patient teaching and counseling
  • opportunities for ROM
  • thorough physical assessment especially of the integument, oral cavity and sensory organs
3
Q

Functions of the skin include

A

protection, secretion, excretion, body temperature regulation and cutaneous sensation

4
Q

Skin consists of 2 primary layers

A
  1. epidermis

2. dermis

5
Q

epidermis

A

shields underlying tissue against water loss and injury and prevents entry of disease-producing microorganisms with the aid of normal flora

6
Q

dermis

A

supports the epidermis. Nerve fibers, blood vessels, sweat glands, sebaceous glands and hair follicles all run through the dermal layer.

7
Q

subcutaneous layer contains

A

blood vessels, nerves, lymph, loose connective tissue (fat cells)

8
Q

Subcutaneous tissue supports

A

upper skin layers to guard against pressure and injury.

9
Q

Changes in skin condition result in alterations of

A

color, thickness, texture, turgor, temperature and hydration

10
Q

turgor

A

the resilience of normal skin when subject to physical distortion.
ex) pinching or pressing (good indicator of hydration).

11
Q

Risk factors for skin impairment

A

immobilization, reduced sensation, nutrition/hydration alterations, secretions/excretions on the skin, vascular insufficiency, external devices and altered cognition.

12
Q

sebum

A

has bactericidal action

13
Q

What factors influence hygiene?

A

social practices, personal preferences, body image, socioeconomic status, health beliefs/motivation, cultural variables, developmental stage, and physical condition.

14
Q

Assessment of the skin

A
  • head to toe assessment of skin
  • inspect beneath medical devices (if possible) such as antiembolic stockings and orthopedic devices for skin breakdown, redness and rashes
15
Q

Head to toe assessment of the skin includes

A

less obvious or difficult to reach surfaces: under the breasts, folds of skin, scrotum, groin, female perineum.

16
Q

Patients may be unable to

A

see or sense (decreased sensory perception) pressure points such as the heels and bony prominences.

17
Q

Common sites for pressure sores

A

lying on back: back of the head, shoulder, elbow, buttocks and heal
lying on side: ear, shoulder, elbow, hip, thigh, leg, and heal
lying on stomach: elbow, rib cage, thigh, knees and toes

18
Q

Documentations of skin

A

accurate documentations of skin condition is essential for patient safety and CMS reimbursment

19
Q

if lesions, blisters, pressure ulcers are noted,

A

use institutional policy and procedure to document these findings.
including photo documentation: size, location, stage (if a pressure ulcer), undermining, tunneling

20
Q

True or False: Never use a previous shifts assessment

A

True. Trust but Verify!

21
Q

The oral cavity

A

mucous membranes of the mouth (especially under the tongue) are filled with blood vessels

22
Q

Saliva

A

cleanses the mouth, dissolves food chemicals to promote taste, moistens food to aid in bolus formation, contains enzymes that aid in the breakdown of starchy foods.

23
Q

What impairs salivary function?

A

medications, exposure to radiation, dehydration and mouth breathing

24
Q

Assessment of the oral cavity: assess for

A
  • poor fitting dentures
  • general condition of the oral cavity: halitosis, receding gum tissue, gingivitis, glossitis, cavities, pain/infection, missing teeth
25
Q

gingivitis

A

inflammation of the gums

26
Q

glossitis

A

inflammation of the tongue

27
Q

Oral Hygiene

A

mouth is a breeding ground for bacteria

28
Q

Evidence of poor oral health results in an increased risk for

A

impaired nutrition and pneumonia (especially in intubated patients and those with decreased gag reflex).

29
Q

What is the problem with using commercially made foam swabs?

A

they are ineffective in removing plaque

30
Q

What is the problem with using lemon-glycerin sponges?

A

they dry mucous membranes and erode tooth enamel

31
Q

Unconscious patients cannot

A

swallow secretions. Secretions often contain gram-negative bacteria that cause pneumonia if aspirated.

32
Q

halitosis

A

foul-smelling breath

33
Q

cheilitis

A

cracked lips

34
Q

What has current evidence shown that reduces the risk for ventilator associated pneumonia (VAP)?

A

chlorhexidine/water rinse

35
Q

What should nurses consider when performing oral hygiene?

A

never use your fingers to hold a patient’s mouth open (don’t stick your fingers in anyone’s mouth.
handle dentures with care: they are expensive!

36
Q

Assessment of Feet and Nails

A
  • assess all patients with particular attention to those with disease that impair peripheral circulation and sensation. May notice an unequal gait.
  • always remove socks/non-skid socks to check the backs of heels.
37
Q

Diabetes and foot/nail hygiene

A

foot ulceration is the most common single precursor to lower-extremity amputations.

38
Q

Teach preventative foot care include:

A

good fitting shoes, wearing socks, inspect daily;use family members if poor mobility/flexibility, never go bare foot or wear open toe sandals, keep nails trimmed and feet moisturized, make regular check ups with podiatrist.

39
Q

Assessment of eyes

A

-check for drainage, crusting.
-Wash gently, inner to outer canthus.
If patient wears glasses, keep them in reach.

40
Q

Assessment of ears

A

cerumen (ear wax).

Does the patient wear hearing aids?

41
Q

Assessment of nose

A

drainage.

decreased sense of smell -> decreases sense of taste -> decreasing appetite -> leads to decreased nutritional status.

42
Q

Special Considerations for an Uncircumcised male

A

imperative to return foreskin to its natural position after cleaning.

43
Q

Why is it imperative to return foreskin to its natural position after cleaning?

A

tightening of foreskin around the shaft of the penis causes local edema and discomfort.
patients with reduced sensation may not feel tightening.

44
Q

How aging affects body tissues: Skin

A
  • decreased elasticity, epidermal cell replacement and resiliency
  • increased dryness and increased risk of bruising
45
Q

How aging affects body tissues: feet and nails

A
  • chronic foot problems
  • systemic disease (diabetes)
  • increased dryness
  • perhaps poor eyesight and mobility to care for feet and nails.
46
Q

How aging affects body tissues: mouth

A

increased dryness due to medications

decreased vascularity in gums, dentures

47
Q

How aging affects body tissues: hair

A

hair distribution changes, scalp hair is thinner and drier

48
Q

How aging affects body tissues: eyes, ears, and nose

A

affects ADL’s

49
Q

How aging affects body tissues: physical condition

A

safety is a priority, limited ROM, impaired sensation

50
Q

Use Critical Thinking Attitudes When Planning Care including:

A

confidence (builds trust), thinking independently, fairness, responsibility/accountability, risk taking, discipline (orderly approach), perseverance, creativity, curiosity, integrity, and humility.

51
Q

Assessment of Self-Care Ability

A

ability to perform or assist with ADL’s safely and efficiently.

52
Q

Assessment of Self-Care Ability includes

A
  • muscle strength, flexibility and balance
  • visual acuity
  • ability to detect thermal/tactile stimuli
  • mental status
  • orientation and cognitive function
  • activity tolerance
  • family involvement
53
Q

Nursing Diagnosis

A

use defining characteristics to support actual or at-risk for hygiene related diagnosis

54
Q

Nursing Diagnosis: Note

A
  • Self-care deficit (specify): r/t impaired mobility disease process, and depression.
  • impaired tissue integrity (risk or actual)
  • impaired oral mucous membranes
  • activity intolerance
  • risk for infection
55
Q

Patient teaching

A
  • use teamwork and collaboration with nursing assistive personnel and other health-care disciplines. PT/OT
  • make instruction relevant
  • adapt instruction to developmental level and personal resources
  • teach how to avoid injury
  • reinforce infection control practices
56
Q

What kinds of patients should not shave with a razor? Why?

A

patients on anticoagulant therapies, with low platelet counts and bleeding disorders.
razors can cause nicks/micro nicks in the skin which can lead to infection.

57
Q

SCIP (Surgical Care Improvement Project)

A

Measure Set: Surgical Care Improvement Project (SCIP)
Set Measure ID#: SCIP-Inf-6
Performance Measure Name: Surgery Patients with Appropriate Hair Removal
Description: Surgery patients with appropriate surgical site hair removal,. No hair removal, or hair removal with clippers or depilatory is considered appropriate. Shaving is considered inappropriate.

58
Q

CHG

A

chlorhexidine gluconate is used for daily bathing. Can leave skin feeling sticky. It helps reduce occurrence of HAI’s.

59
Q

stomatis

A

inflamed, sore mouth