Fundamentals Chapter 19

Question 1

Hygiene

Answer 1

Proper care of the skin, hair teeth and nails
 Protects form infection and disease
 Sense of well being
 Maintain safety, privacy and warmth
 Encourage independence

Question 2

Function of the Skin

Answer 2

o Protection
o First line of defense against bacteria and other organisms;
protects against thermal, chemical, and mechanical injury
o Sebaceous glands make the skin waterproof
o Sensation
o Contains sensory organs for touch, pain, heat, cold and pressure
o Temperature regulation
o Regulates temperature by constricting or dilating blood vessels and activating or inactivating sweat glands

Question 3

Changes that occur to the skin with ageing

Answer 3

o Loss of elastic fibers causes skin to wrinkle and sag
o Skin becomes thinner, fragile, and slower to heal
o Decreased sebaceous activity leaves skin dry and itchy; temperature control is altered by decreased sebaceous gland activity and thinner skin
o Hair becomes thinner, grows more slowly, and loses its color from loss of melanocytes
o Thickening of nails

Question 4

Assessment

Answer 4

o Factors affecting hygiene practices
o Economic status
o Knowledge level
o Ability to perform self-care
o Personal preferences
o Different cultures have different views on hygiene
practices

Question 5

Assessment during bath

Answer 5

o Opportunity for assessment
 Condition of patient’s skin
 Overall physical appearance
 Emotional/Mental status
 Learning needs
 Opportunity for head to toe data collection

Question 6

Skin and Pressure Ulcers

Answer 6

o Ulcers form from local interference with circulation
 Skin blanches or becomes pale
 Darker skin may look purple
 If interference (pressure) removed, skin becomes darker as
blood supply returns (reactive hyperemia)
 Damaged skin becomes “boggy” or stiff and may be warmer or cooler

Question 7

Pressure Ulcers; skin factors

Answer 7

o Immobility
o Inactivity
o Moisture
o Incontinence, Diaphoresis
o Inadequate nutrition
o Advanced Age
o Altered sensory perception/ mental awareness
o Edema
o Friction and Shea

Question 8

Assessment for skin and pressure ulcers

Answer 8

o Braden Scale for predicting pressure sore risk
o Reassess every 24 hours
o Check with turn and reposition
o Pay attention to the skin over bony prominences
o Blanchable skin: damage is not expected
o Medicare does not reimburse for preventable injury
o Document pressure injuries on admission

Question 9

Stage 1

Answer 9

 area of reddened skin that does not blanch when touched
 Discoloration in people with dark skin; warmth, edema, or induration may be present

Question 10

Stage 2

Answer 10

partial-thickness skin loss
 May look like an abrasion, blister, or shallow crater; surrounding skin may feel warmer

Question 11

Stage 3

Answer 11

*full-thickness skin loss
*Looks like a deep crater; may extend into the fascia; subcutaneous tissue damaged or necrotic
* Visible fat
*Undermining/tunneling

Question 12

Stage 4

Answer 12

full-thickness skin loss
 Extensive tissue necrosis or damage to muscle or
supporting structures; bone may be visible; may appear dry and black, often infected

Question 13

Suspected deep tissue injury

Answer 13

 localized discolored intact skin
 Maroon/purple or blood filled blister

Question 14

Unstageable pressure ulcer

Answer 14

full thickness
 Eschar- thick, tough, tan, brown or black
 Slough- wet or stringy, green, yellow, brown, or grey
 Disguises the depth of the wound

Question 15

Preventing Pressure ulcers

Answer 15

o Nursing care is the main factor in preventing pressure ulcers
o Your responsibility is to be aware of risk factors your patient may have and try to lessen them
o Prevention is less time-consuming and expensive than pressure ulcer treatment; assess skin carefully and frequently
o Change patient’s position at least every 2 hours
o Keep heels of immobile patients off the bed
o Avoid positioning directly on the trochanter
o Use trapeze or lift sheet to change position
o Use pressure-reducing devices such as foam pads or mattresses
o Use pressure-reducing devices for patients in wheelchairs
o Shift weight at least once an hour, preferably every 15 minutes
o Keep patients dry
o Use thin foam dressings under splints and equipment if
necessary
o Provide adequate nutrition and fluids

Question 16

Pressure Ulcer treatment

Answer 16

o Most effective treatment is via a team approach
o Patient, family or caregivers, health care providers
o Initial care of a pressure ulcer
o Debridement, wound cleansing, and application of dressings
o If the ulcer is infected, antibiotic therapy used
o Surgery needed to repair some pressure ulcers

Question 17

Nursing Diagnosis for Pressure ulcers

Answer 17

o Pain (acute or chronic)
o Ineffective peripheral tissue perfusion
o Decreased self-esteem
o Altered self care ability
o Altered nutrition
o Altered mobility
o Altered tissue perfusion
o Potential for altered skin integrity
o Impaired skin integrity

Question 18

Planning

Answer 18

o Schedule hygiene care
o Bedpan or urinal
o Oral care
o Bathing
o Shaving
o Nail care
o Dressing
o Change linens
o Back rub

Question 19

Bath purpose

Answer 19

-Four purposes
 Cleanse the skin
 Promote comfort
 Stimulate circulation
 Remove waste products
o May need to give either a partial or complete bath
o Encourage independence
o Water should be warm but should not burn the patient
o Provide for comfort, safety, and privacy
 Water should be warm, but not scalding
 Moisturize skin after bathing
 Bed and rails are up
 Drape and curtains
 Delegate

Question 20

Types of Baths

Answer 20

o Cleansing
 Most common type; done in bed, tub, or shower; offer
patient use of toilet before bathing
 May need assistive devices such as chair or stool in shower or tub
 No longer than 20 minutes
o Perineal Care
 Male- retract foreskin to clean and then replace
 Female- clean form urinary meatus towards rectum
o Homecare
 Safety bars and nonskid tub/shower
o Therapeutic bath
 Whirlpool bath—special whirlpool tub used to cleanse and
stimulate peripheral circulation
 Medicated bath- before surgery, wounds or foot soaks,
oatmeal to relieve dermatitis
 Sitz bath—applies moist heat and cleansing to perineal
area; medication may be added to water
 Sponge bath—may be used to bring down fevers

Question 21

Back Massage

Answer 21

o Communicates caring
o Fosters trust in the nurse-patient relationship
o Provides opportunity to assess skin on the back
o Stimulates circulation of blood to the area
o Reduces tension, promotes relaxation
o Should be performed with morning care and at bedtime
o Essential for patients confined to bed
o Warm lotion
o 3-5 minutes
o Avoid wounds

Question 22

Oral Care

Answer 22

o Lack of oral hygiene increase risk of stroke, heart disease and pneumonia
o Mouth care for the conscious patient
 Raise the head of the bed 45 to 90 degrees
 Place a towel under the chin
 Brush from the gum line to the edge of the teeth
 Monitor for excessive bleeding
 swabs for patients on bleeding precautions
o Unconscious patient
 Full mouth care every 4 hours, moist swabs every 2 hours
 Risk for aspiration- turn head to side
 Lubricate lips

Question 23

Denture Care

Answer 23

o Dentures should be cleaned to prevent irritation to the gums and
infection
o Assess mouth and gums
o A patient may use an adhesive for a better fit
o Care should be provided in the morning and at bedtime
o Do not place on meal tray
o Should be removed 6 hours per day
o Keep in labeled container with water or saline

Question 24

Hair Care

Answer 24

o Improves self esteem/ body image
o Avoid pulling on the scalp. Brush from scalp downward in small
sections
o Alcohol, astringents, or water may be used to loosen hair strands
that are tangled or matted
o Shampoo: Rinse free or shampoo caps if bedbound
o Written informed consent is needed to cut patients hair

Question 25

Shaving

Answer 25

o Be gentle; use short strokes with the safety razor o Check for bleeding precautions or anti-coagulant use first o You may not shave off a beard or mustache without written informed consent

Question 26

Nail care

Answer 26

o Trimming, cleaning under the nails, and cuticle care usually done with the bath o Soak the nails in warm soapy water 5-10 minutes o Use an orangewood stick to clean under nails o Push cuticles back gently o Use nail clippers to cut toenails straight across o Do not cut toenails of patient with diabetes or peripheral vascular disease o Assess nailbeds for circulation, observe for signs of infection

Question 27

Eye Care

Answer 27

o Assess eyes for crusting or drainage o Wipe from inner to outer canthus o Glasses  Use clean warm water and soft cloth to wipe glasses dry o Contacts  Removal of contact lenses  Wash hands thoroughly, and wear gloves  Slide contact down to lower lid and gently pinch o Cleaning contact lenses  Clean with commercially prepared cleaning solutions  Moisten the lens and rub it gently between the fingers  Store in containers labeled right and left o Artificial eye – pressure placed below lower lid will pop prosthesis out

Question 28

Ear Care

Answer 28

o No object including cotton swabs should be inserted into the ear canal o Assess for cerumen (wax) and wipe from outer ear o Primary Care Provider must perform irrigation o Hearing aids  Clean the earpiece daily AS DIRECTED daily to prevent the buildup of wax and debris  Do not submerge hearing aid in water  If hearing aid is not working:  Check to make sure the unit is turned on  Battery is installed correctly (it may need to be replaced)  No cracks or breaks in the plastic housing or tubing

Question 29

Evaluation of the skin

Answer 29

o Patient has no evidence of redness, irritation or breaks in skin integrity o Skin integrity is maintained o Hair is clean and neat o Mucous membranes are moist, intact and odor free

Question 30

Which of the following is not one of the basic purposes of bathing?  Cleanses the body  Promotes comfort  Stimulates conversation  Removes waste products

Answer 30

Stimulates conversation

Question 31

Which of the following is true regarding mouth care?  Mouth care creates halitosis and dental caries.  An unconscious patient should be provided full mouth care at least every 24 hours.  When assisting a conscious patient with mouth care, you should raise the head of the bed 15 to 30 degrees.  Dentures should be kept in a labeled denture container with saline or water when not in the patient’s mouth.

Answer 31

Dentures should be kept in a labled denture caontainer with saline or water when not in the patients mouth