Hygiene Flashcards by Deja Leverette

Science of health and its maintenance

Hygiene

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Three conditions favorable to growth of micro-organisms

warm/dark/moist

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Direct spread through biting, kissing, sex, touching is an example

direct transmission

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Indirect Transmission ( 2)

vechicle

Vehicle – Borne. Inanimate object (fomite/surface):
handkerchiefs, toys, cooking utensils, surgical instruments, food, water, blood or serum transmits disease

Wildlife or flying/crawling insect transports infection
Ex: Lyme disease

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Through sneezing, coughing, spitting, singing or talking (caregiver needs a mask- usually inhaled or enter via the eye)

droplet transmisson

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Airborne Transmission

Disease spread via air currents through droplets or dust

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Bathing Tips:

Check water temperature, offer bedpan before bed bath, wipe front to back for perineal care, ensure tub safety with non-slip surfaces and accessibility for infants.

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Blue

Decreased 02 of cells

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Erythema ( r/t )

Redness of the skin. Related to vasodilatation and inflammation.
Red- Pressure/ Irritation

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PALLOR (r/t)

Pale or whitish Anemia, Ischemia

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Ecchymosis:

Black & Blue Trauma to Vessels

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*Petechiae

Pin Point Trauma to Capillaries

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Purpura-

Common in Elderly Texture- Smooth & Supple Dryness- generalized or Localized

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*Turgor

Recoil 1-2 seconds Dehydration

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Edema:

Swelling Pitting or Non Pitting Causes Heart disease, PVD, restriction, poor venous return

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Lesions Note:

use the assessment tree to determine the proper terminology. In your documentation, describe the type of lesion, size in millimeters or centimeters, shape, configuration, color, drainage, odor, and color of surrounding skin.

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Macular Rash: FLAT Papule: Raised & Solid Vesicle/Bulla:

FLUID FILLED Vesicle: <0.5 cm Bulla (Bullae): >0.5 cm Pustule: PUS FILLED Mixed Bag of Lesions

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*Pressure Injury Skin Tear Cleanliness Temperature Diaphoresis-

profuse sweating Hot- fever, infection, environment Cold – Circulation trouble, aging, environment Warm

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*Normal Eye Assessment Sclera:

White Conjunctiva: pink Cornea: Clear Without drainage, lesions Cleanliness Prosthesis

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*Nasal Assessment Clean,

moist mucosa, drainage free Mucosa pink and intact Abnormal: drainage, crustations, dry, irritated

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*Ear Assessment External ear:

free of drainage Ear lobes get larger with age May have cerumen (wax)

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*Ear Care

No bobby pins, toothpicks or Q-tips Wash and dry Assess for drainage, cerumen Hearing Aids Turn off hearing aid Before inserting into ear

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a condition that creates white patches on your tongue, gums or the inside of your cheeks.

Leukoplakia

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a common form of mouth ulcer, which appears as a painful white or yellow ulcer surrounded by a bright red area

Canker Sores

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The earliest stage of gum disease (periodontal disease)

Gingivitis

bad breath/ dark crusty

Halitosis and Sordes

T or F All skin wounds are NOT pressure injuries Only pressure areas are staged .

T- All skin wounds are NOT pressure injuries Only pressure areas are staged

All skin lesions can be classified as partial thickness. T or F

F All skin lesions can be classified as partial thickness or full thickness.

Pressure Ulcer Prevention and Assessment

-Good skin care, -lifting instead of pulling, -using pressure-relieving device

Results in ischemia (insufficient supply of blood) and hyperemia (excess blood flow engorgement)

1. Pressure Like brush burn, abrasion 2.Friction Caused by gravity and friction Decreases or stops blood flow through the vessels 3.Shearing Wet skin softens and breaks open more easily Wet skin can cause rashes and lead to skin breakdown 4. Moisture Get

stages of stress ulcer (1 and 2)

Stage 1 ulcers have not yet broken through the skin. (RED) Stage 2 ulcers have a break in the top two layers of skin.

stages of stress ulcer ( 3 and 4)

Stage 3 ulcers affect the top two layers of skin, as well as fatty tissue. Stage 4 ulcers are deep wounds that may impact muscle, tendons, ligaments, and bone.

Nanda Dx: For Partial thickness & Stage 1 and Stage 2 –

Impaired Skin Integrity

Nanda Dx: For Full Thickness & Stage 3 and Stage 4

Impaired Tissue Integrity

Assessment of pressure injuries includes evaluating factors like ( hint the abbreviate)

redness, ecchymosis, edema, drainage, approximation

yellow indicates and clear/white indicates

PUS/bulla

What are the characteristics you are looking for during the skin assessment? (8)

- color - pigmentation -texture -moisture - turgor/recoil, -edema, -lesions, -cleanliness -temperature.

Elasticity of the skin and can show the hydration status of the patient

Turgor

How should you assess turgor?

Check on the forearm or the clavicle area or rarely back of the hand - slightly pinch up the skin and analyze the skins recoil time (slow= dehydrated and fast= hydrated)

swelling caused by excess fluid trapped in your body's tissues (most notable in the hands, arms, feet, ankles, and legs)

edema

You would assess it through the edema

GRADING SCALE and by pushing 8 mm on affected area

What is the edema grading scale?

0: no pitting edema 1+ mild pitting slight indentation, no perceptible swelling of the leg (disappears rapid) 2+ mod pitting, indentation subsides 10-15 seconds 3+ deep pitting, indentation remains for short time, leg looks swollen (1 min+) 4+ very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted (2 min+)

___________is a condition characterized by -usually thick, dark hair in women where it usually doesn't grow (face, chest area, etc.) excessive hair growth.

hirsutism

What do you look for in a nail assessment? (6)

- general color and marking -cleanliness -thinness/thickness -adherence to nail bed -shape and contour -capillary refill

Which of the four examination techniques do we use for assessing hair, skin, and nails?

(inspection, percussion, palpation, auscultation)

When inspecting the skin, what information can we get? (6)

-color -uniform -thickness -symmetry -hygiene -lesions

Why is age not something that we can tell during a skin inspection?

Wrinkles do not define a certain age

What are five functions of the skin?

1. protection 2. secretory organ 3. senses pain 4. regulates body temp 6. absorption of vitamins(D)

softening of the skin from prolonged moisture making epidermis prone to injury

Maceration

rubbing away of epidermal layer of skin especially over bony areas caused by friction/shearing

abrasion

Skin tear or injury caused by pressure, friction, shearing force, or moisture.

pressure injuries

Inflammation of sebaceous gland common among adolescence and adults.

acne

Where can you best see jaundice?

sclerae

Name two physiological causes of erythema.

Inflammation and vasodilation

At risk for alteration in epidermis and or dermis. (what impairment)

Skin Integrity Impairment

NIC interventions fo Impaired skin/tissue

bathing/ perineal care/pressure management /skin surveillance and wound care

To provide privacy and warmth during a bed bath, a(n) ____________ should be placed over the resident.

Bath blanket

In addition to promoting cleanliness, comfort and a sense of well-being for the individual, a bed bath also helps prevent __________________.

pressure sores

What kind of baths ( assist, partial, complete) ___________ the nurse helps the patient with areas difficult to reach ( back/feet/legs) _____________ the nurse washes patients entire body without assistant. _____________ the nurse cleanses only the areas that may cause odor/discomfort. (perineum/axillae)

1. Assist bath 2. Complete bath 3. Partial bath

For which type of bath will you most likely have a prescription ?

basin n bath

T of F Assessments, including skin assessments and abdominal assessments, can be done during bathing.

what is the function of the stratum corneum?

outer most layers acts as a barrier it restricts water loss and prevents fluids/pathogens and chemicals from entering the body.

What is a function of brown adipose tissue (BAT) in newborns? a.Generates heat for distribution to other parts of body b.Provides ready source of calories in the newborn period c.Protects newborns from injury during the birth process d.Insulates the body against lowered environmental temperature

Heat generated in brown fat is distributed to other parts of the body by the blood. It is effective only in heat production. The newborn from injury during the birth process. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of heat.

What are the 6 categories of the Braden Scale? MO, NU, F, A, M, S ( some are topics we learned in class)

Sensory perception Moisture Activity Mobility Nutrition Friction and Sheer pts with score of 16 or less are at risk for developing pressure ulcers.

PUSH TOOL

pressure ulcer scale for healing

Impaired Skin Integrity:

Altered epidermis and/or dermis

“Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.” = Impairment

Impaired Tissue Integrity

Wound assessment | 9

- wound tissue: type of tissue present, mobility, texture, turgor, pigment - wound location, shape, size, depth, undermining, tunneling, contraction - wound drainage, odor - signs of infection - bleeding, ecchymosis, burns, exposed structures - scar tissue: banding, pliability, sensation and texture - hair/nail growth - sensation: pain, temp, tactile - factors aggravating wound/scar or causing additional trauma

pressure ulcer formation factors | 6

a. incontinence, b.friction and shear c. immobility d. loss of sensory perception, e. level of activity, f. poor nutrition

How to prevent pressure ulcer formation | bring up devices/ how often to turn

Good skin care Lift rather than pull Use supportive pressure-relieving devices (special mattresses, sheepskin, heel protectors, special beds). NO DONUTS Turn and position Q 2 Hrs. (USE SCHEDULE)

REEDA

R- Redness E- Ecchymosis E- Edema D- Drainage A- Approximation

______-Healthy epithelialization n Granulation buds _______________ Yellow/tan/brown- slough may be adhered loosely or firmly. Black/leathery _______ decreased blood supply( whats the skin looking like)

Red Necrotic tissue Pale

_____* what drianage* contains little cells matter; serum is straw colored; clean wounds

Serous drainage watery

_____*drianag *edamage to capillaries; bright red or dark red-brown

Sanguineous drainage bloody

; combination of bloody and serous drainage; new wounds

Serosanguineous drainage

Thick, odor; infected; pus; yellow or blue green

purulent drainage

Red-tinged pus; small vessels in wound have ruptured

Purosanguineous drainage

Hygiene Flashcards

(77 cards)