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NURS 175 - Nursing Practice Foundations > Lesson 4 - Hygiene and Skin Care > Flashcards

Lesson 4 - Hygiene and Skin Care Flashcards

1
Q

Importance of Hygiene

A

-affects comfort, safety, well-being
-use therapeutic communication
-completing hygiene care can tell more about a patient

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2
Q

Role of Nurse

A

-ensure privacy
-be respectful
-comfort
-safety
-encourage self-care

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3
Q

SDOH and Hygiene

A

-cultural
-personal
-social
-environmental

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4
Q

Newborn Hygiene

A

-rely on others
-have thin skin that can dry out quickly
-skin folds increase incidence of infection
-oral care is important

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5
Q

Children

A

-like to mimic influences
-oral care is important
-head lice is possible

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6
Q

Adolescents

A

-have hormone changes
-body image concerns
-personal grooming is important

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7
Q

Adults

A

-varying skin condition
-practices depend on learned behaviours
-preferences
-expectations from others

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8
Q

Older Adults

A

-skin loses resiliency and moisture due to less active glands
-skin is fragile
-practices depend on varying events

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9
Q

Diabetes Mellitus

A

-chronic vascular changes that impair healing of skin and mucosa

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10
Q

AIDS

A

-fungal infections of the oral cavity are common

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11
Q

Stroke

A

-blind reflex can be impaired
-increased risk for corneal drying

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12
Q

Thin Skin

A

-prone to dryness and breakdown
-less frequent bathing

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13
Q

Skin Risks for Older Adults

A

-risk for infection
-skin folds
-pressure points
-perineum

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14
Q

Dry Skin

A

-cracks
-allows bacteria to enter

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15
Q

Xerostomia

A

-decreased saliva with medications
-common in older adults

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16
Q

Risks of Oral Care for Older Adults

A

-gum disease
-denture damage
-improper denture fit (decreased vascularity)

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17
Q

Gingivitis

A

-gum inflammation

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18
Q

Feet in Older Adults

A

-joint deformity in toes (wear shoes)
-keep feet clean and dry
-watch for sores and ulcers (esp. diabetic)
-ROM limitations prevent seeing feet

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19
Q

Individualizing Care

A

-patients perform tasks differently and nurses need to respect and acomodate that

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20
Q

Level 1 Care

A

-independent

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21
Q

Level 2 Care

A

-assistive devices to complete self care activities

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22
Q

Level 3 Care

A

-One person assistance

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23
Q

Level 4 Care

A

-dependent, requires complete care from provider

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24
Q

Assessment before hygiene care

A

-observe physical condition, integrity of integument, oral cavity, sense organs
-developmental factors
-self-care ability
-hygiene practices
-cultural preferences

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25
Q

Pre-Breakfast AM Care

A

-wash hands and face
-assist to bathroom
-assist with oral care

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26
Q

Post-Breakfast AM Care

A

-bath/shower/bedbath
-foot care
-pericare
-assist to bathroom
-oral hygiene
-change into clean clothes/gown
-attending to bed linens
-tidy room

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27
Q

Hours of Sleep Care

A

-attend to bed linens
-change clothes/gown
-wash hands and face
-oral care
-assist to bathroom
-place necessities close to bedside

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28
Q

Skin Condition/Folds Assessment

A

-skin colour
-skin moisture
-bruises
-tears
-sores
-pressure points

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29
Q

Hair Assessment

A

-moisture
-distribution
-smoothness
-cleanliness

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30
Q

Nails Assessment

A

-length
-condition
-cleanliness
-abnormalities

31
Q

Oral Assessment

A

-xerostomia
-thirst
-halitosis
-teeth condition
-denture equipment
-abnormalities

32
Q

Assessment During Grooming and Dressing

A

-clothing preference
-clothing cleanliness
-eyewear
-hearing aids
-hair style
-deodorant, lotion, make-up
-self-care ability

33
Q

Shaving and Hair Cutting

A

-make sure to get permission

34
Q

Tub Bath Safety Considerations

A

-water temp
-mobilizing in and out of tub
-slippery surfaces
-supervision
-tub cleanliness

35
Q

Bed Bath Safety Considerations

A

-side rails
-warmth
-privacy
-bed linens
-gloves
-back care for caregiver

36
Q

Shower Safety Considerations

A

-water temp
-slippery surface
-supervision
-ability to sit/stand
-call bell

37
Q

Confused Patient Care

A

-caregiver preference
-least distressing method
-prepare environment in advance
-minimize clothesless time
-distractions
-priorities
-visual/hearing aids
-praise
-calm/unrushed

38
Q

Nursing Diagnosis: Hygiene

A

-use critical thinking after assessing patient to identify actual or potential health problems
-ie. arthritis may lead to inability to turn faucet to wash self

39
Q

Steps to Determining Nursing Diagnosis

A

-observe
-assess strength, ROM, coordination
-level of fatigue
-vital signs

40
Q

Planning for Hygiene

A

-involve pt and family
-know available community resources
-consider timing of care

41
Q

Educating About Hygiene

A

-relevant instructions
-adapt to patients facilities
-teach injury prevention
-reinforce infection control

42
Q

Skin

A

-largest organ of the body
-first line of defence
-prevents water loss

43
Q

Epidermis

A

-outermost layer
-mostly dead skin cells

44
Q

Dermis

A

-inner layer
-tensile strength

45
Q

Aging Skin

A

-reduced elasticity
-decreased collagen
-thinning of muscle and tissue
-easily torn skin
-attachment between epidermis and dermis is flattened
-diminished inflammatory response
-slower wound healing
-less subcutaneous padding over bony prominences
-reduced nutritional intake

46
Q

Expected Skin Findings

A

-colour matches genetic background and is consistent
-skin is warm and dry
-brisk turgor return

47
Q

Unexpected Skin Findings

A

-cyanosis, jaundice, pallor
-hot, cool, cold
-sweaty
-clammy (cold and moist)
-delayed turgor
-present pressure wounds

48
Q

Pressure Injury

A

-localized to skin and underlying tissue
-usually over a bony prominence
-results from pressure, shear, friction, moisture, nutrition

49
Q

Effects of Pressure Injuries

A

-costly
-pain
-decreased mobility
-lowered quality of life

50
Q

Pressure Related Factors

A
  1. Pressure Intensity
  2. Pressure Duration
  3. Tissue Tolerance
51
Q

Pressure Intensity

A

-tissue ischemia (reduced blood flow)
-decreased sensation, not cue to shift pressure

52
Q

Nonblanching Erythema

A

-pressure area should become red after removing your finger
-if not, tissue damage may be evident

53
Q

Blanching

A

-occurs in normal red tones of light-skinned patients

54
Q

Characteristics of Dark Skin (RISK OF BREAKDOWN)

A

-colour remains unchanged and doesn’t blanch
-previous injury - skin may be lighter
-localized inflammation may be purple rather than red
-skin is warm to touch
-edema is taut and shiny
-stage 1 skin may have low resilience

55
Q

Pressure Duration

A

-low pressure over long period of time or high pressure over short period of time
-blood flow and nutrient occlusion = cell death

56
Q

Tissue Tolerance

A

-ability of tissue to endure pressure
-shear, friction, moisture affect

57
Q

Impaired Sensory Perception

A

-a risk for pressure injury development
-may not feel increased pressure and pain
-may not move away from pain

58
Q

Impaired Mobility

A

-a risk for pressure injury development
-unable to reposition = more prolonged pressure

59
Q

Alteration in Consciousness Level

A

-don’t understand pressure sensation
-can’t communicate discomfort and pain

60
Q

Shear

A

-a risk for pressure injury development
-force exerted parallel to the skin
-from gravity and resistance
-affects deeper skin layers

61
Q

Friction

A

-a risk for pressure injury development
-ie. skin dragged across bed linens
-affect epidermis

62
Q

Moisture

A

-a risk for pressure injury development
-ulcer formation
-reduced resistance
-soft skin more susceptible to damage

63
Q

Nutrition

A

-a risk for pressure injury development
-proteins (ie. collagen)

64
Q

Tissue Perfusion

A

-a risk for pressure injury development
-need oxygen to heal

65
Q

Infection

A

-a risk for pressure injury development
-prolonged inflammatory phase
-delayed collagen synthesis
-additional tissue destruction

66
Q

Pain

A

-a risk for pressure injury development
-pt can’t tolerate movement
-decreased tissue perfusion

67
Q

Age

A

-a risk for pressure injury development
-decreased inflammatory response
-many physiological changes

68
Q

Stage 1 Ulcer

A

-intact skin
-nonblanchable
-redness over a bony prominence

69
Q

Stage 2 Ulcer

A

-partial thickness loss
-shallow open ulcer
-may be serum filled blister

70
Q

Stage 3 Ulcer

A

-full thickness tissue loss
-subcutaneous fat may be visible
-no bone or tendon or muscle exposed
-may have tunnelling

71
Q

Stage 4 Ulcer

A

-full thickness tissue loss
-exposed bone, tendon, or muscle
-tunnelling

72
Q

Unstageable

A

-full thickness tissue loss
-base is covered by slough or eschar

73
Q

Braden Scale

A

-assesses patients for risk of skin breakdown
1. sensory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. friction and shear
-the lower the score the higher the risk

NURS 175 - Nursing Practice Foundations (11 decks)

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