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

Lesson 4 - Hygiene and Skin Care Flashcards

(73 cards)

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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
Pre-Breakfast AM Care
-wash hands and face -assist to bathroom -assist with oral care
26
Post-Breakfast AM Care
-bath/shower/bedbath -foot care -pericare -assist to bathroom -oral hygiene -change into clean clothes/gown -attending to bed linens -tidy room
27
Hours of Sleep Care
-attend to bed linens -change clothes/gown -wash hands and face -oral care -assist to bathroom -place necessities close to bedside
28
Skin Condition/Folds Assessment
-skin colour -skin moisture -bruises -tears -sores -pressure points
29
Hair Assessment
-moisture -distribution -smoothness -cleanliness
30
Nails Assessment
-length -condition -cleanliness -abnormalities
31
Oral Assessment
-xerostomia -thirst -halitosis -teeth condition -denture equipment -abnormalities
32
Assessment During Grooming and Dressing
-clothing preference -clothing cleanliness -eyewear -hearing aids -hair style -deodorant, lotion, make-up -self-care ability
33
Shaving and Hair Cutting
-make sure to get permission
34
Tub Bath Safety Considerations
-water temp -mobilizing in and out of tub -slippery surfaces -supervision -tub cleanliness
35
Bed Bath Safety Considerations
-side rails -warmth -privacy -bed linens -gloves -back care for caregiver
36
Shower Safety Considerations
-water temp -slippery surface -supervision -ability to sit/stand -call bell
37
Confused Patient Care
-caregiver preference -least distressing method -prepare environment in advance -minimize clothesless time -distractions -priorities -visual/hearing aids -praise -calm/unrushed
38
Nursing Diagnosis: Hygiene
-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
Steps to Determining Nursing Diagnosis
-observe -assess strength, ROM, coordination -level of fatigue -vital signs
40
Planning for Hygiene
-involve pt and family -know available community resources -consider timing of care
41
Educating About Hygiene
-relevant instructions -adapt to patients facilities -teach injury prevention -reinforce infection control
42
Skin
-largest organ of the body -first line of defence -prevents water loss
43
Epidermis
-outermost layer -mostly dead skin cells
44
Dermis
-inner layer -tensile strength
45
Aging Skin
-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
Expected Skin Findings
-colour matches genetic background and is consistent -skin is warm and dry -brisk turgor return
47
Unexpected Skin Findings
-cyanosis, jaundice, pallor -hot, cool, cold -sweaty -clammy (cold and moist) -delayed turgor -present pressure wounds
48
Pressure Injury
-localized to skin and underlying tissue -usually over a bony prominence -results from pressure, shear, friction, moisture, nutrition
49
Effects of Pressure Injuries
-costly -pain -decreased mobility -lowered quality of life
50
Pressure Related Factors
1. Pressure Intensity 2. Pressure Duration 3. Tissue Tolerance
51
Pressure Intensity
-tissue ischemia (reduced blood flow) -decreased sensation, not cue to shift pressure
52
Nonblanching Erythema
-pressure area should become red after removing your finger -if not, tissue damage may be evident
53
Blanching
-occurs in normal red tones of light-skinned patients
54
Characteristics of Dark Skin (RISK OF BREAKDOWN)
-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
Pressure Duration
-low pressure over long period of time or high pressure over short period of time -blood flow and nutrient occlusion = cell death
56
Tissue Tolerance
-ability of tissue to endure pressure -shear, friction, moisture affect
57
Impaired Sensory Perception
-a risk for pressure injury development -may not feel increased pressure and pain -may not move away from pain
58
Impaired Mobility
-a risk for pressure injury development -unable to reposition = more prolonged pressure
59
Alteration in Consciousness Level
-don't understand pressure sensation -can't communicate discomfort and pain
60
Shear
-a risk for pressure injury development -force exerted parallel to the skin -from gravity and resistance -affects deeper skin layers
61
Friction
-a risk for pressure injury development -ie. skin dragged across bed linens -affect epidermis
62
Moisture
-a risk for pressure injury development -ulcer formation -reduced resistance -soft skin more susceptible to damage
63
Nutrition
-a risk for pressure injury development -proteins (ie. collagen)
64
Tissue Perfusion
-a risk for pressure injury development -need oxygen to heal
65
Infection
-a risk for pressure injury development -prolonged inflammatory phase -delayed collagen synthesis -additional tissue destruction
66
Pain
-a risk for pressure injury development -pt can't tolerate movement -decreased tissue perfusion
67
Age
-a risk for pressure injury development -decreased inflammatory response -many physiological changes
68
Stage 1 Ulcer
-intact skin -nonblanchable -redness over a bony prominence
69
Stage 2 Ulcer
-partial thickness loss -shallow open ulcer -may be serum filled blister
70
Stage 3 Ulcer
-full thickness tissue loss -subcutaneous fat may be visible -no bone or tendon or muscle exposed -may have tunnelling
71
Stage 4 Ulcer
-full thickness tissue loss -exposed bone, tendon, or muscle -tunnelling
72
Unstageable
-full thickness tissue loss -base is covered by slough or eschar
73
Braden Scale
-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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