Module 2 Flashcards
Baths and feet, CH 22 (417 cards)
1
Q
What are Activities of Daily Living (ADLs)?
A
ADLs include basic self-care tasks necessary for daily living.
Critical in determining the patient’s ability to perform hygiene tasks
2
Q
Why is it important for nurses to assess a patient’s self-care ability?
A
To determine appropriate support and assistance
Understanding a patient’s self-care capacity is essential for tailored care.
3
Q
Define Hygiene.
A
Activities involved in maintaining cleanliness and grooming
Hygiene practices include bathing, washing hair, and oral care.
4
Q
List three examples of hygiene activities.
A
- Bathing
- Washing hair
- Brushing/flossing teeth
These activities are essential for personal cleanliness and health.
5
Q
What are the benefits of maintaining hygiene?
A
- Promotes comfort
- Improves self-image
- Decreases risk of infection and disease
Good hygiene practices contribute to overall well-being.
6
Q
What are two nursing responsibilities related to hygiene?
A
- Provide necessary hygiene care
- Encourage self-care to foster activity, independence, and self-esteem
Nurses play a crucial role in supporting patients’ hygiene needs.
7
Q
What assessment questions should nurses consider regarding hygiene?
A
- Are the patient’s hygiene needs met?
- Are there any safety concerns?
- What hygiene tasks can be delegated?
These questions help evaluate and ensure proper hygiene care.
8
Q
What personal preferences might influence hygiene practices?
A
- Shower vs. bath
- Timing preferences
- Choice of soaps and shampoos
Individual preferences should be respected in care planning.
9
Q
How do culture and religion influence hygiene practices?
A
- Cultural and spiritual beliefs shape hygiene practices
- Daily vs. weekly bathing norms differ across cultures
Understanding cultural contexts is vital for providing respectful care.
10
Q
What economic factors can impact an individual’s hygiene practices?
A
- Limited resources (e.g., lack of running water)
- Basic needs for food and shelter may take precedence
Economic status can significantly affect hygiene maintenance.
11
Q
How do developmental levels affect hygiene practices in children?
A
- Care provided by parents/caregivers
- Habits, such as brushing teeth, are learned early
Developmental stages influence how hygiene is taught and practiced.
12
Q
True or False: Knowledge and cognitive levels do not affect hygiene practices.
A
False. Patients might not know how to perform hygiene.
Understanding appropriate hygiene practices is crucial for effective self-care.
13
Q
What is the single most effective way to break the chain of infection?
A
Hand Hygiene
Consistent hand hygiene is essential in preventing infections.
14
Q
What are some strategies to promote patient engagement in hygiene and self-care?
A
- Build trust
- Foster self-care management
- Encourage active partnerships between patients and providers
Engaging patients leads to better health outcomes.
15
Q
List some practical applications for nurses in hygiene management.
A
- Determine patient needs and abilities
- Teach hygiene practices
- Identify tasks for delegation
Nurses must balance care with promoting patient independence.
16
Q
What did the study by Caine et al. (2016) suggest about patient-centered approaches?
A
They improve hand hygiene compliance
Evidence supports the effectiveness of involving patients in their care.
17
Q
How should hygiene practices adapt for elderly individuals?
A
- Adjust frequency of bathing to less often. Bathing dries skin out.
- Use moisturizers to suit skin needs
Aging skin requires specific care considerations.
18
Q
Fill in the blank: The role of the nurse in hygiene includes assessment, education, assistance, and _______.
A
[encouragement of independence]
Encouraging independence is key to promoting patient self-care.
19
Q
What is a key takeaway regarding the multifaceted nature of hygiene care?
A
It involves physical, cultural, developmental, and economic aspects
A comprehensive approach to hygiene is essential for effective care.
20
Q
What physiological and emotional factors can interfere with hygiene measures?
A
Self-care deficits can arise due to pain, limited mobility, sensory deficits, cognitive impairment, or mental health disturbances.
21
Q
What impact does pain have on self-care ability?
A
Limits physical ability and motivation to perform ADLs
Drowsiness from pain medication may contribute to deficits.
22
Q
List examples of how pain can affect self-care tasks.
A
- Difficulty bending to wash feet or arms
- Inability to sustain prolonged activity due to discomfort
23
Q
What causes limited mobility in patients?
A
- Joint/muscle problems
- Injury
- Fatigue
- Surgery
- Bedrest
- Pain
24
Q
What barriers can physical obstacles create for patients with limited mobility?
A
- IV lines
- Oxygen tubing
- Catheters
- Casts
25
What nursing implications should be considered for patients with limited mobility?
Provide assistance with movement and hygiene while ensuring patient safety.
26
What impact do sensory deficits have on self-care?
Diminished ability to perform hygiene tasks safely and independently.
27
Give an example of how a visual deficit might affect a patient's hygiene.
Patient unfamiliar with surroundings may need assistance gathering grooming supplies.
28
What nursing actions should be taken for patients with sensory deficits?
Offer step-by-step direction and create a safe environment.
29
What causes cognitive impairment in patients?
* Dementia
* Delirium
* Stroke
* Alzheimer’s
* Brain injuries
30
How can cognitive impairment affect a patient's hygiene? What nursing implications should be considered for patients with cognitive impairment?
Patients may not recognize the need for hygiene. Develop modified hygiene plans and build trust to reduce fear and resistance.
31
How can emotional and mental health disturbances impact hygiene practices?
Depression can lead to neglect of grooming and hygiene due to lack of energy or motivation.
32
Why is it important to respect hygiene preferences in patients?
Promotes patient dignity and trust while accommodating cultural, religious, and personal values.
33
What economic or environmental influences can affect hygiene practices?
* Lack of running water
* Limited financial resources for hygiene supplies
34
What should be the focus of assessments for self-care abilities?
Evaluate functional status and hygiene needs, focusing on ability rather than the quality of hygiene tasks performed.
35
What are common NANDA-I diagnoses for self-care deficits?
* Bathing/Hygiene Deficit
* Dressing/Grooming Deficit
* Feeding Deficit
* Toileting Deficit
* Self-Neglect
36
What is the NOC scale used for in nursing?
To determine specific goals based on the patient's unique deficits.
37
Fill in the blank: For multiple ADL deficits, use _______.
Self-Care: ADLs
38
What is a clinical application example for assessing self-care?
Assessing factors that interfere with self-care and providing tools or support for independence.
39
What does NIC stand for in nursing interventions?
Nursing Interventions Classification
## Footnote
NIC provides standardized interventions for managing self-care deficits.
40
Name two assistive devices that can help with dressing self-care deficits.
* Reachers
* Sock aids
## Footnote
These devices assist patients in dressing independently.
41
What should be done if a patient is unable to bathe independently?
Provide a complete or partial bed bath
## Footnote
This ensures the patient maintains hygiene and comfort.
42
What are two examples of assistive devices that enhance bathing and hygiene?
* Grab bars
* Handheld showerheads
## Footnote
These devices promote safety and independence during bathing.
43
How can nurses assist patients with limited dexterity in oral hygiene?
Use adaptive toothbrushes or flossing aids
## Footnote
These tools make oral care easier for patients.
44
What tool can be used to evaluate functional status in self-care?
Katz Index of Independence in ADLs
## Footnote
This tool assesses various daily activities and levels of assistance required.
45
What are the four levels of assistance required in functional status assessment?
* Independent
* Requires a device or equipment
* Requires help from another person
* Totally dependent
## Footnote
Understanding these levels helps tailor care plans.
46
What should be ensured in a patient's environment for safety and comfort?
* Comfortable room temperature
* Secure bed positioning
* Uncluttered walking and workspace
* Clean and wrinkle-free bed linens
* Accessible call device
## Footnote
A safe environment supports patient independence and comfort.
47
What subjective data should be gathered during a skin assessment?
* Bathing preferences
* Skin care routine
* History of skin problems
* Allergies and reactions
## Footnote
This information helps tailor skin care interventions.
48
What objective data is important in a skin assessment?
* Skin cleanliness
* Texture
* Hydration
* Temperature
* Observations for rashes, lesions, pallor, erythema, jaundice, or cyanosis
## Footnote
Objective data provides a clear picture of skin health.
49
What should be inspected during a feet and nail assessment?
* Cleanliness
* Swelling
* Inflammation
* Infection
* Nail shape and signs of infection or trauma
## Footnote
This assessment is crucial for patients with diabetes or peripheral vascular disease.
50
What subjective data should be assessed regarding the oral cavity?
* Oral hygiene habits
* History of periodontal disease
* Dietary habits
* Factors affecting oral health (smoking, dehydration, medications)
## Footnote
Understanding these factors helps in providing appropriate oral care.
51
What objective data should be gathered during an oral cavity assessment?
* Inspect lips
* Gums
* Teeth
* Tongue
* Mucosa for lesions, bleeding, or unusual odors
## Footnote
Regular oral assessments are essential for maintaining oral health.
52
What subjective data should be assessed for hair and scalp?
* Personal or cultural hair care preferences
* Use of specialized products
* History of hair or scalp conditions
## Footnote
This information is important for personalized hair care plans.
53
What objective data should be observed during a hair and scalp assessment?
* Hair cleanliness
* Texture
* Presence of dandruff, lice, or lesions
## Footnote
These observations help identify potential scalp issues.
54
What are hourly rounds in scheduled hygiene care?
Check on patients every hour to address immediate needs (e.g., pain relief, toileting, repositioning).
55
What does early morning care involve?
Assist with toileting, washing the face and hands, and providing oral care before breakfast or morning activities.
56
What activities are included in morning (A.M.) care?
Help with bathing, dressing, grooming, and transferring to a chair. Straighten bed linens and tidy the room.
57
What is the purpose of afternoon (P.M.) care?
Prepare patients for rest or visitors, providing assistance as needed.
58
What does evening (Eve) care assist with?
Help patients prepare for sleep by offering oral hygiene, toileting, and comfortable positioning.
59
What is a hygiene self-care deficit?
A condition where a patient has difficulty maintaining personal hygiene due to various barriers.
60
What are key assessment questions related to hygiene routine?
How often does the patient bathe? What products do they use for skin, hair, and oral care?
61
What should be assessed for patient safety regarding hygiene care?
Assess for obstacles like IV lines, oxygen tubing, or medical devices that may hinder self-care.
62
Fill in the blank: Early morning care involves assisting with _______.
[toileting, washing the face and hands, providing oral care]
63
True or False: Evening care includes preparing patients for rest.
True
64
What is the focus of morning (A.M.) care?
Help with bathing, dressing, grooming, and transferring to a chair.
65
What intervention can be provided for Mrs. Williams to assist with bathing?
Provide assistive devices for bathing and dressing.
## Footnote
Assistive devices help patients perform self-care activities more independently.
66
What intervention can be implemented for Mr. Gold to assist with feeding?
Offer adaptive utensils and ensure proper oral hygiene tools.
## Footnote
Adaptive utensils are designed to help individuals with limited dexterity eat more easily.
67
How does scheduled hygiene care benefit patients?
Enhances patient comfort and supports routine.
## Footnote
Regular hygiene care routines can make patients feel more at ease and structured.
68
What type of assessments help create tailored care plans?
Functional and environmental assessments.
## Footnote
These assessments provide insights into the patient's abilities and their living conditions.
69
What intervention can be implemented for Mrs. Williams to promote independence in grooming?
Supervise grooming tasks while promoting independence.
## Footnote
This method allows patients to perform tasks with guidance, enhancing their confidence and skills.
70
What should be assessed before delegating hygiene care?
Patient stability
## Footnote
Assess if the patient is stable enough for delegation.
71
What is important to determine regarding Unlicensed Assistive Personnel (UAP) before delegation?
UAP experience with patient's limitations
## Footnote
Determine if the UAP is trained or familiar with the patient’s limitations.
72
What should be included in the specific instructions provided to UAP?
Instructions regarding:
* Patient limitations
* Restrictions
* Assistance required
* Use of assistive devices
* Safety precautions
* Management of obstacles
## Footnote
Provide detailed instructions to ensure proper care.
73
What types of observations should UAP be instructed to make during procedures?
Observations of:
* Skin condition
* Stool appearance
* Urine appearance
## Footnote
UAP should monitor for any changes or issues.
74
What evidence indicates a patient has a self-care deficit orally?
Dry, cracked lips and mouth odor
## Footnote
Evidence of inadequate self-care.
75
Fill in the blank: Mr. Fred Williams has a total _______ due to a cerebral hemorrhage.
Self-Care Deficit
## Footnote
This indicates his inability to perform self-care activities.
76
What is the primary short-term goal for Mr. Williams (a patient with oral deficient) within 24 hours?
Improved oral health score to at least 23 (on a 1–30 scale)
## Footnote
Additional goals include mild to moderate halitosis only, moist oral mucosa and tongue, and healthy oral mucous membranes.
77
What are the NOC outcomes relevant to Mr. Williams' care?
* Oral Health (NOC 1100)
* Tissue Integrity: Skin & Mucous Membranes (NOC 1101)
## Footnote
These outcomes help measure the effectiveness of nursing interventions.
78
What is a recommended NIC intervention for oral care?
Provide research-based oral care every 2–4 hours
## Footnote
This includes using a soft toothbrush or foam stick for cleaning and moisturizing gums.
79
What should be monitored during skin surveillance?
Signs of impaired oral tissue integrity such as dryness, cracking, or lesions
## Footnote
This monitoring should include daily assessments and documentation of the oral cavity condition.
80
What nursing activity involves regular oral assessments?
Examine lips, gums, palate, cheeks, and tongue for moisture, lesions, or odor
## Footnote
Saline rinses may be used to prevent bacterial growth.
81
What is the rationale for using toothbrushes over foam swabs? What about non alcohol mouthwash?
Toothbrushes are more effective than foam swabs for plaque removal and mucosal stimulation. Non alcohol is less drying.
## Footnote
This is particularly important for unconscious patients who have reduced saliva production.
82
What are the potential systemic complications to prevent with oral care interventions?
* Sepsis
* Respiratory infections (like pneumonia). Bacteria get aspirated (meaning go to the lungs)
## Footnote
Research-based interventions are essential to lower the risk of these complications.
83
Fill in the blank: The use of _______ rinses helps prevent bacterial growth.
saline
## Footnote
Saline rinses are a part of the individualized nursing activities for oral care.
84
True or False: Educating family members about assisting with oral care is part of individualized nursing activities.
True
## Footnote
Family involvement is crucial for maintaining oral health, especially for patients like Mr. Williams.
85
What subjective data should be collected if a patient wears glasses?
Determine WHEN they use them (e.g., reading or driving), all the time?
## Footnote
This information helps tailor care to the patient’s visual needs.
86
What subjective data should be collected if a patient wears contact lenses?
Type (hard, soft, disposable), cleaning and storage practices, history of eye irritation or infection
## Footnote
Understanding lens type and care can prevent complications.
87
What objective data should be inspected in eye care?
Redness, lesions, swelling, or discharge; color of the conjunctivae
## Footnote
These signs can indicate underlying issues requiring attention.
88
How should patient preferences be incorporated into care routines?
Consider soap, shampoo, and clothing choices; hairstyling preferences . It shows respect and compassion.
## Footnote
This approach promotes patient autonomy and satisfaction.
89
What safety considerations should be taken during care?
Ensure the environment is safe and clutter-free; maintain assistive devices and follow proper precautions for immobile patients
## Footnote
A safe environment reduces the risk of accidents.
90
What is important regarding delegation in nursing?
Provide clear instructions to UAPs and supervise their tasks as needed
## Footnote
Effective delegation ensures quality care and accountability.
91
What does continuous assessment involve in nursing care?
Use care activities to evaluate the patient’s overall self-care abilities, cognition, and mobility
## Footnote
Regular assessments help adjust care plans as needed.
92
What are research-based practices in hygiene care?
Follow evidence-based guidelines to ensure the efficacy of hygiene interventions
## Footnote
Evidence-based practices improve patient outcomes and care quality.
93
What is H.S. (Hour of Sleep) Care?
Care that prepares the patient for sleep, involving similar activities as in the afternoon
## Footnote
H.S. Care also includes additional measures to promote relaxation.
94
What additional activity is performed during H.S. (Hour of Sleep) Care?
A back massage to promote relaxation
## Footnote
This is intended to help the patient unwind and prepare for sleep.
95
Fill in the blank: During H.S. (Hour of Sleep) Care, necessary items such as call light, water, and urinal should be placed _______.
within reach
## Footnote
This ensures that the patient can access these items easily during the night.
96
What actions are taken regarding lights and television during H.S. (Hour of Sleep) Care?
Turn off lights and television and close the door based on patient preferences
## Footnote
This is done to create a conducive sleeping environment.
97
What patient preferences should be confirmed?
Preferred bathing products and water temperature
## Footnote
Also ask about hair styling preferences and oral hygiene tools.
98
What observations should the UAP make during bathing?
Look for redness, swelling, or signs of irritation
## Footnote
Report dryness, maceration, excoriation, or rashes.
99
What should be monitored for complaints during bathing?
Complaints of pain or discomfort
## Footnote
This is essential to ensure Mrs. Williams' comfort.
100
What observations should the UAP make during oral hygiene?
Condition of lips, tongue, and mucous membranes
## Footnote
Report any sores, cracks, bleeding, or persistent bad breath.
101
What signs of oral health issues should be reported?
Sores, cracks, bleeding, or persistent bad breath
## Footnote
These can indicate underlying problems that need attention.
102
What should a nurse check for during a focused skin assessment?
Pruritus, dry skin, maceration, excoriation, pressure injuries
## Footnote
Special attention should be paid to bony prominences and skin folds.
103
What aspects should be evaluated during an oral health assessment?
Hydration of mucosa, tongue, lips, lesions, halitosis, signs of infection
## Footnote
Overall comfort and ability to tolerate care should also be assessed.
104
What should be done if a patient's needs or preferences are not met?
Reassess care by UAP, offer corrective care, provide feedback to UAP, document incident, communicate findings
## Footnote
Ensuring patient comfort and hygiene is essential.
105
What is the outer layer of the skin called?
Epidermis
## Footnote
It is composed of keratinized cells.
106
What are the functions of the epidermis?
* Waterproofing
* UV protection (via melanin)
* Shedding every 3-4 weeks
## Footnote
These functions are crucial for maintaining skin health.
107
What is the inner layer of the skin called?
Dermis
## Footnote
It contains blood vessels, lymphatics, nerves, and glands.
108
What are the functions of the dermis?
* Nutrient supply
* Sensory input
* Structural support
## Footnote
These functions play a vital role in skin health and overall body function.
109
What is the primary function of the skin in terms of protection?
Barrier against bacteria, thermal injury, and chemicals
## Footnote
Sebum secretion reduces bacterial growth.
110
What types of receptors are found in the skin?
Temperature, pressure, touch, and pain receptors
## Footnote
These receptors contribute to the sensation function of the skin.
111
How does the skin regulate body temperature?
Through blood vessel dilation/constriction and sweat gland activation
## Footnote
This helps maintain fluid balance and temperature homeostasis.
112
What substances do sweat glands excrete?
Water, nitrogenous wastes, sodium chloride, and fatty acids
## Footnote
This is part of the secretion/excretion function of the skin.
113
What is formed by the skin when exposed to UV light?
Vitamin D
## Footnote
This process converts cholesterol to Vitamin D.
114
What is pruritus and what are its common causes?
Itching caused by dryness or skin conditions
## Footnote
Pruritus can lead to scratching and skin breakdown.
115
What risks are associated with dry skin?
Cracking, burning, or itching
## Footnote
These conditions can exacerbate skin problems.
116
What causes maceration of the skin?
Prolonged moisture, such as incontinence
## Footnote
This leads to skin softening and increased susceptibility to injury.
117
What is excoriation and what causes it?
Loss of superficial skin layers caused by scratching or digestive enzymes in feces
## Footnote
This can result in further skin damage.
118
What causes abrasions on the skin?
Friction or shearing forces
## Footnote
Commonly occurs over bony prominences.
119
What are pressure injuries and what causes them?
Injuries caused by prolonged compression and poor perfusion
## Footnote
Risk areas include bony prominences.
120
What is acne and who is it most common among?
Inflammation of sebaceous glands, common among adolescents and young adults
## Footnote
This condition can lead to scarring and emotional distress.
121
What are the causes of burns?
Thermal, electrical, chemical, or radioactive agents
## Footnote
Burns can vary in severity and require different treatment approaches.
122
What should be assessed regarding the patient's limitations?
Patient’s limitations and level of assistance required
## Footnote
This includes understanding the patient's physical and cognitive abilities.
123
What are examples of assistive devices used in skin and hygiene care?
Assistive devices include:
* Gait belts
* Shower chairs
## Footnote
These devices help provide support and safety during care.
124
What skin conditions should be checked during hygiene care?
Check for:
* Redness
* Irritation
* Presence of lesions over bony prominences
## Footnote
These conditions can indicate pressure ulcers or other complications.
125
What aspect of cleanliness should be monitored?
Cleanliness of skin folds and under breasts or abdominal folds
## Footnote
Accumulation of moisture and debris in these areas can lead to skin issues.
126
How should care be aligned with the patient?
Care should align with:
* Patient’s needs
* Limitations
* Preferences
## Footnote
This personalized approach enhances patient comfort and compliance.
127
What signs should be monitored for during hygiene care?
Monitor for signs of:
* Skin complications
* Oral complications
## Footnote
Early detection allows for timely intervention.
128
What are key components of effective delegation in hygiene care?
Effective delegation requires:
* Clear instructions
* Supervision
* Evaluation
## Footnote
This ensures that care is delivered safely and effectively.
129
What are the essential factors for maintaining healthy skin?
Hydration, Circulation, and Nutrition
## Footnote
Compromise in any of these factors increases the risk of skin breakdown.
130
What causes dampness that affects skin integrity?
Excessive sweating, urinary or fecal incontinence
## Footnote
These conditions can lead to maceration, increasing the risk of skin breakdown.
131
What is the effect of dampness on the skin?
Maceration increases the risk of breakdown, especially in skin folds
## Footnote
Maceration refers to the softening of the skin.
132
What causes dehydration that affects skin integrity?
Vomiting, diarrhea, fever, insufficient fluid intake
## Footnote
Dehydration leads to dry, cracked skin that is prone to injury.
133
What is the effect of dehydration on the skin?
Dry, cracked skin, prone to injury
## Footnote
This condition significantly increases the risk of skin breakdown.
134
How does nutritional status affect skin integrity in thin individuals?
Dry, fragile skin increases susceptibility to injury
## Footnote
Thin individuals may have less padding and moisture in their skin.
135
What are the skin integrity risks for obese individuals?
Difficulty reaching certain areas, risk of fungal infections, odor, and skin irritation
## Footnote
Obesity can lead to skin issues due to friction and moisture retention.
136
What causes insufficient circulation affecting skin integrity?
Immobility, vascular disease, inadequate nutrition
## Footnote
Insufficient circulation can lead to local tissue death and ulceration.
137
What is the effect of insufficient circulation on the skin?
Local tissue death, ulceration, and impaired healing due to reduced oxygen supply
## Footnote
This can significantly increase the risk of pressure ulcers.
138
What are some examples of skin diseases that affect skin integrity?
Impetigo, measles, chickenpox
## Footnote
These diseases can cause lesions requiring specialized hygiene care.
139
What is jaundice and how does it affect the skin?
Accumulation of bile pigments in the skin causing yellow discoloration, itchy and dry skin
## Footnote
Jaundice increases the risk of injury to the skin.
140
How does UV exposure affect skin integrity?
Increases the risk of skin damage
## Footnote
Sunbathing or tanning bed use can lead to long-term skin issues.
141
What risks are associated with tattoos and piercings?
Infection and scarring
## Footnote
These body modifications can compromise skin integrity if not properly cared for.
142
What is a characteristic of infants' skin?
Fragile, easily injured skin.
## Footnote
Infants require gentle handling and special care due to their delicate skin.
143
How does children's skin differ from infants' skin?
Skin becomes more resistant to injury and infection.
## Footnote
Adults must supervise hygiene to maintain cleanliness in children.
144
What happens to the skin during adolescence?
Enlarged sebaceous glands lead to increased oil production.
## Footnote
This change makes the skin oily and prone to acne.
145
What age-related changes increase the risk for pressure ulcers in older adults?
Thinner skin, loss of elasticity, reduced moisture retention.
## Footnote
These changes also contribute to delayed wound healing.
146
List the functions of the skin.
* Protection
* Sensation
* Regulation of body temperature
* Secretion and excretion
* Vitamin D formation
## Footnote
These functions are essential for maintaining overall health.
147
How does the skin regulate body temperature?
Skin dilates/constricts blood vessels and activates/inactivates sweat glands.
## Footnote
Perspiration evaporates to cool the body.
148
What are some effects of aging on the skin?
* Thinner epidermis and dermis
* Decreased elasticity and collagen production
* Reduced sebaceous gland activity, causing dryness
* Slower regeneration and healing processes
## Footnote
These changes contribute to various skin issues in older adults.
149
What is important for ensuring room comfort during skin assessment?
Warm temperature and reduced drafts.
150
What are the subjective data points to assess in skin assessment?
Hygiene Practices, skincare practices, Skin Problems current & past, Allergies, Disease History.
- prescription, OTC, herbal remedies
151
What kind of allergies should be documented during skin assessment?
Reactions to food, medications, plants, products
152
What specific disease history or physiology are relevant to skin assessment?
Decreased mobility, circulation, incontinence, poor nutrition, or lack of knowledge.
153
What is the first step in the objective data collection for skin assessment?
Inspect the skin head-to-toe. General appearance of skin.
154
What conditions should be observed on the skin?
Presence of rashes, lumps, lesions, or cracks.
Maceration, excoriations
155
What colors should be observed during skin assessment?
Pallor, erythema, jaundice, cyanosis.
156
What is being assessed when checking texture and turgor of the skin?
Hydration and elasticity.
157
What temperature evaluations should be made during skin assessment?
Evaluate warmth or coolness.
158
You see a wound. What do you check for?
Wound drainage or tube-related skin issues.
159
What signs of skin damage should be noted during assessment?
Signs of maceration, excoriation, or abrasion.
160
Where is pressure injury most likely?
Pressure injury development over bony prominences.
161
What is pallor?
Unusual paleness due to reduced blood flow or hemoglobin
## Footnote
Pallor can be a sign of various medical conditions, including anemia or shock.
162
Define erythema.
Redness caused by increased blood flow or inflammation
## Footnote
Erythema can occur due to infections, allergic reactions, or sunburn.
163
What causes jaundice?
Yellowing due to elevated bilirubin levels
## Footnote
Jaundice often indicates liver dysfunction or hemolysis.
164
What does cyanosis indicate?
Bluish color indicating decreased oxygenation
## Footnote
Cyanosis can be a sign of respiratory or cardiovascular issues.
165
List some preventive care measures for skin integrity.
* Proper moisture management for dampness
* Encouraging hydration to prevent dryness
* Supporting circulation through repositioning and mobility assistance
* Addressing developmental skin care needs tailored to the patient’s age and health status
## Footnote
These measures help maintain skin health and prevent complications.
166
Do you perform a skin assessment every time you help with hygiene?
Yes. It enables early detection and intervention for skin problems
## Footnote
Early intervention can prevent more serious skin conditions.
167
What is the structural change in the epidermis with aging? What happens because of this?
Thinner, decreased rate of cell turnover. The reduced cell turnover contributes to a slower healing process. Skin appears paler and somewhat translucent. This is because there are less melanocytes to provide pigment.
## Footnote
## Footnote
This affects the skin's overall appearance and healing process.
168
What structural changes occur in subcutaneous tissues as one ages?
Thinner and more fragile, with less fat
## Footnote
This impacts cushioning and protection over bony prominences.
169
What are the clinical effects of thinner subcutaneous tissues?
Reduced cushioning and protection over bony prominences, impaired thermoregulation
## Footnote
This increases sensitivity to cold.
170
How do collagen and elastin fibers in the dermis change with aging?
Weaken and lose elasticity . causes wrinkles
## Footnote
This leads to visible signs of aging such as wrinkles.
171
What happens to sebaceous and sweat glands with aging?
Decreased activity, less ability to
## Footnote
This contributes to dry, scaly, and itchy skin.
172
What clinical effects result from decreased activity of sebaceous and sweat glands?
Skin becomes dry, scaly, and itchy; reduced ability to regulate body temperature in hot weather
## Footnote
This can lead to discomfort and heat-related issues.
173
What is the effect of aging on hormone production, specifically estrogen and progesterone?
Decreased production
## Footnote
This is linked to skin dryness and thinning.
174
What are the clinical effects of decreased estrogen and progesterone?
Drying and thinning of the skin
## Footnote
Hormonal changes significantly affect skin health.
175
How does skin vascularity change with aging?
Decreased vascularity
## Footnote
This impacts skin temperature and healing.
176
What are the clinical effects of decreased skin vascularity?
Skin becomes cool and pale; slower wound healing due to reduced blood flow
## Footnote
Vascular changes affect overall skin health.
177
What happens to hair follicles as a person ages?
Reduced number and activity
## Footnote
This leads to changes in hair quality.
178
What are the clinical effects of reduced hair follicle activity?
Hair becomes thin and grows more slowly
## Footnote
Aging significantly affects hair growth.
179
How do melanocytes change with aging?
Decreased numbers
## Footnote
This affects skin pigmentation.
180
What are the clinical effects of decreased melanocytes?
Hair turns gray or white; skin pigmentation becomes uneven
## Footnote
This includes areas of hyper- or hypo-pigmentation.
181
What structural changes occur in nails with aging?
Thicker, softer, and slower growth
## Footnote
These changes can affect nail care.
182
What are the clinical effects of aging nails?
Nails tear or break more easily; reduced ability to maintain nail hygiene
## Footnote
Nail health is crucial for overall hand health.
183
What types of skin growths become more common with aging?
Warts, liver spots or age spots
## Footnote
These growths often result from sun exposure.
184
What are the clinical effects of common skin growths due to aging?
Most are harmless, but some (e.g., skin cancers) require medical evaluation
## Footnote
Regular skin checks are important for early detection.
185
What are the progressive structural changes in aging skin associated with?
Functional impairments, including reduced healing, protection, thermoregulation, and hydration
186
What clinical considerations should be taken into account for older adults?
Higher risk for:
* Pressure injuries
* Temperature-related issues
* Dryness and irritation
* Infections due to fragile and thinning skin
187
What should be the nursing focus for older adults regarding skincare?
Gentle skincare routines, hydration and moisturization, monitoring for abnormal growths or pigmentation changes, protecting bony prominences with cushioning
188
True or False: Aging skin has no impact on healing and protection.
False
189
Fill in the blank: Older adults are at higher risk for ______ due to fragile and thinning skin.
infections
190
Name one functional impairment caused by the progressive structural changes in aging skin.
Reduced healing
191
List two clinical considerations for older adults related to skin issues.
* Dryness and irritation
* Temperature-related issues
192
What is a key aspect of nursing care for older adults to prevent injuries?
Protecting bony prominences with cushioning
193
What is the definition of pallor?
Pale skin lacking underlying pink tones.
194
How is pallor assessed in light-skinned patients?
General skin pallor.
195
How is pallor assessed in dark-skinned patients?
Look for ashen gray or yellow tones.
196
What are the causes of pallor?
Reduced blood flow or hemoglobin levels.
197
What is the definition of erythema?
Redness of the skin due to vasodilation and inflammation.
198
How is erythema assessed in dark-skinned patients?
Palpate for warmth to detect erythema.
199
What are physiological causes of erythema?
* Inflammation (e.g., due to infection or injury)
* Increased blood flow (e.g., in response to heat)
200
What is the definition of jaundice?
Yellow discoloration caused by accumulation of bile pigments.
201
Where is jaundice best seen?
Sclerae of the eyes.
202
What causes jaundice?
Impaired liver function.
203
What is the definition of cyanosis?
Bluish discoloration due to decreased oxygenation or circulation.
204
How is cyanosis assessed in dark-skinned patients?
Examine conjunctivae, tongue, buccal mucosa, palms, and soles for a dull dark color.
205
What are the causes of cyanosis?
Cardiac, pulmonary, or peripheral vascular problems.
206
Fill in the blank: _______ is characterized by pale skin lacking underlying pink tones.
Pallor
207
True or False: Erythema is caused by vasoconstriction.
False
208
Fill in the blank: The yellow discoloration of skin known as _______ is due to the accumulation of bile pigments.
Jaundice
209
What is the definition of Skin Integrity Impairment Risk?
At risk for damage to the epidermis and/or dermis.
210
What are some risk factors for Skin Integrity Impairment Risk?
* Dampness
* Dehydration
* Immobility
* Poor nutrition
* Skin diseases
* Jaundice
* Systemic diseases
211
Provide an example diagnosis for Skin Integrity Impairment Risk.
Skin Integrity Impairment Risk related to immobility secondary to casts and traction.
212
What is the definition of Skin Integrity Impairment?
Inability to maintain intact skin.
213
What are the characteristics of Skin Integrity Impairment?
* Cracks
* Breaks
* Loss of skin layers
214
Provide an example diagnosis for Skin Integrity Impairment.
Skin Integrity Impairment related to decreased peripheral circulation secondary to arteriosclerosis.
215
What is the risk of infection related to?
Skin lacerations or abrasions.
216
What self-esteem disturbance is related to?
Appearance of lesions secondary to severe eczema.
217
Why is Mrs. Williams at risk for impaired skin integrity?
* Immobility leads to pressure injury risks
* Potential dampness from incontinence increases the risk of maceration
218
Why is Mr. Gold at risk for impaired skin integrity?
* Jaundice leads to dryness and itching
* Decreased circulation increases risk of ulcers and delayed healing
219
What are the specific risks for both Mrs. Williams and Mr. Gold?
* Pressure injuries due to immobility
* Dryness and cracking due to decreased hydration or systemic conditions
* Infection risk from breaks in the skin or lesions
220
What is the standardized NOC outcome related to skin and mucous membranes?
Tissue Integrity: Skin and mucous membranes
## Footnote
This outcome focuses on the maintenance and health of skin and mucous membranes.
221
Define Primary Intention in wound healing.
Healing of clean wounds with minimal scarring
## Footnote
Primary intention typically involves surgical incisions or trauma that heals by direct closure.
222
What does Secondary Intention refer to in wound healing?
Healing of open wounds with granulation tissue
## Footnote
Secondary intention occurs when wounds are left open to heal naturally.
223
What is the standardized NOC outcome related to self-care?
Self-Care: Hygiene
## Footnote
This outcome emphasizes the importance of personal hygiene in maintaining skin integrity.
224
What is the goal related to self-esteem in planning outcomes for skin integrity?
Improve patient’s perception of self
## Footnote
This goal highlights the psychological aspect of skin integrity and its impact on self-esteem.
225
What individualized goal pertains to skin integrity?
Skin will remain intact and free of secretions or lesions
## Footnote
This goal focuses on the physical health of the skin.
226
What is one individualized goal for improving skin dryness and hydration?
Patient will adhere to a regimen to improve skin dryness and hydration
## Footnote
This goal emphasizes the importance of hydration for skin health.
227
List two standardized NIC interventions for impaired skin integrity.
* Bathing
* Wound care
## Footnote
These interventions help maintain skin integrity and promote healing.
228
What is a NIC intervention for risk of impaired skin integrity?
Bedrest care
## Footnote
Bedrest care is crucial in preventing further skin breakdown.
229
Name two interventions for pressure ulcer prevention.
* Positioning
* Pressure management
## Footnote
These strategies are vital in preventing pressure ulcers in at-risk patients.
230
Fill in the blank: For risk of impaired skin integrity, _______ precautions are necessary.
Circulatory
## Footnote
Circulatory precautions help maintain blood flow and prevent skin issues.
231
What is the primary purpose of bathing in nursing activities?
Removes perspiration and bacteria to prevent odor and infection
## Footnote
Bathing also improves circulation through warmth and friction, stimulates deeper breathing, and provides sensory input.
232
List additional benefits of bathing for patients.
* Builds nurse-patient relationship
* Promotes relaxation
* Enhances comfort
* Improves self-image
## Footnote
These benefits contribute to overall patient well-being.
233
What nursing consideration should be taken during bathing?
Always assess skin condition during the bath
## Footnote
This helps in identifying potential issues early.
234
What is the purpose of a back massage in nursing?
Promotes relaxation and circulation
## Footnote
Back massage can enhance the comfort of the patient.
235
What are the contraindications for performing a back massage?
* Fractured ribs
* Burns
* Recent heart surgery
## Footnote
These conditions may exacerbate the patient's situation.
236
What can skin assessments during hygiene routines help detect?
* Maceration
* Erythema
* Pressure injuries
* Cracks or lesions
## Footnote
Early detection of these issues is crucial for patient care.
237
What should skin care interventions focus on?
* Maintaining integrity
* Promoting healing
* Preventing complications
## Footnote
These interventions are essential for effective patient management.
238
What is required when delegating tasks to UAPs?
Clear instructions and follow-up
## Footnote
This ensures the quality of care provided to patients.
239
True or False: Bathing and massage provide opportunities for health promotion and patient interaction.
True
## Footnote
These activities are integral to enhancing patient care and comfort.
240
Fill in the blank: Bathing improves _______ through warmth and friction.
circulation
## Footnote
This aspect is important for patient recovery and comfort.
241
What should be considered when choosing the type of bath?
Nursing Judgment, Patient Preferences, Self-Care Ability, Medical Plan of Care
## Footnote
These factors ensure that the chosen bathing method aligns with the patient's needs and condition.
242
What is an Assist Bath?
Nurse helps the patient reach difficult areas
## Footnote
This is suitable for patients with partial self-care ability but limited mobility or flexibility.
243
What is a Complete Bath?
Nurse washes the entire body for the patient
## Footnote
This is indicated for patients who cannot assist in bathing, such as those who are unconscious or critically ill.
244
What is a Partial Bath?
Nurse cleanses only areas that may cause odor or discomfort
## Footnote
This is for patients for whom a complete bath is too exhausting or unnecessary.
245
Fill in the blank: An Assist Bath is indicated for patients with _______.
partial self-care ability
246
True or False: A Complete Bath is suitable for all patients regardless of their ability to assist.
False
247
What are the key factors in nursing judgment for choosing a bath type?
Patient’s condition, endurance, medical care plan
## Footnote
These factors help in assessing the most appropriate bathing method.
248
Fill in the blank: A Partial Bath cleanses areas such as _______ and _______.
axillae, perineum
249
What are bed baths designed for?
Patients who remain in bed but may have varying degrees of self-care ability.
250
What are prepackaged bathing products?
Pre-moistened disposable washcloths
## Footnote
They ensure consistent technique among caregivers and prevent rough scrubbing.
251
What are the benefits of prepackaged bathing products?
* Ensures consistent technique among caregivers
* Prevents rough scrubbing with traditional washcloths
* Reduces skin damage and microbial contamination
* Ideal for patients with mild skin integrity concerns or limited endurance
252
Describe a towel bath.
Large towel and bath blanket saturated with a warmed solution.
253
What are the benefits of a towel bath?
* No need to towel-dry; solution dries quickly
* Reduces nursing time
* Preferred for patients with moderate skin integrity issues or dementia
* Minimal friction reduces risk of irritation for sensitive skin
254
What is a bag bath?
Uses 8–10 washcloths moistened with sterile/distilled water or pH-balanced soap.
255
What are the benefits of a bag bath?
* Each washcloth is used for a specific body area to reduce cross-contamination
* No-rinse solution minimizes skin dryness
256
What is the traditional method of a basin and water bath?
Uses a disposable basin, water, washcloths, lotion, and soap.
257
When is a basin and water bath indicated?
* For grossly soiled patients (e.g., blood, feces)
* When prepackaged options are unavailable or refused
258
What are the risks associated with a basin and water bath?
Potential for healthcare-associated infections (HAIs) from biofilm in basins or tap water.
259
What is recommended to minimize risks in a basin and water bath?
* Use distilled, sterile, or filtered water when possible
* Incorporate chlorhexidine solution to reduce skin colonization by bacteria
260
What precautions are required for vulnerable patients during bed baths?
Stricter precautions for patients with impaired immunity or open wounds.
261
What is a shower?
A quick and refreshing method for cleansing
## Footnote
Showers are suitable for ambulatory patients capable of managing most of the care themselves.
262
What are the indications for using a shower?
Suitable for ambulatory patients and ideal for energy-efficient, comfortable options
## Footnote
Patients should be capable of managing most of their care independently.
263
What safety considerations should be taken for showers?
Monitor for fall risks, provide nonskid mats, and handrails for safety
## Footnote
Ensuring safety is crucial to prevent accidents.
264
What is a tub bath?
Immersing the patient in a tub of water
## Footnote
Tub baths are for ambulatory patients needing assistance due to pain or stiffness.
265
What are the indications for using a tub bath?
For ambulatory patients needing assistance due to pain or stiffness
## Footnote
Tub baths provide relaxation and help cleanse crusty or soiled areas.
266
What benefits does a tub bath provide?
* Soothes sore muscles and joints
* Promotes relaxation and relieves stress
## Footnote
Tub baths are particularly beneficial for overall well-being.
267
What safety measures should be implemented for tub baths?
* Equip with handrails and nonskid surfaces
* Use hydraulic lifts for dependent patients
## Footnote
Safety measures are essential to prevent accidents during bathing.
268
What are the purposes of bathing methods?
* Health: Removes sweat and bacteria
* Relaxation: Improves circulation
* Social Interaction: Builds nurse-patient relationships
## Footnote
Bathing serves multiple roles in patient care.
269
What special considerations should be made for patients with dementia during bathing?
Use towel baths or prepackaged baths to minimize stress and agitation
## Footnote
These methods reduce discomfort and enhance patient cooperation.
270
What should be avoided when bathing critically ill patients?
Avoid excessive manipulation to prevent exhaustion
## Footnote
Care should be gentle to avoid additional strain on the patient.
271
What bathing methods are recommended for critically ill patients?
Use prepackaged or basin baths with chlorhexidine for infection control
## Footnote
This approach helps maintain hygiene while minimizing patient stress.
272
What should be used in showers and tubs to enhance patient safety?
Nonskid mats and handrails
## Footnote
These measures help prevent falls and injuries.
273
What is a key consideration when adjusting water for bathing?
Adjust water temperature to prevent burns or discomfort
## Footnote
Proper temperature settings are essential for patient safety.
274
How can healthcare providers prevent healthcare-associated infections (HAIs) during bathing?
Avoid reusing basins
## Footnote
Reusing basins can lead to cross-contamination and infections.
275
What solution is recommended for high-risk patients to prevent infections?
Chlorhexidine solutions
## Footnote
Chlorhexidine is effective in reducing microbial load on the skin.
276
What should nurses monitor for during patient baths?
Skin condition for breakdown, redness, or lesions
## Footnote
Regular assessment helps identify potential skin issues early.
277
What patient response should be evaluated during bathing?
The patient’s response to the activity (e.g., tolerance, comfort)
## Footnote
Understanding patient comfort is crucial for quality care.
278
Bathing types should be tailored to what aspects of the patient?
Specific needs, abilities, and preferences
## Footnote
Personalization enhances the bathing experience for patients.
279
What are evidence-based techniques mentioned for infection prevention during bathing?
Prepackaged products or chlorhexidine solutions
## Footnote
These techniques are supported by research to improve patient outcomes.
280
What are the top priorities during patient bathing?
Safety and comfort
## Footnote
Ensuring these priorities is especially important for vulnerable patients.
281
Bathing offers opportunities for what aspects of nursing care?
Assessment, relaxation, and strengthening the nurse-patient relationship
## Footnote
Bathing can be a holistic approach to patient care.
282
What is a therapeutic bath?
A bath given for a specific purpose, such as to relax muscles or remove scales from the skin.
283
Why is distilled or sterile water preferred for therapeutic baths?
Current research suggests hospital water supplies may harbor pathogens and contribute to HAIs.
284
What should be done with the tub after a therapeutic bath if a disposable sitz tub is not available?
Clean the tub thoroughly, preferably with a chlorhexidine-based product.
285
What are examples of therapeutic baths?
* Oatmeal or coal tar baths for psoriasis
* Warm sitz baths for cleansing perineum and soothing inflammation
286
What is the perineum?
The area between the anus and vulva in females, or the anus and scrotum in males.
287
What is the purpose of perineal care?
To promote comfort and prevent odor, skin excoriation, and infection.
288
When should perineal care be given more frequently?
When the patient is incontinent of urine or feces or has drainage from the area.
289
How can patient privacy be protected during perineal care?
Provide privacy by shutting the door, pulling bed curtains, and draping properly.
290
True or False: Patients with dementia often enjoy bathing.
False.
291
What are common reasons for agitation in dementia patients during bathing?
Pain, cold, fear, and loss of control.
292
What is one effective method to reduce aggressive behavior in dementia patients during bathing?
Giving a towel bath or bag bath.
293
Fill in the blank: The bath does not have to be performed at the same time every day, nor in the way _______.
[we have always done it here]
294
What should caregivers focus on when bathing patients with dementia?
Focus on the patient, not the task, and provide choices.
295
What are some caring tips for bathing a patient with dementia?
* Distract with food or relaxing music
* Use a gentle shower head
* Bathe one part of the body each day
* Ensure continuity of care
* Provide privacy
* Avoid sensory overload
* Foster independence
* Explain procedures simply
* Do not rush
296
What is the rationale for providing perineal care?
To promote comfort and prevent odor, skin excoriation, and infection.
297
True or False: It is necessary to bathe a person who is resisting.
False.
298
What should you let the patient know before you touch them during bathing?
Let the patient know before you touch them or spray them with any fluids.
299
What is one way to help patients with dementia feel less fearful during bathing?
Provide continuity of care so they can build a relationship with the caregiver.
300
What are therapeutic baths?
Baths prescribed by a primary care provider for a specific purpose
## Footnote
Examples include relaxing muscles or treating skin conditions.
301
What is an example of a bath used for skin conditions?
Oatmeal or Coal Tar Baths
## Footnote
These baths are commonly used for conditions like psoriasis.
302
What is a warm sitz bath used for?
Cleansing and soothing inflammation in perineal, vaginal, or rectal areas
## Footnote
It is effective for discomfort in these regions.
303
What is one nursing responsibility when administering therapeutic baths?
Ensure the use of distilled, sterile, or specially filtered water
## Footnote
This reduces risks of healthcare-associated infections (HAIs).
304
What should be added to therapeutic baths?
Medically prescribed substances
## Footnote
These substances are added to achieve specific therapeutic effects.
305
Why is it important to maintain the prescribed water temperature in therapeutic baths?
For patient safety and comfort
306
What is perineal care?
Cleansing the area between the anus and vulva (female) or anus and scrotum (male)
## Footnote
This promotes comfort and prevents infection.
307
When is perineal care provided more frequently?
For patients who are incontinent of urine or feces, or have drainage or infections in the area
## Footnote
This is important for maintaining hygiene.
308
What is the purpose of perineal care?
Prevents bacterial growth, odor, and skin excoriation
## Footnote
It promotes comfort and reduces infection risk.
309
What should be done to maintain patient privacy during care?
Close doors, pull bed curtains, and drape the patient appropriately
## Footnote
This helps to ease embarrassment.
310
What causes body odor?
Bacterial growth on perspiration
311
What is the best intervention to reduce body odor?
Daily bathing to remove sweat and bacteria
312
Why is perineal care important?
To promote hygiene, comfort, and prevent infection or skin breakdown
313
How can privacy be protected during patient care?
Use privacy curtains, keep the patient covered, and maintain a professional demeanor
314
What challenges do patients with dementia face during bathing?
Patients may experience pain, fear, cold, or loss of control, leading to agitation or aggression
## Footnote
Examples of agitation include yelling, hitting, or pinching.
315
What is a strategy to reduce agitation in dementia patients during bathing?
Focus on Comfort by adjusting water temperature and avoiding painful actions
## Footnote
For instance, washing arthritic joints gently.
316
What alternative bathing methods can be used for dementia patients?
Towel baths or prepackaged products to minimize stress
## Footnote
Avoid forcing daily showers or tub baths.
317
True or False: Towel baths increase the risk of skin problems in dementia patients.
False
## Footnote
Towel baths are sufficient for hygiene.
318
What should be done for patients who resist bathing?
They should not be forced to bathe
## Footnote
Adapt the timing and method instead.
319
What techniques can enhance the bathing experience for dementia patients?
Use prepackaged products for efficiency and offer baths at preferred times
## Footnote
For instance, when the patient is calm.
320
How can family members support bathing for patients with dementia?
Educate them about flexible bathing techniques
## Footnote
This includes being patient-centered.
321
What caring tips should be followed while bathing a patient with dementia?
Provide choices, build trust, and reduce sensory overload
## Footnote
Dim lights, warm the room, and play soft music.
322
What should be avoided to reduce sensory overload during bathing?
Avoid sudden actions or strong water sprays
## Footnote
These may frighten the patient.
323
How can independence be promoted during bathing for dementia patients?
Encourage participation, such as washing their face
## Footnote
This helps maintain their dignity.
324
What creative approach can be taken if a patient resists a full bath?
Bathe one body part at a time
## Footnote
This approach can reduce anxiety.
325
What is a key teaching point for caregivers of dementia patients?
Train them to use flexible, patient-centered techniques
## Footnote
This ensures better care.
326
Which patients require nurse-assisted perineal care?
Mrs. Williams and Mr. Gold
## Footnote
Mrs. Williams has immobility and possible incontinence, while Mr. Gold is at risk for skin breakdown due to jaundice and dryness.
327
Which patient is most likely to feel embarrassed by perineal care?
Male patients with female nurses
## Footnote
This embarrassment may stem from modesty or cultural norms.
328
What are the key benefits of towel baths?
Effective for hygiene, reduce agitation, promote comfort
## Footnote
Towel baths provide an alternative to full tub or shower baths while maintaining cleanliness.
329
What are therapeutic baths tailored for?
Specific conditions
## Footnote
Therapeutic baths use sterile or filtered water to prevent healthcare-associated infections (HAIs).
330
What is essential for perineal care?
Hygiene, odor control, and infection prevention
## Footnote
Maintaining privacy and professionalism is also crucial to ease embarrassment.
331
What should be the focus when bathing patients with dementia?
Comfort
## Footnote
Avoid forcing the task and use alternative methods like towel baths to minimize stress.
332
What should caregivers be educated on regarding bathing patients?
Patient-centered approaches
## Footnote
Educating caregivers helps them understand how to provide care that respects the patient's needs and dignity.
333
What is the nurse's role in patient hygiene care?
Assess individual needs, adapt techniques, build trust
## Footnote
Prioritize patient dignity and consider both physical and emotional factors.
334
Fill in the blank: Therapeutic baths always follow _______ and facility guidelines.
[provider prescriptions]
335
True or False: Cleanliness always requires a full tub or shower bath.
False
## Footnote
Alternative methods like towel baths can maintain cleanliness effectively.
336
What are the challenges faced when bathing patients who are morbidly obese?
Difficulties in skin assessment and hygiene due to limited mobility and skinfolds
## Footnote
Additional challenges include increased risk of odor and fungal infections, moisture retention, pressure injuries, and shear and friction injuries.
337
What increased risks are associated with bathing morbidly obese patients?
* Odor and fungal infections in skinfolds
* Moisture retention leading to maceration
* Pressure injuries caused by skinfolds, tight clothing, or catheters
* Shear and friction injuries during repositioning
## Footnote
These risks arise due to the unique physical challenges of morbid obesity.
338
Fill in the blank: To assist with reaching difficult areas during bathing, a _______ should be provided.
[trapeze]
339
What hygiene interventions should be used for morbidly obese patients?
* Use handheld showers and long-handled brushes
* Provide a trapeze to assist with reaching difficult areas
* Adapt home hygiene methods for consistency
* Ensure thorough rinsing and drying, particularly in skinfolds
## Footnote
These interventions help maintain hygiene and skin integrity.
340
What moisture management strategies are recommended for morbidly obese patients?
* Use moisture barrier creams in skinfolds and the perineal area
* Increase air circulation with fans if permitted
* Change linens frequently and manage incontinence promptly
* Use prescribed antifungal treatments for infections
## Footnote
Proper moisture management is crucial to prevent skin issues.
341
What are the recommendations for pressure relief for morbidly obese patients?
* Reposition the patient often to redistribute pressure
* Separate skinfolds with towels
* Reposition catheters and tubes frequently to prevent rubbing
## Footnote
Regular repositioning is key to preventing pressure injuries.
342
How can shear and friction injuries be prevented when bathing morbidly obese patients?
* Use a trapeze for movement
* Avoid sheepskins; instead, use a waterproof and breathable mattress cover
* Keep linens wrinkle-free to reduce friction
## Footnote
Minimizing shear and friction is essential for skin protection.
343
What are the key goals of bathing older adults?
Prevent skin dryness and injury, promote comfort and independence in ADLs
344
What types of baths are recommended for older adults?
Bag baths or towel baths
345
What are the benefits of using bag baths or towel baths?
Addresses itching and irritation, improves skin integrity with less stress
346
What type of cleansers should be used for bathing older adults?
No-rinse pH-balanced cleansers
347
Why should soap be avoided when bathing older adults?
Soap can strip natural oils
348
What should be done immediately after soiling the skin?
Clean the skin and apply moisturizers
349
What special considerations should be taken for frail elderly or bed-bound patients?
Require gentle techniques, may need less frequent bathing
350
What is the term for a nurse bathing a bedridden patient without assistance?
Complete bath
351
What are the advantages of towel or bag baths?
Reduces skin irritation and stress, improves skin integrity, saves time and minimizes agitation
352
What types of baths may require medical prescriptions?
Therapeutic baths (e.g., oatmeal, coal tar, sitz baths)
353
What is the importance of foot care?
Necessary for hygiene, proper posture, ambulation, and tissue health.
## Footnote
Older adults and patients with chronic conditions are at higher risk for foot problems.
354
What causes a corn?
Cone-shaped thickening caused by pressure on bony prominences.
## Footnote
Results from ill-fitting shoes.
355
What are calluses?
Thickened skin on weight-bearing areas (heels, soles).
## Footnote
Wider and less painful than corns.
356
What is Tinea Pedis commonly known as?
Athlete’s Foot.
## Footnote
A fungal infection due to moisture accumulation in unventilated shoes.
357
What are the symptoms of Tinea Pedis?
Itching, burning, scaling, and cracking between toes.
358
What is an ingrown toenail?
Nail grows into surrounding soft tissue, causing pain, swelling, and inflammation.
## Footnote
Often results from improper nail trimming or tight shoes.
359
What causes foot odor?
Caused by bacteria interacting with perspiration in a warm, moist environment.
360
What are plantar warts?
Painful viral growths on pressure points (heels, balls of feet).
361
What are pressure injuries?
Develop over bony prominences due to unrelieved pressure.
## Footnote
Common areas: Heels, ankles, great toes.
362
What is a bunion also known as?
Hallux Valgus.
363
What causes bunions?
Tight shoes, high heels, genetics, arthritis.
364
What should be inspected daily for preventive foot care?
Skin integrity, lesions, or cracks; redness, swelling, or signs of infection
## Footnote
Regular inspections help in early detection of potential issues.
365
What type of shoes should be used to prevent foot issues?
Properly fitting shoes
## Footnote
Properly fitting shoes help prevent pressure and friction.
366
How should toenails be trimmed to prevent ingrown nails?
Trim straight across
## Footnote
Avoid cutting corners when trimming toenails.
367
What exercises promote circulation in feet?
Movement or range-of-motion exercises
## Footnote
Encouraging activity helps maintain healthy blood flow.
368
What should be done to address moisture issues in foot care?
Keep feet dry, especially between toes; use antifungal powders or sprays for tinea pedis
## Footnote
Moisture management is crucial in preventing fungal infections.
369
What should diabetic patients be taught regarding foot care?
Inspect feet daily and seek early intervention for injuries or infections
## Footnote
Early detection is vital for preventing serious complications.
370
Why should patients be advised against going barefoot?
To prevent injuries
## Footnote
Going barefoot increases the risk of cuts and infections.
371
What hygiene interventions are required for morbidly obese patients?
Customized hygiene interventions for skinfolds, moisture, pressure, and friction management
## Footnote
Specialized care helps address unique challenges faced by morbidly obese patients.
372
What techniques should be prioritized for older adults' foot care?
Gentle, moisturizing techniques
## Footnote
Older adults often have fragile skin that requires special care.
373
What are effective bathing alternatives for older adults?
Towel or bag baths
## Footnote
These methods are less stressful and easier on fragile skin.
374
What complications can regular foot inspections help prevent?
Ulcers, infections, and pressure injuries
## Footnote
Regular inspections are key to maintaining foot health.
375
What common foot issues should be addressed with appropriate care?
Corns, calluses, and fungal infections
## Footnote
Addressing these issues early can prevent more serious problems.
376
What may cold, pale, or dusky feet indicate?
Impaired circulation or tissue perfusion.
377
What do warm, pink feet typically suggest?
Healthy circulation and oxygenation.
378
What should be checked for skin integrity?
Lesions, cracks, calluses, corns, blisters, or pressure injuries.
379
Where should you examine for fungal infections or moisture-related issues?
Between the toes.
380
What are some signs of impaired nails to inspect for?
Thickened, ingrown, or discolored nails.
381
What circulation and sensation assessments should be performed?
Capillary refill, pulses, and signs of arterial insufficiency.
382
What symptoms should be checked for neuropathy, especially in patients with diabetes?
Symptoms related to nerve damage or loss of sensation.
383
What focused question can assess foot health?
Do you experience pain or discomfort in your feet?
384
What nursing diagnosis is related to mechanical pressure from improperly fitting shoes?
Impaired Skin (or Tissue) Integrity.
385
What risk for impaired skin integrity is related to diabetes mellitus?
Altered sensation secondary to diabetes mellitus.
386
What nursing diagnosis relates to foot pain secondary to arthritis?
Impaired Walking.
387
What are the NOC outcomes for tissue integrity?
Skin and mucous membranes remain intact.
388
What individualized goal should a patient aim for regarding foot care?
Inspect feet daily for signs of injury or irritation.
389
What is an example of a NIC intervention for foot care?
Regular cleaning and inspection of feet.
390
What should be used to prevent dryness in foot care?
Appropriate moisturizers (avoid between toes).
391
What is a key component of circulatory care?
Promote arterial and venous circulation through exercises or positioning.
392
What should be monitored for signs of breakdown, infection, or poor healing?
Skin Surveillance.
393
What should be done to prevent infection and odor after washing feet?
Dry feet thoroughly, especially between toes.
394
How should nails be trimmed to protect soft tissues?
Trim nails straight across.
395
What should be avoided to prevent drying the skin?
Soaking feet for long periods.
396
What is the recommended frequency for washing feet?
Daily with warm water and mild soap
## Footnote
It is important to dry feet thoroughly after washing.
397
What should be applied to feet to prevent dryness?
Moisturizer, avoiding areas between the toes
## Footnote
This helps maintain skin hydration and prevents cracking.
398
What should be inspected daily on the feet?
Cuts, blisters, redness, swelling, or sores
## Footnote
Regular inspection helps in early detection of problems.
399
What type of shoes should be worn for proper foot care?
Well-fitting shoes with supportive soles
## Footnote
This reduces the risk of foot injuries and discomfort.
400
What types of shoes should be avoided?
High heels and tight shoes
## Footnote
These can cause foot pain and deformities.
401
What material should socks be made of for foot care?
Breathable materials (e.g., cotton)
## Footnote
This helps keep feet dry and comfortable.
402
How should nails be trimmed to prevent ingrown toenails?
Straight across and file sharp edges
## Footnote
Avoid cutting nails too short or into the corners.
403
What are the risks associated with diabetes that affect foot care?
Impaired circulation, neuropathy, and infections
## Footnote
These conditions increase the likelihood of foot complications.
404
What is a self-care measure for diabetic patients regarding foot inspection?
Inspect feet daily for signs of injury, redness, or swelling
## Footnote
Early detection is crucial for preventing serious issues.
405
What should diabetic patients avoid to prevent foot injuries?
Walking barefoot
## Footnote
This is important to protect feet from cuts and injuries.
406
What temperature of water should be used to wash diabetic patients' feet?
Lukewarm water
## Footnote
Always check the temperature with the wrist or elbow to avoid burns.
407
What should be kept dry to prevent fungal infections?
Feet, especially between the toes
## Footnote
Moist environments can lead to fungal growth.
408
What should diabetic patients avoid doing to corns or calluses?
Trimming them; seek professional care instead
## Footnote
Improper trimming can lead to injuries or infections.
409
What should be reported to a healthcare provider immediately?
Non-healing sores, infections, or changes in skin color
## Footnote
Prompt reporting can prevent serious complications.
410
Why should diabetic patients have regular foot exams?
To prevent complications like infections or amputations
## Footnote
Early intervention is key in managing foot health.
411
What should be monitored for early signs of complications?
Skin color, temperature, and integrity
## Footnote
Monitoring these factors is crucial for early detection of potential issues.
412
Which specific patient population requires special attention regarding circulation and neuropathy?
Diabetic patients
## Footnote
Diabetic patients are at higher risk for complications related to circulation and nerve damage.
413
What are key interventions to promote healthy foot care?
Healthy foot care habits, proper footwear, routine inspection
## Footnote
These practices help in preventing foot-related complications.
414
What professional services should be utilized for advanced foot care needs?
Callus trimming and other advanced care needs
## Footnote
Professional services can provide specialized care that may be necessary for patients.
415
What is an important education point for patients regarding foot care?
Importance of daily foot care and inspection
## Footnote
Educating patients on daily care can help prevent serious complications.
416
What should patients be taught to report early?
Any abnormalities
## Footnote
Early reporting can lead to timely interventions and prevent serious complications.
417
What complications can diabetic patients face if foot care is neglected?
Delayed healing, infection, gangrene
## Footnote
These complications can be severe and require immediate attention.
