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EPCC Nursing Foundations > Skin Integrity + Hygiene > Flashcards

Skin Integrity + Hygiene Flashcards

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1
Q

A pt has an injured foot, which type of therapy caused vasoconstriction and less blood to the wound

A

Ice therapy

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2
Q

Hot and cold therapy have a rebound affect after how long?

A

30 min.

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3
Q

What type of infection does leukocytes indicate?

A

UTI
HIGH WBC COUNT
INFECTION

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4
Q

What are the two major functions of the nurse when it comes to skin care

A

Maintain skin integrity (don’t let the pt skin become impaired)
Promote wound healing

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5
Q

What is hygiene?

A

science of health and maintenance

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6
Q

What is the purpose of hygiene?

A

it is self care that is highly personal and determined by the person and their cultural values and practices

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7
Q

What are factors that influence individual hygienic behaviors?

A

Culture
Religion
Environment
Developmental age preschoolers do well independently and encouragement
Health and energy Mobility and energy levels
Personal preferences

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8
Q

Where do children learn their personal hygiene from?

A

Home (learned at an exceedingly early age)

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9
Q

What is the sequence of performing hygiene?

A

Head to toe

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10
Q

What is early morning care and when is it provided to the pt?

A

As soon as the pt wakes up
Give an opportunity to void/ urinate
Give wash cloth to wash hands and face
Give oral care

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11
Q

What are the nurses roles in hygiene care?

A

Helping the pt urinating, defecating, helping them after vomiting or becoming soiled from perspiration or wound drainage

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12
Q

What is morning care and when is it provided?

A

After the pt eats breakfast
Elimination needs
o Bath or shower.
o Perineal care.
o Back massages.
o Oral/ nail/ and hair care.
o Making pts bed.

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13
Q

What is hour of sleep or PM care and when is it provided?

A

o Elimination needs.
o Washing face and hands.
o Oral hygiene
o Back massage.

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14
Q

What is PRN care and when is it provided?

A

Provided when the pt needs it. Changing the cloths and linen. More frequent bathing.

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15
Q

What is the key descriptor of skin?

A

Good, patent, healthy skin

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16
Q

What is the purpose of bathing?

A

To remove excess oil, perspiration, dead skin cells and bacteria
STIMULATES CIRCULATION
It is an opportunity to assess skin even though you can assess skin without bathing.
To give a sense of wellness and comfort.

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17
Q

When a pt soils themselves or has an accident which type of care is provided?

A

PRN Care

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18
Q

If the nurse sees something present on the skin that wasnt there before, what is the doing?

A

Assessing the skin

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19
Q

What is the purpose of a cleansing bath?

A

Hygiene

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20
Q

What is the temperature for a bath?

A

43-46C or 110-115F

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21
Q

The nurse is supposed to clean pts using which method?

A

Rubbing ling smooth strokes from the distal to proximal parts of the extremities.
Unless contraindicated bc the pt has thrombosis.

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22
Q

List the types of cleansing baths

A

Complete
Self-help
Partial
Bag
Towel
Tub
Shower

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23
Q

When should the water for a bed bath be changed?

A

When the water is dirty or cold.

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24
Q

A dependent pt requires this type of bath and it includes washing what?

A

Complete bed bath
Washing the ENTIRE body

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25
A pt confined to bed and able to bathe themself with the help of the nurse for washing their back and possibly their feet is what type of bath?
Self-help (assisted bed bath)
26
This type of bath is performed on pts in critical care and in some long term care settings
Bag bath
27
Describe how a bag bath is prepared
10-12 presoaked disposable wash clothes warmed in a microwave ~1 minute but timing depends on how to get it to the correct temperature (43-46C or 110-115F) Each area of the body is cleaned with a different cloth Air dry skin because the emollient needs to remain on the skin (softener)
28
What type of bath is used for pts who are bedridden or have dementia?
Towel bath
29
The nurse would provide this care for a pt that can help themselves but are confined to bed by washing their back or dependent pts would receive this bath
Partial bath
30
Some ambulatory pts prefer to take this bath in a sink and the nurse can assist by washing their back
Partial
31
What areas are to be cleaned during a partial bath?
the parts that may cause discomfort or odor if neglected are washed: Face Hands Axillae Perineal area **areas that may cause odor**
32
Dependent pts would receive these types of bath
Tub Complete Partial
33
A pt that is ambulatory and requires minimal assistance from the nurse would take this type of bath:
Shower (with the aid or a shower chair if necessary)
34
This type of bath omits cleaning the arms, chest, abdomen, legs and feet
partial bath
35
List the types of therapeutic baths
Medicated Sitz
36
This bath is for mothers after child birth, pts after rectal surgery, or have hemorrhoids
Sitz
37
What the purpose of therapeutic baths?
physical effects to soothe irritated skin to treat an area (perineum)
38
What does a sitz bath do?
soothe and heal the perineum
39
Where is a therapeutic bath taken?
bathtub disposable plastic sitz bath over a toilet bowl
40
What is the purpose of a medicated bath?
soothing irritated or itchy skin from sunburns, hives, or skin diseases
41
This bath is for pts with irritated or itchy skin, that could be from from sunburns, hives, or skin diseases
Medicated
42
How would the nurse prepare a medicated bath?
Fill the tub 1/3 or 1/2 full Water at comfortable temperature (43-46C or 110-115F) Medication is placed in the water (Na Bicarb, aveeno oatmeal, bath oils)
43
How long should the pt remain in the bath for a medicated bath?
20-30 minutes
44
If the pts arms and chest need to be treated, should these areas also be submerged in the solution?
Yes
45
If the window is open or air is coming into the room while the nurse is giving the pt a bath, the pt will experience which type of heat loss making them cold.
Convection
46
If assisting pt into shower and tub, explain how they can signal for help what is the acceptable timeframe to leave the pt alone?
2-5 minutes
47
What strategies would be used when bahing a pt with dementia?
Speaking soft (using low tone of voice) Moving to their energy level Offering two choices (letting them be independent) The nurse needs to be organized Play music Cover the pt as much as possible
48
If a dementia pt is combative or difficult to work with or if they try to hit you, what should you do?
Stop the bath completely and come back and try again at a later time.
49
Who is the best source of information when it comes to bathing dementia pts or learning about their routine?
Family members or care givers
50
Describe the epidermis
the thinnest layer of the skin hydrates the body produces new skin cells by regeneration **makes melanin** (skin color) protects sublayers from damage foul odor due to sweat pores exiting this layer
51
Which skin layer produces skin color/ skin pigment
epidermis
52
Describe the dermis
processes sensation of pain, heat/ cold (temperature), pressure, and touch produces sweat (sweat glands are in this layer) Produces hair (hair follicles are in this layer)
53
Which layer provides sensation
the dermis or dermal layer
54
Describe the hypodermis or SQ layer
a cushion for muscle and bone produces connective tissue - proteins/ lipids regulates body temperature
55
Describe partial thickness wounds
the dermis and epidermis heal by regeneration
56
describe full thickness wounds
dermis, epidermis, and hypodermis (SQ) *(all 3 layers)* + muscle and bone require connective tissue repair
57
Which layer of the skin hydrates the body
epidermis
58
What is the process that controls sweat
perspiration and evaporation
59
In the process that controls sweat, which type of heat loss is occurring
radiation and conduction
60
Radiation causes the body to gain _______
heat
61
The body producing heat is called
conduction
62
Heat gain is called
radiation
63
Describe conduction
body heat lost to nearby objects through direct physical touch
64
Radiation and conduction work thorugh
vasoconstriction and vasodilation
65
How does the body get rid of heat
evaporation
66
What is the function of the hypodermis or subcutaneous tissue
is a cushion between the dermis/ epidermis and muscle and bone produces lipids and proteins regulates body temperature
67
What is the type of tissues in the hypodermis
adipose tissue connective tissue (bone, blood, muscles, cartilage)
68
What are other functions of the hypodermis (subQ)
stores fat (energy) shock absorber regulates body temp produces hormones
69
What would happen if the hypodermis was destroyed
bone and muscle would be exposed requires connective tissue repair (bone, blood, muscles, cartilage)
70
Describe what muscle tissue is
fibrous connective tissue
71
If only two layers of the skin is damaged and they heal by regenerations, what kind of thickness is this
Partial
72
If 3 layers of the skin is damaged and requires connective tissue repair, what kind of thickness is this?
full thickness
73
The NANDA dx for 3 layers (epidermis, dermis, subQ/ hypodermis) is destroyed, what is it called?
Impaired tissue integrity
74
What are the 5 functions of the kin
1. Protection from injuries 2. Regulated body temperature (hypodermis/ subcutaneous) 3. Secretes sebum 4. Transmits sensation (dermis) 5. Produces and absorbs vitamin D
75
A function of the skin is protection, what is the skin protecting the body from?
protects underlying tissue from injury or trauma patent healthy skin = skin that is not broken protects the body from bacteria or microorganisms
76
How does the body regulate body temperature as its function
evaporation and perspiration vasoconstriction and vasodilation
77
Cooling the body when working out is a process of
radiation and conduction evaporation and perspiration vasocon. and vasod.
78
Describe the function of the skin secreting sebum
it is oil that softens the skin, lubricates hair, creates **skin turgor** and skin elasticity
79
Does sebum decrease in older adults
yes
80
True or False: Elderly adults have increased moisture on their skin?
False
81
Which function of the skin protects the body from humidity
Sebum - a process opens to get rid of heat loss
82
This is an action of sebum on the skin
bactericidal
83
This is condition when the epidermis does not produce color
albinism
84
When UV lights hit the skin it activates a receptor to produce
Vitamin D
85
The skin can produce and make this
vitamin D
86
A pt who cant bathe themself requires this type of bath
complete
87
Described situations when a pt would need a complete bath
brain injury (coma) quadriplegic unconscious hospice
88
How frequently do pts need to be repositioned
every 2 hours

EPCC Nursing Foundations (43 decks)

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