220- hygiene

Question 1

personal hygiene

Answer 1

cleanliness and grooming that promotes physical and Psychological well being and enchants the healing process. (nurses responsibly)

Question 2

Body first line of defense

Answer 2

intact skin

Question 3

what helps prevent skin injury

Answer 3

Adequate nutrition and hydration of cells

Question 4

what maintains skin cell life

Answer 4

adequate circulation

Question 5

what is the BRADEN scale?

Answer 5

used to predict the likelihood of a patient developing a pressure injury. Rating 1-4 on sensory perception, moisture, activity, mobility, nutrition and friction and shear.

Question 6

skin in elderly

Answer 6

thinning of sub Q and dermal layer
decreased activity of glands
longer cell renewal
nail changes
decreased collagen fiber

Question 7

oral Assessment

Answer 7

lips
color and surface of gums
teeth
tongue
hard and soft palates
dentures

Question 8

medical treatment that create a dry environment in the mouth and require extra oral care

Answer 8

oxygen therapy
nasogastric tubes
side effects of medications
mouth breathing that occurs with infection
mechanical ventilation

Question 9

what is the purpose for bathing?

Answer 9

cleaning/conditiong the skin
relaxation
promotes circulation
improved self esteem and well being
movement and exercise
gives the nurse assessment opportunity
strengthens nurse/patient relationship

Question 10

types of bath

Answer 10

shower (if walking, use arm bag for IV)
bathing (complete and partial assist)
CHG bath (chlorine hexadine wipes that prevent pathogen from entering skill)
Bag bath (Bag of no rinse wipes just add water)

Question 11

giving the bath

Answer 11

Gather all items
privacy and warmth
wash using no rise cleaner
dry
lotion

Question 12

CHG clothes reduce

Answer 12

the risk of MDRO organisms and HAI’s

Question 13

Things that require chlorhexidine baths

Answer 13

central lines
PICC lines and med lines
hemodialysis catheters

Question 14

process for med/surg units using CHG

Answer 14

Bath the patient first then use CHG wipes, dry and lotion patient

Question 15

Wipe warmer light system

Answer 15

orange=not ready
yellow= cloth is warming
green=take first
solid green= cloth is ready
blinking green= cloth will expire soon, use first
red=dispose

Question 16

CHG Instructions

Answer 16

work from top to bottom
6 wipes total
1. neck chest abdomen and groin
2. back and buttocks
3. left arm
4. right arm
5. left leg
6. right leg

do not use on face or perineal area
do not us on mucous membranes or abraded skin

Question 17

Pure wick criteria

Answer 17

strict I&O ordered w/ incontinent and unable to use bedpan or commode
post surgery and requires immobilization
approved by wound car or surgery
palliative care CMO
patient is crucially ill with life threatening hemodynamic/respiratory instabillty

Question 18

best practice pure wick

Answer 18

suction low
replace 8-12 Horus
empty every 8 hours
do not use barrier cream
replace suction tubing every 30 days
not agitated patients

Question 19

perineal care

Answer 19

clean from least to most contaminated
clean vaginal area with no rinse cleaners NOT soap
per-bottles for rinsing and cleaning
apply skin barrier creams if appropriate
react foreskin to clean

Question 20

foley care

Answer 20

wash 6 inches down the tube
seal in tact
NO LOOPS
NOT ON FLOOR

Question 21

eyes, ear, nose care

Answer 21

cleaning eyes from inner to outer cantos
don’t forget glasses
assess hearing aid function
water soluble ointments only for nares
check to see if O2 tubing is breaking down skin behind ears

Question 22

benefits if back massage

Answer 22

general body conditioner
relieves tension and promotes relaxation
lets the nurse look for skin breakdown
improves circulation
decrease pain distress and anxiety
may improve sleep

Question 23

hair care

Answer 23

wash hair
comb hair
offer to shave face
care for beards and mustaches

Question 24

taking care of diabetic feet

Answer 24

wash feet daily with lukewarm water
dry feet especially between toes
apply moisturizer but NOT between toes
check feet for blisters, cuts, redness
trim toe nails straight across
change sock daily and avoid tight fitting
DO NOT walk barefooted
examine shoes daily for cracks stones or nails

Question 25

lines get gathered

Answer 25

first thing in the morning.

Question 26

before leaving the rooms

Answer 26

position for comfort
light/noise of tv
call light in reach
bed in low position
Head of bed elevated
side rails as appropriate

table everything
remove trash
bedside bag
curtains open
room stocked
check sharps containers