220- hygiene Flashcards
personal hygiene
cleanliness and grooming that promotes physical and Psychological well being and enchants the healing process. (nurses responsibly)
Body first line of defense
intact skin
what helps prevent skin injury
Adequate nutrition and hydration of cells
what maintains skin cell life
adequate circulation
what is the BRADEN scale?
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.
skin in elderly
thinning of sub Q and dermal layer
decreased activity of glands
longer cell renewal
nail changes
decreased collagen fiber
oral Assessment
lips
color and surface of gums
teeth
tongue
hard and soft palates
dentures
medical treatment that create a dry environment in the mouth and require extra oral care
oxygen therapy
nasogastric tubes
side effects of medications
mouth breathing that occurs with infection
mechanical ventilation
what is the purpose for bathing?
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
types of bath
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)
giving the bath
Gather all items
privacy and warmth
wash using no rise cleaner
dry
lotion
CHG clothes reduce
the risk of MDRO organisms and HAI’s
Things that require chlorhexidine baths
central lines
PICC lines and med lines
hemodialysis catheters
process for med/surg units using CHG
Bath the patient first then use CHG wipes, dry and lotion patient
Wipe warmer light system
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
CHG Instructions
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
Pure wick criteria
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
best practice pure wick
suction low
replace 8-12 Horus
empty every 8 hours
do not use barrier cream
replace suction tubing every 30 days
not agitated patients
perineal care
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
foley care
wash 6 inches down the tube
seal in tact
NO LOOPS
NOT ON FLOOR
eyes, ear, nose care
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
benefits if back massage
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
hair care
wash hair
comb hair
offer to shave face
care for beards and mustaches
taking care of diabetic feet
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
lines get gathered
first thing in the morning.
before leaving the rooms
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
