Ch 39 Flashcards
Wile performing PT hygiene, what else should you integrate into the process?
Physical assessment, wound care, ROM exercises
What should the nurse do before performing basic hygiene measures on a PT
Assess pts physical and cognitive ability
What are some factors that would influence a patients hygiene practice?
Personal, sociocultural, economic, developmental factors
What can put a PT at a greater risk for impaired skin integrity?
Reduced sensation, vascular insufficiency, immobility
What should a nurse do for a suffering PT before performing hygiene?
Administer symptom relief therapies
What measures should be taken while performing oral care on an unconscious PT?
Prevent aspiration
The nurse assisting a PT with rheumatoid arthritis to bathe at the sink. During the bath the PT states that she is tires. The nurse notices the PT is breathing rapidly and the pulse is rapid. What’s is the nurses best response?
Help the PT return to bed
A PT who is cognitively impaired and has dementia behavior requires hygiene care. The PT often displays aggressive behavior. What techniques make the bathing experience less stressful?
Allow the PT to perform as much of the care as possible.
Try an alternative to traditional bathing such as the “bag bath”
What is the priority concern when providing oral hygiene for a PT who is unconscious?
Preventing aspiration
A male nurse caring for a female Muslim PT who has an indwelling Foley catheter. The nurse learns that the PT does not want him to help her with personal hygiene care. What are the next steps the nurse should take?
Find a female nurse to help the patient.
Asking the if she prefers a facility member assist with the care
You are helping a female PT bathe. The PT says she can finish bathing before you clean her perineal care, but the PT is having symptoms of discomfort and burning. What action do you take initially?
Explain to the PT that, because of her symptoms, you need to observe the perineal area
Your PT wears full dentures. His usual denture care includes taking the teeth out once a day to brush. He wears the dentures overnight. You are concerned that he might be at risk for developing denture-induced stomatitis. What points do you include in a teaching plan for denture care?
Do not wear damaged or poorly fitting dentures
Observe the mouth for reddened areas under the dentures and small red sores on the roof of the mouth
See dentist regularly
Rinse dentures after meals
A PT who is undergoing chemo has inflamed gums and oral mucosa and painful sores in the mouth. What oral care actions are appropriate?
Applying water soluble moisturizing gel on the oral mucosa
Encourage intake of soft food
During bathing your pt experiences SOB and labored breathing with a respiratory rate of 30. Th bed is in a flat position. You change the bed to:
Fowlers
A nurse teaching a family member caregiver how to bathe the patient explains the importance of using long strokes on the patients extremities, moving from distal to proximal. These strokes are used to:
Stimulate venous return
