Ch. 40 Hygiene (Week 2)

Question 1

When performing hygiene on a patient, what is this a good time to also do

Answer 1

Perform ongoing assessment such as range of motion, application of dressings, observation of pressure injuries or inspection of IV sites

Question 2

Proper hygiene care requires an understanding of what

Answer 2

anatomy and physiology of skin, feet, hands, nails, oral cavity, hair, eyes, nose and ears

Question 3

What are some factors that influence hygiene

Answer 3

1. Social practices - in some cultures they may only wash themselves every other day
2. Personal preferences - if you have oily hair you may want to wash your hair every other day
3. Body image
4. Socioeconomic status - people that are unhoused they may have a hard time finding the necessities
5. Health benefits and motivation
6. Cultural variables
7. Developmental stage - things will look different depending on what developmental stage the patient is in
8. Physical condition - can the patient do their own hydient are they parapelegic

Question 4

How would you use critical thinking while performing hygiene

Answer 4

• Integrate nursing knowledge with knowledge from other disciplines
• Think about prior experiences
• Determine whether there are any environmental factors that will impact patient care
• Prior to assessment review the patient’s medical record for new information
• Rely on professional standards

Question 5

What is the cornerstone of everything we do

Answer 5

Assessment

Question 6

What is the first step of the nursing process and how can we apply it to hygiene

Answer 6

First Step is Assessment
- Through the patient’s eyes - explore a perspective regarding hygiene care by asking about personal care products desired
- Assessment of self care ability
- Any environmental factors that will affect patient care and hygiene practices
- Assessment of a patients hygiene status requires a complete nursing history and a physical assessment (brief history to determine priority areas) - skin, feet and nails, oral cavity, hair, eyes, ears, nose, use of sensory aids, hygiene care products, cultural influences

Question 7

Patients that are at risk for hygiene problems may be at risk that results from what

Answer 7

• Side effects of medications or other medical therapy
• Lack of knowledge
• immobilization
• inability to perform hygiene
• Physical condition that potentially injures the skin, mouth, feet and nails or hair

Question 8

What are some examples of nursing diagnosis

Answer 8

Activity intolerance
impaired mobility
impaired health maintenance
impaired skin integrity
low self esteem

Question 9

How does planning from the nursing process apply to hygiene

Answer 9

• Outcomes. - Partner with the patient and family to identify expected outcomes to develop a mutually agreed on plan of care based on the patients nursing diagnosis - make outcomes measurable and achievable.
• Setting priorities
• Teamwork and collaboration - collaborate with other health team members, family caregivers, community agencies as needed

Question 10

How does the implementation step from the nursing process apply to hygiene

Answer 10

• health promotion
• Acute and continuing care
• Bathing and skin care - complete bed bath, partial bed bath and perineal care
• Back rubs
• Foot and nail care
• Oral hygiene - brushing, flossing, patients with special needs
• Hair and scalp care - brushing, combing, shampooing, shaving and mustache and beard care
• Care of the eyes, ears and nose

Question 11

How does the implementation step from the nursing process apply to hygiene

Answer 11

• Environment - look at the environment make sure that everything is clean
• maintain comfort
• beds, bedmaking, linens are all clean

Question 12

What are common bed positions

Answer 12

Fowlers - semi sitting position - 45 to 90 degrees

Semi-Fowlers - head of bed raised to 30-45 degress

Trednelenburg’s - entire bedframe tiled with head of bed down

Reverse trednelenburg - entire bedframe tiled with foot of bed down

Question 13

How does the evaluation step of the nursing process apply to hygiene

Answer 13

Evaluation of hygiene is based on outcomes of care, a patients sense of comfort, relaxation and well being and a patients understanding of hygiene techniques

Question 14

What are some safety guidelines for nursing skills

Answer 14

• Follow safety principles for prevention of infection and patient injury
• perform hygiene measures while moving from clean to dirty
• Continence issues pose threats to a patient’s skin integrity, increase the risk of falls and increase social isolation
• wear PPE
• Test the temperature of water or solutions
• keep personal hygiene items in patient reach
• Give proper direction to AP when delegating
• Monitor lab findings such as coagulation studies before administering oral hygiene or shaving a patient
• Determine patient’s or family caregiver’s knowledge, experience and health literacy

Question 15

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration

Answer 15

Modified left lateral recumbent position and Semi-Fowler’s position with head to side

Question 16

What safety precautions are important when doing foot care for a patient that has diabetes

Answer 16

Assess skin for redness, abrasions and open areas daily
apply lotion to feet daily
clean between toes after bathing

Because of a patient’s risk for infection, it is important to assess skin for redness, abrasions, and open areas daily. Apply lotion to feet daily to keep the skin hydrated, but do not leave excess lotion on the skin. Clean between toes carefully after bathing to avoid maceration. Do not cut nails or soak the feet of a patient with diabetes mellitus without a health care provider’s order because this may create skin breakdown and open sores, leading to skin breakdown or infection.

Question 17

Which of the following factors directly impairs salivary gland secretion

Answer 17

Radiation therapy and dehydration

Question 18

When performing mouth care to a patient who has a reduced level of consciousness which physical assessment techniques should you apply

Answer 18

oxygen saturation
respirations
gag reflex

Question 19

The american dental association suggests that patients who are at risk for poor hygiene use the following interventions

Answer 19

use fluoride toothpaste
use 0.12% cholorhexidine gluconate oral rinses for high risk patients
use a soft toothbrush for oral care

Question 20

What are the steps to providing oral care to a patient who has a decreased level of consciousness

Answer 20

1. Raised bed, lower, side, real, and position in Patient, close to side of the bed with head of bed raised up to 30°.
2. Remove partial plate or dentures if present.
3. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway.
4. Using a brush moistened with Clore hexedine paste, clean, chewing an inner tooth surface his first.
5. Gently brush tongue, but avoid stimulating, gag reflex.
6. For patients without teeth, use a toothette moistened in chlorhexidine, rinse to clean oral cavity 

Question 21

The nurse delegates to the assistive personnel, hygiene, care for an alert, older adult patient who had a stroke which interventions would be appropriate for this assistive personnel to accomplish during the bath

Answer 21

Providing range of motion exercises to extremities
Providing special skin care as indicated by nurse

Checking distal, pulses, determining the type of treatment for stage, one pressure injury, and changing a dressing over an intravenous site. All require a nurses assessment and clinical decision making and should not be delegated to assistive personnel. 

Question 22

The nurse will delegate hygiene care for two patients of different cultures to the assistive personnel. What cultural information does the nurse need to provide to the assistive personnel?

Answer 22

Specific hygiene products
Timing of hygiene care
The need for gender, congruent caregiver
Religious practices