Chapter 15: Personal Care Flashcards
What is an ADL?
activity of daily living
What is excoriation?
a break in skin integrity caused by scratching or scraping
What is maceration?
softening and breaking down of the skin due to prolonged fluid exposure
What is leukoplakia?
a condition causing white patches on mucous membranes that may be cancerous
What is mottling?
skin discoloration caused by pooling blood that is blotchy or marbled in appearance
What is seborrhea?
overactive sebaceous glands resulting in excess sebum
What is tinea capitus?
ringworm of the scalp
What does venous return refer to?
the flow of blood back to the heart
What are nits?
Lice eggs
What care is included in the early a.m?
Toileting, washing hands/face, oral care (based on preference), offering water
When is a.m. care provided?
After breakfast
What care does a.m care consist of?
Bathing, toileting, oral care (based on patient preference), shaving, hair care, dress/gown changes, straightening/changing linens
When does p.m care occur?
after lunch
What care is included in p.m. care?
positioning, toileting, offering fluids
When is h.s. care?
at bedtime (hour of sleep)
What kind of care happens at h.s.?
assisting patient in preparing for sleep, offering fluids, oral care/denture care, clearing path to bathroom, straighten linens and obtain extra pillows or blankets as needed, adjust lights, temp, diabetic care, remove glasses/hearing aids
What is head hair’s main function?
to insulate the head from losing body heat (40%)
What are the benefits of bathing?
removing dead skin cells, improving circulation, providing opportunity for assessment, gives tactile sensory for pt.’s with or w/o neurosensory deficits, improved self-esteem, reinforces the nurse-patient relationship
What factors do patients determine regarding bathing?
time and type (determined by level of ability to perform own)
How often do residents in LTC bathe?
2-3x/week
What are the three levels of care for a patient?
self-care, assisted care, total care
When should more frequent peri-care be provided?
when the patient is incontinent (urine or feces)
Why does an elderly person’s skin dry out more easily?
decreased circulation
What should be determined before bathing a patient?
the timing, the pt.’s culture (may determine sex preference), the patient’s abilities, and assistance needed
What does washing from cleanest to dirtiest prevent?
bacteria transfer
What does washing from distal to proximal provide?
improved venous blood return and circulation
Why should you clean the farthest appendage first?
to avoid dirtying what has been already cleaned
When should you change the water when giving a bath?
when the water is dirty, soapy, cool or after peri-care, feet cleaning or armpit washing
Why might a hot shower cause a patient to faint?
because heat causes vasodilation which can drop the blood pressure
When should you stay with a patient during bathing even if they do not need your assistance?
first bathing post surgery
When is delegation of bathing appropriate?
when the patient is stable, the outcome is expected, and if they’ve been taught the importance of checking the patient and listening if they’ve called
What should the nurse be assessing during bathing?
skin integrity and signs of fatigue (ability to perform their level of self-care)
What assistive devices should you use if a patient can’t stand or can’t sit all the way down in a tub?
a shower chair or bench
What is the importance of a back massage?
improving patient-nurse relationship
Who is contraindicated to receive a back massage?
patients with heart conditions or with fractured ribs/vertebrae
What might happen if a back massage is given to a patient with a heart condition?
vagus nerve stimulation
What should be assessed during oral care?
teeth for decaying or broken teeth, gums for redness or excessive bleeding, mucosal ulcerations, leukoplakia
What should the nurse be aware of and do when providing oral care for an unconscious patient?
aspiration, position laterally; keep suction handy; assess for sordes; use the least amount of fluid possible, less than 5mL
What is sordes?
a crust collecting on teeth and/or lips
When should a back massage be performed?
h.s. or after bathing
Who might need special mouth care?
a patient on NPO, receiving O2 via cannula/mask, with an NG tube, or unconscious
What reflex may occur in an unconscious patient during oral care?
the jaw may bite down; make a padded tongue blade using gauze and tape
How is oral care performed on a conscious patient?
45 degrees to the teeth, brush in small circles across biting surfaces, set needed items on bedside if applicable
What is a partial denture called?
a bridge
How should you clean dentures?
using cool water, a washcloth lining the sink to prevent breaks, store overnight in a denture cup with water and a cleaning tab if needed
How often do most men shave?
daily
Who should only be shaved using an electric razor?
patients taking anticoagulants or diabetics
In which direction to the hair growth should you shave?
in the same direction of hair growth
What kind of shaving may be done in women?
legs, axillae, lips/chin
What should be assessed during nail care?
discoloration, ridges, clubbing, redness surrounding nails/tissue
What is a sign of fungal infection in toenails?
thick, yellowed toenails
What differences in nail care should occur in diabetics?
only filing to prevent cuts in tissue
What should be assessed during hair care?
the scalp for lesions, tinea capitus, dandruff, lice and nits, sepborrhea
What differences does African American hair have compared to Caucasian hair?
hair can mat and tangle easier, oil may be applied to the scalp
What is the best way to provide accurate care for African American hair?
by talking to the patient, family, or others with experience
What can be used to wash hair if a patient is on bedrest and can’t get to the shower or tub?
rinse-free shampoo or shampoo cap
What should you assess when providing care for piercings?
redness, swelling, pain, discharge at site
When should jewelry be removed?
if it interferes with surgery, intubation, diagnostic testing like an MRI, or catheterization
What kind of jewelry does not need to be removed when going into an MRI?
nonmagnetic stainless steel or titanium
How are contact lenses removed?
pull down on lower lid, place one finger across the upper lid, apply gentle but firm pressure, ask the pt. to blink (hard lenses will pop out, soft will wrinkle)
What is a complete removal of an eye called?
enucleation
What is a blind globe?
an intact but blind eye
What artificial eye device might be used on a blind or implanted globe?
scleral cover shell
What should you be careful not to do when removing an ocular prosthesis from a blind or implanted globe?
not to touch or press the cornea
In what order should an artificial eye be placed?
upper eyelid, then lower eyelid
What is used to clean a hearing aid?
soapy water on the ear mold, tapping on the screen or filter if applicable, other aids/parts with a damp cloth
How do you check a battery on a hearing aid?
turn on and turn to full volume while listening for a whistle, if no whistle, replace battery
What is an open bed?
a bed made with top linens fanfolded to the foot of the bed
What is a surgical bed?
a bed made with the top linens fanfolded to the side
When making a bed, what intervention decreases of risk of breaks in skin integrity?
ensuring there are no wrinkles
How can you provide privacy when giving patient care?
curtains, speaking softly, moving locations if needed
How can the patient’s environment be controlled to their benefit?
removing unpleasant sights/smells, controlling noise, clutter, keeping pathway to bathroom cleared from equipment
What is trendelenburg position used for?
to return blood to the vital organs/brain
What is reverse trendelenburg used for?
to elevate a patient’s head without bending at the waist
How can foot-drop be prevented?
by grasping the top linens and pulling upward, creating slack
When and how is a complete bed bath done?
when the patient is unable to get out of bed using a basin of water at the bedside
When and how is an assisted bath done?
in bed with the pt. sitting up, using a basin at the bedside; the pt. may or may not be able to do some of their care
What is a partial bath?
a bath only bathing select body parts
What is a therapeutic bath?
a tub bath given for a specific reason; medicated, whirlpool for light debridement, etc.
What is a bag bath?
a bath using 12-15 warmed washcloths soaked in a no-rinse cleanser
What is a towel or blanket bath?
a bath done using a bath blanket, towel, and/or washcloths that are soaked and warmed in a no-rinse cleanser
What is an ocular prosthesis?
an artificial eye
