Chapter 15: Personal Care

Question 1

What is an ADL?

Answer 1

activity of daily living

Question 2

What is excoriation?

Answer 2

a break in skin integrity caused by scratching or scraping

Question 3

What is maceration?

Answer 3

softening and breaking down of the skin due to prolonged fluid exposure

Question 4

What is leukoplakia?

Answer 4

a condition causing white patches on mucous membranes that may be cancerous

Question 5

What is mottling?

Answer 5

skin discoloration caused by pooling blood that is blotchy or marbled in appearance

Question 6

What is seborrhea?

Answer 6

overactive sebaceous glands resulting in excess sebum

Question 7

What is tinea capitus?

Answer 7

ringworm of the scalp

Question 8

What does venous return refer to?

Answer 8

the flow of blood back to the heart

Question 9

What are nits?

Answer 9

Lice eggs

Question 10

What care is included in the early a.m?

Answer 10

Toileting, washing hands/face, oral care (based on preference), offering water

Question 11

When is a.m. care provided?

Answer 11

After breakfast

Question 12

What care does a.m care consist of?

Answer 12

Bathing, toileting, oral care (based on patient preference), shaving, hair care, dress/gown changes, straightening/changing linens

Question 13

When does p.m care occur?

Answer 13

after lunch

Question 14

What care is included in p.m. care?

Answer 14

positioning, toileting, offering fluids

Question 15

When is h.s. care?

Answer 15

at bedtime (hour of sleep)

Question 16

What kind of care happens at h.s.?

Answer 16

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

Question 17

What is head hair’s main function?

Answer 17

to insulate the head from losing body heat (40%)

Question 18

What are the benefits of bathing?

Answer 18

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

Question 19

What factors do patients determine regarding bathing?

Answer 19

time and type (determined by level of ability to perform own)

Question 20

How often do residents in LTC bathe?

Answer 20

2-3x/week

Question 21

What are the three levels of care for a patient?

Answer 21

self-care, assisted care, total care

Question 22

When should more frequent peri-care be provided?

Answer 22

when the patient is incontinent (urine or feces)

Question 23

Why does an elderly person’s skin dry out more easily?

Answer 23

decreased circulation

Question 24

What should be determined before bathing a patient?

Answer 24

the timing, the pt.’s culture (may determine sex preference), the patient’s abilities, and assistance needed

Question 25

What does washing from cleanest to dirtiest prevent?

Answer 25

bacteria transfer

Question 26

What does washing from distal to proximal provide?

Answer 26

improved venous blood return and circulation

Question 27

Why should you clean the farthest appendage first?

Answer 27

to avoid dirtying what has been already cleaned

Question 28

When should you change the water when giving a bath?

Answer 28

when the water is dirty, soapy, cool or after peri-care, feet cleaning or armpit washing

Question 29

Why might a hot shower cause a patient to faint?

Answer 29

because heat causes vasodilation which can drop the blood pressure

Question 30

When should you stay with a patient during bathing even if they do not need your assistance?

Answer 30

first bathing post surgery

Question 31

When is delegation of bathing appropriate?

Answer 31

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

Question 32

What should the nurse be assessing during bathing?

Answer 32

skin integrity and signs of fatigue (ability to perform their level of self-care)

Question 33

What assistive devices should you use if a patient can’t stand or can’t sit all the way down in a tub?

Answer 33

a shower chair or bench

Question 34

What is the importance of a back massage?

Answer 34

improving patient-nurse relationship

Question 35

Who is contraindicated to receive a back massage?

Answer 35

patients with heart conditions or with fractured ribs/vertebrae

Question 36

What might happen if a back massage is given to a patient with a heart condition?

Answer 36

vagus nerve stimulation

Question 37

What should be assessed during oral care?

Answer 37

teeth for decaying or broken teeth, gums for redness or excessive bleeding, mucosal ulcerations, leukoplakia

Question 38

What should the nurse be aware of and do when providing oral care for an unconscious patient?

Answer 38

aspiration, position laterally; keep suction handy; assess for sordes; use the least amount of fluid possible, less than 5mL

Question 39

What is sordes?

Answer 39

a crust collecting on teeth and/or lips

Question 40

When should a back massage be performed?

Answer 40

h.s. or after bathing

Question 41

Who might need special mouth care?

Answer 41

a patient on NPO, receiving O2 via cannula/mask, with an NG tube, or unconscious

Question 42

What reflex may occur in an unconscious patient during oral care?

Answer 42

the jaw may bite down; make a padded tongue blade using gauze and tape

Question 43

How is oral care performed on a conscious patient?

Answer 43

45 degrees to the teeth, brush in small circles across biting surfaces, set needed items on bedside if applicable

Question 44

What is a partial denture called?

Answer 44

a bridge

Question 45

How should you clean dentures?

Answer 45

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

Question 46

How often do most men shave?

Answer 46

daily

Question 47

Who should only be shaved using an electric razor?

Answer 47

patients taking anticoagulants or diabetics

Question 48

In which direction to the hair growth should you shave?

Answer 48

in the same direction of hair growth

Question 49

What kind of shaving may be done in women?

Answer 49

legs, axillae, lips/chin

Question 50

What should be assessed during nail care?

Answer 50

discoloration, ridges, clubbing, redness surrounding nails/tissue

Question 51

What is a sign of fungal infection in toenails?

Answer 51

thick, yellowed toenails

Question 52

What differences in nail care should occur in diabetics?

Answer 52

only filing to prevent cuts in tissue

Question 53

What should be assessed during hair care?

Answer 53

the scalp for lesions, tinea capitus, dandruff, lice and nits, sepborrhea

Question 54

What differences does African American hair have compared to Caucasian hair?

Answer 54

hair can mat and tangle easier, oil may be applied to the scalp

Question 55

What is the best way to provide accurate care for African American hair?

Answer 55

by talking to the patient, family, or others with experience

Question 56

What can be used to wash hair if a patient is on bedrest and can’t get to the shower or tub?

Answer 56

rinse-free shampoo or shampoo cap

Question 57

What should you assess when providing care for piercings?

Answer 57

redness, swelling, pain, discharge at site

Question 58

When should jewelry be removed?

Answer 58

if it interferes with surgery, intubation, diagnostic testing like an MRI, or catheterization

Question 59

What kind of jewelry does not need to be removed when going into an MRI?

Answer 59

nonmagnetic stainless steel or titanium

Question 60

How are contact lenses removed?

Answer 60

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)

Question 61

What is a complete removal of an eye called?

Answer 61

enucleation

Question 62

What is a blind globe?

Answer 62

an intact but blind eye

Question 63

What artificial eye device might be used on a blind or implanted globe?

Answer 63

scleral cover shell

Question 64

What should you be careful not to do when removing an ocular prosthesis from a blind or implanted globe?

Answer 64

not to touch or press the cornea

Question 65

In what order should an artificial eye be placed?

Answer 65

upper eyelid, then lower eyelid

Question 66

What is used to clean a hearing aid?

Answer 66

soapy water on the ear mold, tapping on the screen or filter if applicable, other aids/parts with a damp cloth

Question 67

How do you check a battery on a hearing aid?

Answer 67

turn on and turn to full volume while listening for a whistle, if no whistle, replace battery

Question 68

What is an open bed?

Answer 68

a bed made with top linens fanfolded to the foot of the bed

Question 69

What is a surgical bed?

Answer 69

a bed made with the top linens fanfolded to the side

Question 70

When making a bed, what intervention decreases of risk of breaks in skin integrity?

Answer 70

ensuring there are no wrinkles

Question 71

How can you provide privacy when giving patient care?

Answer 71

curtains, speaking softly, moving locations if needed

Question 72

How can the patient’s environment be controlled to their benefit?

Answer 72

removing unpleasant sights/smells, controlling noise, clutter, keeping pathway to bathroom cleared from equipment

Question 73

What is trendelenburg position used for?

Answer 73

to return blood to the vital organs/brain

Question 74

What is reverse trendelenburg used for?

Answer 74

to elevate a patient’s head without bending at the waist

Question 75

How can foot-drop be prevented?

Answer 75

by grasping the top linens and pulling upward, creating slack

Question 76

When and how is a complete bed bath done?

Answer 76

when the patient is unable to get out of bed using a basin of water at the bedside

Question 77

When and how is an assisted bath done?

Answer 77

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

Question 78

What is a partial bath?

Answer 78

a bath only bathing select body parts

Question 79

What is a therapeutic bath?

Answer 79

a tub bath given for a specific reason; medicated, whirlpool for light debridement, etc.

Question 80

What is a bag bath?

Answer 80

a bath using 12-15 warmed washcloths soaked in a no-rinse cleanser

Question 81

What is a towel or blanket bath?

Answer 81

a bath done using a bath blanket, towel, and/or washcloths that are soaked and warmed in a no-rinse cleanser

Question 82

What is an ocular prosthesis?

Answer 82

an artificial eye