Chapter 6 Flashcards
Personal care
Tasks concerned with body appearance and hygiene
Hygiene
Keep bodies clean and healthy
Grooming
Caring for fingernails and hair
Personal care is part of ADLs t/f?
True
Am care
1.Offering bedpan/urinal
2. Wash face/ hands
3. Hair care, dressing and shaving
4. Mouth care before or after breakfast
Pm care
-bed pan or urinal before bed
- wash face/hands
-giving snack
- mouth care
-changing into night clothes
-giving backrub
What should you do if someone needs extra help
Try to let them do it, then document
What should you do when resident receives call
Leave to give them privacy
How should you treat resident’s private time and belongings
With respect
Should you interrupt when a resident is dressing?
No
What should you keep in you when providing personal care?
Small notepad
What should you write in your small notepad?
Patient symptoms and concerns which will be reported and documented to the nurse
What causes pressure points
Immobility
Pressure points
Areas of the body that bear too much weight
Bony prominences
Bone lies too close to skin
Areas at higher risk for skin breakdown
Elbows
Shoulder blades
Tailbone
Hips
Knees (in and out)
Ankles
Heels
Toes
Back of head
Ears
Under breasts or scrotum
Folds of buttocks
Or abdomen
Skin between legs
Bottom of pelvis (butt bones)
Lateral position
Side supported
Areas of risk in lateral position
Side of ear
Ear
Shoulder
Hip
Greater trochanter
Knees
Ankles
Prone position
Swimming, on stomach
Pressure danger zones prone position
Cheek
Collarbone
Breasts
Abdomen
Genitals
Knees
Toes
Supine position
Lying on back palms up
Supine position danger zones
Back of head
Shoulder blades
Butt bones
Elbows
Sacrum (base spine)
Between legs
Heels
Pressure sores
Skin breakdown
Shearing
Rubbing or friction that because skin moves one way and bones move in other or stay the same
Stage 1 pressure injury
Redness doesn’t go away after removing pressure. Different skin tone in darker people
Stage 2 pressure injury
Partial skin loss, injury is pink or red and moist. Could look like blister
Stage 3 pressure sore
Fat or muscle visible in injury slough and eschar
Slough
Yellow, tan, green or gray moist skin
Eschar
Dead tissue
Can be hard or soft
Black, brown, tan,
Can look like scab
Down to muscle but not through muscle
Stage 4 pressure sore
Full thickness skin loss
Down to bone
Like crater
Unstageable pressure injury
Full thickness skin and tissue loss but it’s covered in slough and eschar
Deep tissue pressure injury
Deep red, purple or maroon
Appears as blood filled blister
Painful area that may be warmer or cooler
Discoloration may be different
How often should position be changed when lying down?
Every 2 hrs
Can you massage pressure sores?
No
Fowlers position
Bed front raised 45-60º
Keep bed free from
Wrinkles and crumbs
How do you keep buttocks free from moisture
Use bed pad
How do you relieve pressure from bony prominences
Use pillows and other assistive devices
When in wheelchair Try to_____ to prevent pressure sores and improve circulation
Lift up hips
What must the bottom of a resident’s bed be kept free from
Wrinkles and crumbs
Cloth covered items that keep hand or fingers in a normal, natural position
Handrolls
May be caused by pulling a resident across the sheet transferring him
Shearing
Skin should be kept clean and
Dry
Keeps covers from resting on the legs and feet
Bed cradle
One type of material tat prevents air from circulating, causing skin to sweat
Plastic
At minimum, number of hours to reposition immobile resident
2
Skin this color should not be massaged
Red
In overweight residents you should pay extra attention to
Skin between folds
Key for keeping skin healthy
Proper nutrition
Draw sheets
Help move residents preventing shearing. Half a bed sheet
Where should draw sheet be positioned
Between shoulders and butt
Foot board
Padded boards placed against feet for proper alignment
Foot drop
Weakness of foot muscles
Orthotic device
Helps support and align limb and improve it’s functioning. Splints are a type
Trochanter rolls
Rolled towels or blankets used to keep resident’s hips and legs from turning outward
Abduction pillows/wedges/splints
Pillows between legs from knees to ankles. Helps with proper positioning
Splints should be ___ so skin doesn’t stick
Lined
Partial bath includes
Hand, face, underarm, perineum, (feet)
What should be washed every day
Hands, face, perineum, underarms
Can you leave resident while bathing?
No, make sure you get everything first
Change your gloves before giving ____ during bath
Peri-care
Start with the ___ eye
Opposite
What is your chest?
Shoulders to pubis
Always make sure you pull skin back down on penis after washing t/f
True
Before applying cream on resident
Warm it up
Use ____ strokes for back rubs
Long upward
Clean tub after ___ uses
Every
Nail care should be given when
Nails are dirty, have jagged edges or assigned
When can an NA cut toe nails?
Never, unless specially trained
Best time to put cream on is after
Bath
Pediculosis
Infestation of lice
Safety razor
Sharp blade with special casing to prevent cuts
Disposable razor
Requires shaving cream or soap, biohazard
Electric razor
Safest and easiest. No soap or shaving cream
Hold the skin ___ when shaving
Taut
Shave in direction of
Hair growth
Dress with
Weak
Undress with
Strong
Affected/ involved side
Side with problems
Ted hose
Promote circulation by squeezing legs
Should you rub an embolism?
No
Embolism
Obstruction of blood vessel, usually because of clot
Signs of poor oral care
- Irritation
2.Raise areas - Coated or swollen tongue
- Ulcers
- Dry cracked bleeding lips
- Decayed teeth
- Bad breath
Oral care should be done
At least 2 times
After breakfast and after last meal
+
When requested
How often oral care if unconscious
Every hour
Why should unconscious patients get oral care every hour
Lack of fluid makes it dry
Only swabs with ___ amounts of fluid should be used to clean mouth of unconscious patients
Tiny
Position for oral care for unconscious patients
Side
Dentures should never be cleaned with __ water
Hot
Dentures cannot
Dry out
Dentures should be in ___ cup when not worn
Denture cup
Line sink with ___ before starting denture care
Towels
When removing dentures take
Bottom out first
When inserting dentures put ___ in first
Top
Fracture pan
Pan for people with broken hips who can’t raise pelvis
How often should urinals and bedpans be rinsed?
Every time
Pour bedpans and urinals out in
Toilet not sink
Fracture pan positioned with handle towards
Foot of bed
Align bedpan with
Tailbone
Portable commode
Used by ambulatory when bathroom is too far
Semi fowlers
30-45
High fowlers
60-90º
Positioning
Helping residents into positions that promote comfort and health
How many people to move resident up in bed
2
Problems from not moving
Muscle contractures
Pressure sores
Muscle contracture
Muscle gets short
Logrolling
Moving resident as a unit without disturbing alignment
When is logrolling necessary?
Neck, back or spinal cord injury
Dangle
Sit up with legs hanging over bed
Regain balance
Stabilize BP
Prevent fainting
Take orthostatic BP
Pulse+BP
Lie, sit, stand/dangle
(2 min between)
When is orthostatic BP taken
Patient is dizzy or faints
When is patient orthostatic
BP drops
Pulse goes up
How to place hands for dangling
Under thighs and shoulder blades
Ergonomics
Making things safer to suit worker abilities
Most places have
Lift free policies
Transfer belt should be positioned
Over clothing, to the side of navel
Transfer belt helps residents who are
Unsteady, weak or uncoordinated
Transfer belts can’t be used if
Resident has fragile bones or fractures
Slide board
Helps with transfer patients who can’t bear weight
If resident starts to fall
Bend knees and guide to floor
Wheelchair should be placed on
Unaffected side
Who can help with lifts
Anyone except housekeeping
Can you operate lift alone?
No
How to prevent spread of lice
Tell nurses as soon as you see them or signs
Don’t share head stuff
Partial bath includes washing
Genitals
Former name for pressure sores
Decubitus ulcers
Aspiration
Foreign objects getting into lungs..water, spit, food. Can cause pneumonia
