Chapter 9 Flashcards
Patient room environment: what are the factors affecting the environment?
-temperature(68 to 74f 20 to 23c)
-ventilation(to keep stale air and odors from lingering in the room )
-noise
-odors (are kept to minimum)
-lighting
Life span considerations older adults ?
-become chilled
-mobility limited
-impaired circulation -(Impaired circulation or neurologic changes sometimes decrease the older person’s ability to sense temperature changes in water, so use caution to prevent burns)
-effects of soap and detergents on skin-( frequent bathing and use of detergent soaps have harmful effects on the skin of most older adults and rehydration)
Room Equipment ?
-bedside stand( patient personal articles and hygienic equipment
-bed
-overbed table (is on wheels and is adjustable to various height over the bed or chair)
-chair
-lights
Hygiene ?
-the principal of health
-includes care of skin,hair,hands,feet,.eyes ,ears,nose,mouth,back and perineum
Personal hygiene?
Self-care measures people use to maintain their health and prevent disease
Hygiene Nurses are ?
role models and tech by example
Bathing ? -
-often delegated to unlicensed assistive personnel
-Maintain a water temperature of 110 F (about 43°C) if the purpose is to apply heat to the affected area.
-the purpose is to promote healing or to produce relaxation, use a water temperature of about 98to 102F (34to 39C)
-20 to 30 minutes
- observe vertigo dizziness or syncope fainting
Therapeutic baths?
-cool water
-warm tub bath
-hot water tub bath
-sitz bath
Other Baths ?
-complete bed bath ( Patient who are totally dependent and require a total system )
-partial bath ( Assist those body part that are inaccessible to the patient )
-tepid sponge bath (A tepid sponge bath is administered to reduce the elevated temperature of patients who are febrile (condition characterized by an elevated body temperature).
-medicated bath ( -include agents such as oatmeal , cornstarch , Burow’s solution, and sodium bicarbonate (alkaline bath).
- reduce tension, relax the patient , and relieve the pruritus caused by certain skin disorders )
Assemble the necessary supplies bathing patient ?
-Bath blanket -Bath towels (2)
-Disposable gloves
-Drapes
-Gown or patient’s own pajamas or nightgown
-Hygiene articles , such as lotion , powder , and deodorant -Laundry bag or hamper soap
-Soap and dish-wash basin-wash clothes
Characteristics of normal skin ?
-Good turgor (elastic and firm); generally smooth and soft
-Intact without abrasions
-Localized changes in texture across surface
-Skin color variations from body part to body part
-Warm and moist
Prevention/treatment-impaired skin integrity?
(1) optimal healing of the impaired skin without complications
(2) a decrease in the patient’s discomfort ;
(3) a decrease in length of stay in the facility if a discharge is planned
(4) a decrease in the cost of ongoing care .
Pressure Injuries (Pressure Ulcers)?
-occurs when there is sufficient pressure on the skin to cause the blood vessels in an area to collapse ( The flow of blood and fluid to the cells is impaired, resulting in ischemia, or lack of oxygen and nutrients, to the cells.)
Pressure Injuries (pressure ulcers) factors that play a role in pressure ulcers?
-Shearing force (The first is shearing force .This occurs when the tissue layers of skin slide on each other , causing subcutaneous blood vessels to kink or stretch and resulting in an interruption of blood flow to the skin)
-Friction (The second mechanical factor is friction .
The rubbing of skin against another surface produces friction , which may remove layers of tissue .
This may occur when)
-If reddened areas are found, assess the area by gently pressing on the reddened area with a loved finger the area does not blanch when pressure is applied , injury to the tissue is likely
Pressure injuries Prevention/interventions ?
-never message reddened area
-nutrition support
-observe hydration decrease skin turgid and recessed eye
-reposition chair bound patient every 1 hr
-Place patients who are at risk for skin impairment on a pressure
-relieving mattress or chair cushion.
-Other pressure relieving devices to try are therapeutic beds and mattresses
Intact skin with non -blanchable redness of a localized area usually over a bony prominence .
The area may be painful firm, soft, warmer or cooler as compared to adjacent tissue Category I may be difficult to detect in individuals with dark skin tones
CategoryStage 1
Stages of Pressure Injury steps
-Partial thickness loss of dermis presenting as shallow open ulcer with a red pink wound bed, without slough
May also present as an intact or open/ ruptured serum -filled or sero sanginous filled blister
Category/ Stage 2: Partial thickness loss of dermis presenting as shallow open ulcer with a red pink wound bed, without slough
May also present as an intact or open/ ruptured serum -filled or sero sanginous filled blister
Stages of Pressure Injury steps?
Full thickness tissue loss. Subcutaneous fat may be visible but bone , tendon or muscle are not exposed .
Slough may be present but does not obscure the depth of tissue loss
Category / Stage 3 :
Full thickness tissue loss with exposed bone tendon or muscle
Slough or eschar may be present Often includes undermining and tunnelling
Category / Stage IV 4 :
Heat and Cold therapy ?
-Patients with injury may benefit from the application of heat or cold therapy
-Can be either dry or moist
-Heat applications generally are used to provide comfort and to speed healing
-Cold normally is used to decrease swelling and to reduce pain
Systemic effects of heat application.?
Heat produces vasodilation (dilation of the blood vessels).
-Vasodilation causes increased blood flow to the area of the body -can result in increased pulse , dizziness , and shortness of breath.
-more nutrients are brought to the area , increase tissue growth
-more antibodies and leukocytes to
Systemic effects of cold application?
Exposure of the skin to cold results in vasoconstriction (narrowing of blood vessels ) .
Vasoconstriction decreases blood flow to the
Components of Patients ?
-Oral hygiene ( care of the oral cavity) helps maintain a healthy state of the mouth , the teeth , the gums , and the lips)
-Dentures ( a set of artificial teeth not permanently fixed or implanted ) are the patient’s personal property
-Hair care ( Combing, brushing, and shampooing are basic hygiene measures needed by all patients)
-Shaving(Remember that an electric razor should those patients who have a bleeding disorder or who are undergoing anticoagulant therapy (medications that increase the tendency to bleed ). Do not allow a disorder)
-Hand, foot and nail care (Observe patients with diabetes mellitus or peripheral vascular disease for adequate circulation to the feet. The elderly are also at risk for foot disorders)
-Eye, ear, and nose care
-given special attention , cleaning their eyes from inner to the outer canthus
-The ears are cleaned during the bed bath. A clean corner of a moistened washcloth rotated gently into the ear canal works best -able to clean the nose, give assistance , using a saline solution
-moistened washcloth or cotton
-tipped applicator. Never insert the applicator beyond the cotton tip.
Perineal care risk give me examples?
for acquiring an infection : for example , patients with indwelling catheters
patients recovering from rectal or genital surgery , and postpartum patients .
(If patients can perform - is provided twice daily)
Back Care and Back Rubs ?
-Given after baths
-Promote relaxation , relieve muscle tension , and stimulate circulation
-Contraindications–if the patient has conditions such as fractures of the ribs or vertebral column , burns pulmonary embolism , or open wounds .
(3 to 5) mintutes
Perineal Care ?Care of the genitalia male
- -full water 105 to 109f
-41 to 43 c
-Gently grasp shaft of penis.
-Retract foreskin of uncircumcised patient
-Wash tip of penis with circular motion.
-Cleanse from meatus outward and female
Skin Care?
-As long as skin remains intact and healthy, its physiologic function remains optimal
- When physical condition changes , skin often reflects this with changes in color texture, thickness , turgor temperature , and hydration
Bedmaking?
-The patient’s bed is usually made in the morning after the bath
-When possible, the bed is made while is not occupied when the patient is unable to be out of bed the nurse will make an occupied bed
-The patient’s safety is always foremost in the nurse’s mind comfort and privacy are also important
Assisting the patient with elimination?
unable to get bathroom
-bedpan
( device for receiving feces or urine from either male or female patients confined to bed)
Urinal,
(a device for collecting urine from male patients ; urinals for female patients)
care of patient with incontinence?
-Caution UAP to be aware of the patient’s dignity and self-esteem needs and to take measures to prevent violating these needs .
-Ensure that UAP know standard precautions guidelines related to handling of body fluids .
-Be sure UAP report information such as abdominal pain increased episodes of incontinence , changes in appearance of urine or stool , and evidence of skin breakdown .
-The nurse is responsible for ensuring that all patients are given adequate privacy for elimination and that cultural modesty standards are observed .
STAGES OF PRESSURE
INJURIES
- depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough ( yellow , tan , gray green or brown ) and / or eschar (tan brown or black ) in the wound bed
Full thickness skin or tissue loss
Unstageable / Unclassified ?
Apply ointment to the junction of the catheter and urethral meatus ?
- Reduces irritation and reduces spread of microorganisms .
-If ointment is ordered, open a package of sterile cotton
-tipped applicators. Do not touch the cotton tip
Perineal care Genta Female ?
-full water 105 to 109f 41 to 43C
-Wash labia majora ( larger fold or lip) and labia minora (smaller fold or lip)
-Separate labia to expose the urinary meatus opening ) and the vaginal orifice.
- Wash downward toward rectum with smooth stroke
-Catheter care
-Cleanse around urethral meatus and adjacent catheter
Perineal care ?
(pericare, or care of the genitalia) is part of the complete bed bath those patients most in need of meticulous pericare are those at risk
Patients with musculoskeletal Heat applications generally ?
are used to provide comfort discomfort , such as joint or back pain , may benefit from application of heat to the area)
Cold normally is used ?
to decrease swelling and to reduce pain .
Cold often is used for sprains , fractures , and nosebleeds or after some surgical procedures , such as tonsillectomies)
Hot , moist compresses increase?
circulation to the affected area , decrease edema , and consolidate any purulent exudate that may be present. it
Warm soaks ?
increase circulation to the affected area , reduce edema , aid in the débride ment of wounds , relax muscles , and can be used to apply a medicated solution to large areas
Therapeutic baths
sitz bath ?
-sitz bath ( reducing inflammation of the perineal and anal areas of the patient who has undergone rectal or vaginal surgery or childbirth.
Discomfort from hemorrhoids or a fissure also is relieved with a sitz bath )
Therapeutic baths
hot water tub?
-hot water tub bath(relieve muscle soreness and muscle spasms adults 113-115 f 45-45C)
Therapeutic baths
cool water and warm tub?
-cool water (relieves tension The water temperature is tepid , 98.6 F (37 C )
-warm tub bath(reduce muscle tension 110f 43c)
STAGES OF PRESSURE
INJURIES
Purple or maroon localized area of discolored intact skin or blood
- filled blister due to damage of underlying soft tissue from pressure and / or shear
The area may be preceded by tissue that is painful , firm mushy , boggy , warmer or cooler as to adjacent tissue
Suspected Deep Tissue Injury depth unknown?
localized area of skin intact with nonblanchable redness
Stage I
– partial-thickness loss of dermis
Stage II
full-thickness tissue loss in which subcutaneous fat is sometimes
visible, but bone, tendon, and muscle are not exposed
Stage III –
involves full-thickness tissue loss with exposed bone, tendon, or
muscle
Stage IV –
full-thickness tissue loss, a wound base covered by
slough and/or eschar in the wound bed that will usually be tan, brown, or black
Unstageable/unclassified –
wound appears as a localized purple or maroon
area of discolored intact skin or a blood-filled blister
Suspected deep tissue injury –
