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Exam 2 Fundamental Class > Chapter 9 > Flashcards

Chapter 9 Flashcards

1
Q

Patient room environment: what are the factors affecting the environment?

A

-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

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2
Q

Life span considerations older adults ?

A

-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)

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3
Q

Room Equipment ?

A

-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

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4
Q

Hygiene ?

A

-the principal of health
-includes care of skin,hair,hands,feet,.eyes ,ears,nose,mouth,back and perineum

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5
Q

Personal hygiene?

A

Self-care measures people use to maintain their health and prevent disease

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6
Q

Hygiene Nurses are ?

A

role models and tech by example

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7
Q

Bathing ? -

A

-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

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8
Q

Therapeutic baths?

A

-cool water

-warm tub bath

-hot water tub bath

-sitz bath

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9
Q

Other Baths ?

A

-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 )

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10
Q

Assemble the necessary supplies bathing patient ?

A

-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

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11
Q

Characteristics of normal skin ?

A

-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

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12
Q

Prevention/treatment-impaired skin integrity?

A

(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 .

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13
Q

Pressure Injuries (Pressure Ulcers)?

A

-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.)

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14
Q

Pressure Injuries (pressure ulcers) factors that play a role in pressure ulcers?

A

-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

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15
Q

Pressure injuries Prevention/interventions ?

A

-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

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16
Q

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

A

CategoryStage 1

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17
Q

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

A

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

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18
Q

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

A

Category / Stage 3 :

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19
Q

Full thickness tissue loss with exposed bone tendon or muscle

Slough or eschar may be present Often includes undermining and tunnelling

A

Category / Stage IV 4 :

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20
Q

Heat and Cold therapy ?

A

-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

21
Q

Systemic effects of heat application.?

A

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

22
Q

Systemic effects of cold application?

A

Exposure of the skin to cold results in vasoconstriction (narrowing of blood vessels ) .
Vasoconstriction decreases blood flow to the

23
Q

Components of Patients ?

A

-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.

24
Q

Perineal care risk give me examples?

A

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)

25
Q

Back Care and Back Rubs ?

A

-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

26
Q

Perineal Care ?Care of the genitalia male

A
  • -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
27
Q

Skin Care?

A

-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
28
Q

Bedmaking?

A

-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

29
Q

Assisting the patient with elimination?
unable to get bathroom

A

-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)

30
Q

care of patient with incontinence?

A

-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 .

31
Q

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

A

Full thickness skin or tissue loss

Unstageable / Unclassified ?

32
Q

Apply ointment to the junction of the catheter and urethral meatus ?

A
  • 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
33
Q

Perineal care Genta Female ?

A

-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

34
Q

Perineal care ?

A

(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

35
Q

Patients with musculoskeletal Heat applications generally ?

A

are used to provide comfort discomfort , such as joint or back pain , may benefit from application of heat to the area)

36
Q

Cold normally is used ?

A

to decrease swelling and to reduce pain .
Cold often is used for sprains , fractures , and nosebleeds or after some surgical procedures , such as tonsillectomies)

37
Q

Hot , moist compresses increase?

A

circulation to the affected area , decrease edema , and consolidate any purulent exudate that may be present. it

38
Q

Warm soaks ?

A

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

39
Q

Therapeutic baths
sitz bath ?

A

-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 )

40
Q

Therapeutic baths
hot water tub?

A

-hot water tub bath(relieve muscle soreness and muscle spasms adults 113-115 f 45-45C)

41
Q

Therapeutic baths
cool water and warm tub?

A

-cool water (relieves tension The water temperature is tepid , 98.6 F (37 C )

-warm tub bath(reduce muscle tension 110f 43c)

42
Q

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

A

Suspected Deep Tissue Injury depth unknown?

43
Q

localized area of skin intact with nonblanchable redness

A

Stage I

44
Q

– partial-thickness loss of dermis

A

Stage II

45
Q

full-thickness tissue loss in which subcutaneous fat is sometimes
visible, but bone, tendon, and muscle are not exposed

A

Stage III –

46
Q

involves full-thickness tissue loss with exposed bone, tendon, or
muscle

A

Stage IV –

47
Q

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

A

Unstageable/unclassified –

48
Q

wound appears as a localized purple or maroon
area of discolored intact skin or a blood-filled blister

A

 Suspected deep tissue injury –

Exam 2 Fundamental Class (8 decks)

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