Foundations (Hygiene, Positioning, Safety, Sleep, Rest) Flashcards
Bathing, grooming, dressing, eating, toileting, and “being mobile” are referred to as
ADLs-Activity of Daily Living
are wipes used for patients with central lines and patients who are immune compromised.
Chlorhexidine(CHG) bath
Baths promote cleanliness, decrease infections, allow the nurse the assess the skin thoroughly, and, most importantly, they
promote circulation
The dirtiest area on the patient is the
Perineum
should always be worn for men and women perineal care
Gloves
Vaginal areas should always be washed ____________ toward the rectum to prevent fecal contamination from being carried toward the vagina
“front to back”
Patients with diabetes have poor ____________, therefore, impaired wound healing. They can become infected or even gangrenous. Their skin also burns easily, and they don’t heal well.
peripheral circulation
Clean and moisturize the feet but avoid
the areas of the toes(want to keep the areas between the toes dry)
Do NOT use ____________ as they have a drying effect on the oral mucosa, and they can change the pH in the mouth
lemon glycerin mouth swabs
When using a bed pan you want to do this to help with elimination
elevate the head of the bed
a state of decreased or absent use of an organ or body part
Disuse
the inability to move the whole body or a body part
Immobility
decrease in size of a tissue or organ due to inactivity
Atrophy
abnormal shortening of a muscle that causes resistance to stretching and eventually, if not management, a state of permanent flexion
Contractures
Lesion caused by unrelieved pressure that damages underlying tissue because of diminished perfusion
pressure injury
The pressure exerted against the skin in a direction parallel to thebody surface
shear
A general term for damage to the epidermis
Excoriation
Softening of the skin due to prolonged contact with water (think of the “wrinkles” on your fingertips after being in water for a long time
Maceration
Straining against a closed glottis (bearing down like having a bowel movement)
Valsalva’s Maneuver
increases whenthe patient is on bedrest (related to the effects of the heart having to push bloodagainst gravity) even though demand of body cells for oxygen is decreased.
Paradoxically, cardiovascular workload
Defined as a drop in SBP (systolic) of 20 mmHg or more, or a drop in DBP (diastolic) of 10 mmHg or more, along with symptoms such as dizziness or lightheadedness within 3 minutes of the patient going from a supine to a standing position
Orthostatic Intolerance (also called Orthostatic Hypotension)
Triangular-shaped bar on a chain that is attached to a bar over the bed. Allows a patient whose arms are strong enough to lift him/herself off the bed surface for bedpan placement
Trapeze
Prolonged plantar flexion causes damage to the peroneal nerve and can cause permanent plantar flexion known as
Footdrop
Prolonged ___________ causes damage to the peroneal nerve and can cause permanent plantar flexion known as footdrop
plantar flexion
Prevents external rotation of the hip (which can become a permanent disability) by keeping the hip adducted. A rolled upback blanket or sandbag is used-extended from the lateral aspect of the hip to the popliteal space.
Trochanter roll
High-Fowler’s: HOB
60–90-degree elevation
Semi-Fowler’s: HOB
45–60-degree elevation
Low-Fowler’s:
30-degree elevation
Whole bed “slant” with the feet higher than the head
Trendelenburg
Whole bed “slant with head higher than the feet
Reverse Trendelenburg
Flat on the back (also called dorsal recumbent)
Supine
Chest down, flat. Face can be down or turned to the side
Prone
Weight on hip and shoulder
Side Lying
Side lying but further toward prone (not completely on chest) with one leg over the other.
Sims
Less restrictive than wrist restraints
Vest-type (Posey)
All 4 limbs are restrained
4-point restraints
excessive sleepines.
Hypersomnolence
related to difficulty falling asleep, staying asleep-experiencing frequent awaking from sleep, only able to sleep in short periods, or even sleep that leaves you feeling like you need more sleep
Insomnia
results from a lack of airflow through nose and mouth for periods of 10 seconds or longer while the individual is sleeping
Sleep apnea
the mechanism of sleeping and waking is not functioning correctly. Most sufferers report excessive daytime sleepiness. Patients with this disorder fall asleep without being able to control it and not necessarily at appropriate sleep times
Narcolepsy
