Fund Nur 50 - week 1.1 Flashcards
ISBAR
I—Introduction
S—Situation
B—Background
A—Assessment
R—Recommendation
Q—Question and answer
assessment
identify needs during hygiene, check skin, edema
signs for skin (CTTJB
redness - esp over bony prominences, rash, temp and color, skin trigger, jaundice, cyanosis, ruddy of lower extremities, bruising.
observe patients’ capabilities for hygiene - who is at risk…(PVD for hygiene)
older, bedridden, dementia, immune compromised, diabetes, PVD, dexterity, immobile, arthritis
bathing - don’t make…
assumptions, ask questions
if you delegate to a CNA, you need to make
parameters. Nurses can delegate. You are responsible for the oversight. ex - if a patient has a red area, CNA needs to notify you so you can perform an assessment.
if patient has PVD or diabetes, only who can perform foot care?
nurse - can only perform assessment of foot care. No foot soaks for diabetics.
partial bed baths
for patients who are very ill. bathing only body parts that cause discomfort or odor. under arms, under breasts, face, hands
for independent showers, what criteria? (4 things)
1) can patient follow directions, 2) is the patient ambulatory, 3) has a steady gait w/out any dizziness 4) do you have an order for the patient to get up ad lib.
during shower, wear..
PPE
no baby powder
ever, in perineal care. Talc is gone now bc of potential cancer. Corn starch baby powder is contraindicated bc of pulmonary issues, inhilation, etc.
shaving precautions or contraindications
anti-coagulents, bleeding disorder, if so, must use patient’s designated electric shaver. If patient has beard, you need verbal consent to shave it off, and document it as well.
how often is oral care for unconscious patient?
every 2 hours. That includes oral care brushing and suctioning, and place them on their side when performing that care. Bacteria in teeth causes pneumonia
reservoir
bacteria can survive, ex. fomite, health care workers’ hands
portal of exit and entry
mouth, wound, gi tract, mucous, respiratory
modes of transmission
droplet and airborne. droplet (large molecules) = coughing and sneezing. airborne = droplets suspended in air or dust
modes of transmissions - vectors - types of illnesses
malaria, Zika, Lyme, Plague. and you need a susceptible host.
try to have patient…
carry out as many activities on their own as possible, but provide assistance if needed.
purpose of bathing (SCIA)
keep skin intact, promote comfort, prevent infection, assess patient.
considerations when performing hygiene (needs)
patient’s preferences, values, and needs. More affluent patient, products might be important. Transient patient - maybe where they’re going to be discharged over the type of product used.
culturally appropriate bathing
some cultures might not bathe for a period of time.
geriatric patients
skin is very delicate, even tape can tear it. if there is a deficit, be careful. chronic illness, diabetes,
things to consider before bathing (what you always forget)
is there a patient order, is the patient able to take care of themselves, are they bedridden.
some patients don’t have the oxygen stores or energy stores for a
bed bath. You need to assess the patient.
tub or shower is..
most ideal for bathing, but there might be contraindications.
If a patient can shower independently, you need to
escort them to shower, show them where emergency call light is
bag bath
some in warmer or heated up in special microwave. Some you can add the warm water.
evidence based practice tells us that
prepacked baths are preferred bc the studies show lower risk of healthcare infection, decrease microbial count, nurses prefer it bc it’s fast, no reservoir of water in basin, cost of towels and basins, etc.
