Fundamentals Chapter 19 Flashcards
Hygiene
Proper care of the skin, hair teeth and nails
Protects form infection and disease
Sense of well being
Maintain safety, privacy and warmth
Encourage independence
Function of the Skin
o Protection
o First line of defense against bacteria and other organisms;
protects against thermal, chemical, and mechanical injury
o Sebaceous glands make the skin waterproof
o Sensation
o Contains sensory organs for touch, pain, heat, cold and pressure
o Temperature regulation
o Regulates temperature by constricting or dilating blood vessels and activating or inactivating sweat glands
Changes that occur to the skin with ageing
o Loss of elastic fibers causes skin to wrinkle and sag
o Skin becomes thinner, fragile, and slower to heal
o Decreased sebaceous activity leaves skin dry and itchy; temperature control is altered by decreased sebaceous gland activity and thinner skin
o Hair becomes thinner, grows more slowly, and loses its color from loss of melanocytes
o Thickening of nails
Assessment
o Factors affecting hygiene practices
o Economic status
o Knowledge level
o Ability to perform self-care
o Personal preferences
o Different cultures have different views on hygiene
practices
Assessment during bath
o Opportunity for assessment
Condition of patient’s skin
Overall physical appearance
Emotional/Mental status
Learning needs
Opportunity for head to toe data collection
Skin and Pressure Ulcers
o Ulcers form from local interference with circulation
Skin blanches or becomes pale
Darker skin may look purple
If interference (pressure) removed, skin becomes darker as
blood supply returns (reactive hyperemia)
Damaged skin becomes “boggy” or stiff and may be warmer or cooler
Pressure Ulcers; skin factors
o Immobility
o Inactivity
o Moisture
o Incontinence, Diaphoresis
o Inadequate nutrition
o Advanced Age
o Altered sensory perception/ mental awareness
o Edema
o Friction and Shea
Assessment for skin and pressure ulcers
o Braden Scale for predicting pressure sore risk
o Reassess every 24 hours
o Check with turn and reposition
o Pay attention to the skin over bony prominences
o Blanchable skin: damage is not expected
o Medicare does not reimburse for preventable injury
o Document pressure injuries on admission
Stage 1
area of reddened skin that does not blanch when touched
Discoloration in people with dark skin; warmth, edema, or induration may be present
Stage 2
partial-thickness skin loss
May look like an abrasion, blister, or shallow crater; surrounding skin may feel warmer
Stage 3
*full-thickness skin loss
*Looks like a deep crater; may extend into the fascia; subcutaneous tissue damaged or necrotic
* Visible fat
*Undermining/tunneling
Stage 4
full-thickness skin loss
Extensive tissue necrosis or damage to muscle or
supporting structures; bone may be visible; may appear dry and black, often infected
Suspected deep tissue injury
localized discolored intact skin
Maroon/purple or blood filled blister
Unstageable pressure ulcer
full thickness
Eschar- thick, tough, tan, brown or black
Slough- wet or stringy, green, yellow, brown, or grey
Disguises the depth of the wound
Preventing Pressure ulcers
o Nursing care is the main factor in preventing pressure ulcers
o Your responsibility is to be aware of risk factors your patient may have and try to lessen them
o Prevention is less time-consuming and expensive than pressure ulcer treatment; assess skin carefully and frequently
o Change patient’s position at least every 2 hours
o Keep heels of immobile patients off the bed
o Avoid positioning directly on the trochanter
o Use trapeze or lift sheet to change position
o Use pressure-reducing devices such as foam pads or mattresses
o Use pressure-reducing devices for patients in wheelchairs
o Shift weight at least once an hour, preferably every 15 minutes
o Keep patients dry
o Use thin foam dressings under splints and equipment if
necessary
o Provide adequate nutrition and fluids
Pressure Ulcer treatment
o Most effective treatment is via a team approach
o Patient, family or caregivers, health care providers
o Initial care of a pressure ulcer
o Debridement, wound cleansing, and application of dressings
o If the ulcer is infected, antibiotic therapy used
o Surgery needed to repair some pressure ulcers
Nursing Diagnosis for Pressure ulcers
o Pain (acute or chronic)
o Ineffective peripheral tissue perfusion
o Decreased self-esteem
o Altered self care ability
o Altered nutrition
o Altered mobility
o Altered tissue perfusion
o Potential for altered skin integrity
o Impaired skin integrity
Planning
o Schedule hygiene care
o Bedpan or urinal
o Oral care
o Bathing
o Shaving
o Nail care
o Dressing
o Change linens
o Back rub
Bath purpose
-Four purposes
Cleanse the skin
Promote comfort
Stimulate circulation
Remove waste products
o May need to give either a partial or complete bath
o Encourage independence
o Water should be warm but should not burn the patient
o Provide for comfort, safety, and privacy
Water should be warm, but not scalding
Moisturize skin after bathing
Bed and rails are up
Drape and curtains
Delegate
Types of Baths
o Cleansing
Most common type; done in bed, tub, or shower; offer
patient use of toilet before bathing
May need assistive devices such as chair or stool in shower or tub
No longer than 20 minutes
o Perineal Care
Male- retract foreskin to clean and then replace
Female- clean form urinary meatus towards rectum
o Homecare
Safety bars and nonskid tub/shower
o Therapeutic bath
Whirlpool bath—special whirlpool tub used to cleanse and
stimulate peripheral circulation
Medicated bath- before surgery, wounds or foot soaks,
oatmeal to relieve dermatitis
Sitz bath—applies moist heat and cleansing to perineal
area; medication may be added to water
Sponge bath—may be used to bring down fevers
Back Massage
o Communicates caring
o Fosters trust in the nurse-patient relationship
o Provides opportunity to assess skin on the back
o Stimulates circulation of blood to the area
o Reduces tension, promotes relaxation
o Should be performed with morning care and at bedtime
o Essential for patients confined to bed
o Warm lotion
o 3-5 minutes
o Avoid wounds
Oral Care
o Lack of oral hygiene increase risk of stroke, heart disease and pneumonia
o Mouth care for the conscious patient
Raise the head of the bed 45 to 90 degrees
Place a towel under the chin
Brush from the gum line to the edge of the teeth
Monitor for excessive bleeding
swabs for patients on bleeding precautions
o Unconscious patient
Full mouth care every 4 hours, moist swabs every 2 hours
Risk for aspiration- turn head to side
Lubricate lips
Denture Care
o Dentures should be cleaned to prevent irritation to the gums and
infection
o Assess mouth and gums
o A patient may use an adhesive for a better fit
o Care should be provided in the morning and at bedtime
o Do not place on meal tray
o Should be removed 6 hours per day
o Keep in labeled container with water or saline
Hair Care
o Improves self esteem/ body image
o Avoid pulling on the scalp. Brush from scalp downward in small
sections
o Alcohol, astringents, or water may be used to loosen hair strands
that are tangled or matted
o Shampoo: Rinse free or shampoo caps if bedbound
o Written informed consent is needed to cut patients hair
Shaving
o Be gentle; use short strokes with the safety razor
o Check for bleeding precautions or anti-coagulant use first
o You may not shave off a beard or mustache without written informed consent
Nail care
o Trimming, cleaning under the nails, and cuticle care usually done
with the bath
o Soak the nails in warm soapy water 5-10 minutes
o Use an orangewood stick to clean under nails
o Push cuticles back gently
o Use nail clippers to cut toenails straight across
o Do not cut toenails of patient with diabetes or peripheral
vascular disease
o Assess nailbeds for circulation, observe for signs of infection
Eye Care
o Assess eyes for crusting or drainage
o Wipe from inner to outer canthus
o Glasses
Use clean warm water and soft cloth to wipe glasses dry
o Contacts
Removal of contact lenses
Wash hands thoroughly, and wear gloves
Slide contact down to lower lid and gently pinch
o Cleaning contact lenses
Clean with commercially prepared cleaning solutions
Moisten the lens and rub it gently between the fingers
Store in containers labeled right and left
o Artificial eye – pressure placed below lower lid will pop prosthesis
out
Ear Care
o No object including cotton swabs should be inserted into
the ear canal
o Assess for cerumen (wax) and wipe from outer ear
o Primary Care Provider must perform irrigation
o Hearing aids
Clean the earpiece daily AS DIRECTED daily to prevent the
buildup of wax and debris
Do not submerge hearing aid in water
If hearing aid is not working:
Check to make sure the unit is turned on
Battery is installed correctly (it may need to be replaced)
No cracks or breaks in the plastic housing or tubing
Evaluation of the skin
o Patient has no evidence of redness, irritation or breaks in skin integrity
o Skin integrity is maintained
o Hair is clean and neat
o Mucous membranes are moist, intact and odor free
Which of the following is not one of the basic purposes of bathing?
Cleanses the body
Promotes comfort
Stimulates conversation
Removes waste products
Stimulates conversation
Which of the following is true regarding mouth care?
Mouth care creates halitosis and dental caries.
An unconscious patient should be provided full mouth care at least every 24 hours.
When assisting a conscious patient with mouth care, you should raise the head of the bed 15 to 30 degrees.
Dentures should be kept in a labeled denture container with saline or water when not in the patient’s mouth.
Dentures should be kept in a labled denture caontainer with saline or water when not in the patients mouth
