Hygiene Flashcards
Science of health and its maintenance
Hygiene
Three conditions favorable to growth of micro-organisms
warm/dark/moist
Direct spread through biting, kissing, sex, touching is an example
direct transmission
Indirect Transmission ( 2)
vechicle
Vehicle – Borne. Inanimate object (fomite/surface):
handkerchiefs, toys, cooking utensils, surgical instruments, food, water, blood or serum transmits disease
Wildlife or flying/crawling insect transports infection
Ex: Lyme disease
Through sneezing, coughing, spitting, singing or talking (caregiver needs a mask- usually inhaled or enter via the eye)
droplet transmisson
Airborne Transmission
Disease spread via air currents through droplets or dust
Bathing Tips:
Check water temperature, offer bedpan before bed bath, wipe front to back for perineal care, ensure tub safety with non-slip surfaces and accessibility for infants.
Blue
Decreased 02 of cells
Erythema ( r/t )
Redness of the skin. Related to vasodilatation and inflammation.
Red- Pressure/ Irritation
PALLOR (r/t)
Pale or whitish Anemia, Ischemia
Ecchymosis:
Black & Blue Trauma to Vessels
*Petechiae
Pin Point Trauma to Capillaries
Purpura-
Common in Elderly Texture- Smooth & Supple Dryness- generalized or Localized
*Turgor
Recoil 1-2 seconds Dehydration
Edema:
Swelling Pitting or Non Pitting Causes Heart disease, PVD, restriction, poor venous return
Lesions Note:
use the assessment tree to determine the proper terminology. In your documentation, describe the type of lesion, size in millimeters or centimeters, shape, configuration, color, drainage, odor, and color of surrounding skin.
Macular Rash: FLAT Papule: Raised & Solid Vesicle/Bulla:
FLUID FILLED Vesicle: <0.5 cm Bulla (Bullae): >0.5 cm Pustule: PUS FILLED Mixed Bag of Lesions
*Pressure Injury Skin Tear Cleanliness Temperature Diaphoresis-
profuse sweating Hot- fever, infection, environment Cold – Circulation trouble, aging, environment Warm
*Normal Eye Assessment Sclera:
White Conjunctiva: pink Cornea: Clear Without drainage, lesions Cleanliness Prosthesis
*Nasal Assessment Clean,
moist mucosa, drainage free Mucosa pink and intact Abnormal: drainage, crustations, dry, irritated
*Ear Assessment External ear:
free of drainage Ear lobes get larger with age May have cerumen (wax)
*Ear Care
No bobby pins, toothpicks or Q-tips Wash and dry Assess for drainage, cerumen Hearing Aids Turn off hearing aid Before inserting into ear
a condition that creates white patches on your tongue, gums or the inside of your cheeks.
Leukoplakia
a common form of mouth ulcer, which appears as a painful white or yellow ulcer surrounded by a bright red area
Canker Sores
The earliest stage of gum disease (periodontal disease)
Gingivitis
bad breath/ dark crusty
Halitosis and Sordes
T or F
All skin wounds are NOT pressure injuries Only pressure areas are staged .
T- All skin wounds are NOT pressure injuries Only pressure areas are staged
All skin lesions can be classified as partial thickness.
T or F
F
All skin lesions can be classified as partial thickness or full thickness.
Pressure Ulcer Prevention and Assessment
-Good skin care,
-lifting instead of pulling,
-using pressure-relieving device
Results in ischemia (insufficient supply of blood) and hyperemia (excess blood flow engorgement)
- Pressure Like brush burn, abrasion
2.Friction Caused by gravity and friction Decreases or stops blood flow through the vessels
3.Shearing Wet skin softens and breaks open more easily Wet skin can cause rashes and lead to skin breakdown
4. Moisture Get
stages of stress ulcer (1 and 2)
Stage 1 ulcers have not yet broken through the skin. (RED)
Stage 2 ulcers have a break in the top two layers of skin.
stages of stress ulcer ( 3 and 4)
Stage 3 ulcers affect the top two layers of skin, as well as fatty tissue.
Stage 4 ulcers are deep wounds that may impact muscle, tendons, ligaments, and bone.
Nanda Dx: For Partial thickness & Stage 1 and Stage 2 –
Impaired Skin Integrity
Nanda Dx: For Full Thickness & Stage 3 and Stage 4
Impaired Tissue Integrity
Assessment of pressure injuries includes evaluating factors like ( hint the abbreviate)
redness,
ecchymosis,
edema,
drainage,
approximation
yellow indicates and clear/white indicates
PUS/bulla
What are the characteristics you are looking for during the skin assessment? (8)
- color
- pigmentation
-texture
-moisture - turgor/recoil,
-edema,
-lesions,
-cleanliness
-temperature.
Elasticity of the skin and can show the hydration status of the patient
Turgor
How should you assess turgor?
Check on the forearm or the clavicle area or rarely back of the hand
- slightly pinch up the skin and analyze the skins recoil time (slow= dehydrated and fast= hydrated)
swelling caused by excess fluid trapped in your body’s tissues (most notable in the hands, arms, feet, ankles, and legs)
edema
You would assess it through the edema
GRADING SCALE and by pushing 8 mm on affected area
What is the edema grading scale?
0: no pitting edema
1+ mild pitting slight indentation, no perceptible swelling of the leg (disappears rapid)
2+ mod pitting, indentation subsides 10-15 seconds
3+ deep pitting, indentation remains for short time, leg looks swollen (1 min+)
4+ very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted (2 min+)
___________is a condition characterized by
-usually thick, dark hair in women where it usually doesn’t grow (face, chest area, etc.)
excessive hair growth.
hirsutism
What do you look for in a nail assessment? (6)
- general color and marking
-cleanliness
-thinness/thickness
-adherence to nail bed
-shape and contour
-capillary refill
Which of the four examination techniques do we use for assessing hair, skin, and nails?
(inspection, percussion, palpation, auscultation)
When inspecting the skin, what information can we get? (6)
-color
-uniform
-thickness
-symmetry
-hygiene
-lesions
Why is age not something that we can tell during a skin inspection?
Wrinkles do not define a certain age
What are five functions of the skin?
- protection
- secretory organ
- senses pain
- regulates body temp
- absorption of vitamins(D)
softening of the skin from prolonged moisture making epidermis prone to injury
Maceration
rubbing away of epidermal layer of skin especially over bony areas caused by friction/shearing
abrasion
Skin tear or injury caused by pressure, friction, shearing force, or moisture.
pressure injuries
Inflammation of sebaceous gland common among adolescence and adults.
acne
Where can you best see jaundice?
sclerae
Name two physiological causes of erythema.
Inflammation and vasodilation
At risk for alteration in epidermis and or dermis.
(what impairment)
Skin Integrity Impairment
NIC interventions fo Impaired skin/tissue
bathing/ perineal care/pressure management /skin surveillance and wound care
To provide privacy and warmth during a bed bath, a(n) ____________ should be placed over the resident.
Bath blanket
In addition to promoting cleanliness, comfort and a sense of well-being for the individual, a bed bath also helps prevent __________________.
pressure sores
What kind of baths ( assist, partial, complete) ___________ the nurse helps the patient with areas difficult to reach ( back/feet/legs)
_____________ the nurse washes patients entire body without assistant.
_____________ the nurse cleanses only the areas that may cause odor/discomfort. (perineum/axillae)
- Assist bath
- Complete bath
- Partial bath
For which type of bath will you most likely have a prescription ?
basin n bath
T of F
Assessments, including skin assessments and abdominal assessments, can be done during bathing.
T
what is the function of the stratum corneum?
outer most layers acts as a barrier it restricts water loss and prevents fluids/pathogens and chemicals from entering the body.
What is a function of brown adipose tissue (BAT) in newborns?
a.Generates heat for distribution to other parts of body
b.Provides ready source of calories in the newborn period
c.Protects newborns from injury during the birth process
d.Insulates the body against lowered environmental temperature
Heat generated in brown fat is distributed to other parts of the body by the blood. It is effective only in heat production. The newborn from injury during the birth process. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of heat.
What are the 6 categories of the Braden Scale?
MO, NU, F, A, M, S ( some are topics we learned in class)
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and Sheer
pts with score of 16 or less are at risk for developing pressure ulcers.
PUSH TOOL
pressure ulcer scale for healing
Impaired Skin Integrity:
Altered epidermis and/or dermis
“Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.” = Impairment
Impaired Tissue Integrity
Wound assessment
9
- wound tissue: type of tissue present, mobility, texture, turgor, pigment
- wound location, shape, size, depth, undermining, tunneling, contraction
- wound drainage, odor
- signs of infection
- bleeding, ecchymosis, burns, exposed structures
- scar tissue: banding, pliability, sensation and texture
- hair/nail growth
- sensation: pain, temp, tactile
- factors aggravating wound/scar or causing additional trauma
pressure ulcer formation factors
6
a. incontinence,
b.friction and shear
c. immobility
d. loss of sensory perception,
e. level of activity,
f. poor nutrition
How to prevent pressure ulcer formation
bring up devices/ how often to turn
Good skin care
Lift rather than pull
Use supportive pressure-relieving devices (special mattresses, sheepskin, heel protectors, special beds). NO DONUTS
Turn and position Q 2 Hrs. (USE SCHEDULE)
REEDA
R- Redness
E- Ecchymosis
E- Edema
D- Drainage
A- Approximation
______-Healthy
epithelialization n Granulation buds
_______________
Yellow/tan/brown-
slough may be adhered loosely or firmly. Black/leathery
_______ decreased blood supply( whats the skin looking like)
Red
Necrotic tissue
Pale
_____* what drianage* contains little cells matter; serum is straw colored; clean wounds
Serous drainage
watery
_____*drianag *edamage to capillaries; bright red or dark red-brown
Sanguineous drainage
bloody
; combination of bloody and serous drainage; new wounds
Serosanguineous drainage
Thick, odor; infected; pus; yellow or blue green
purulent drainage
Red-tinged pus; small vessels in wound have ruptured
Purosanguineous drainage
