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Nur 111 > Hygiene > Flashcards

Hygiene Flashcards

1
Q

Science of health and its maintenance

A

Hygiene

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2
Q

Three conditions favorable to growth of micro-organisms

A

warm/dark/moist

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3
Q

Direct spread through biting, kissing, sex, touching is an example

A

direct transmission

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4
Q

Indirect Transmission ( 2)

vechicle

A

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

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5
Q

Through sneezing, coughing, spitting, singing or talking (caregiver needs a mask- usually inhaled or enter via the eye)

A

droplet transmisson

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6
Q

Airborne Transmission

A

Disease spread via air currents through droplets or dust

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7
Q

Bathing Tips:

A

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.

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8
Q

Blue

A

Decreased 02 of cells

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9
Q

Erythema ( r/t )

A

Redness of the skin. Related to vasodilatation and inflammation.
Red- Pressure/ Irritation

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10
Q

PALLOR (r/t)

A

Pale or whitish Anemia, Ischemia

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11
Q

Ecchymosis:

A

Black & Blue Trauma to Vessels

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12
Q

*Petechiae

A

Pin Point Trauma to Capillaries

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13
Q

Purpura-

A

Common in Elderly Texture- Smooth & Supple Dryness- generalized or Localized

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14
Q

*Turgor

A

Recoil 1-2 seconds Dehydration

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15
Q

Edema:

A

Swelling Pitting or Non Pitting Causes Heart disease, PVD, restriction, poor venous return

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16
Q

Lesions Note:

A

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.

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17
Q

Macular Rash: FLAT Papule: Raised & Solid Vesicle/Bulla:

A

FLUID FILLED Vesicle: <0.5 cm Bulla (Bullae): >0.5 cm Pustule: PUS FILLED Mixed Bag of Lesions

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18
Q

*Pressure Injury Skin Tear Cleanliness Temperature Diaphoresis-

A

profuse sweating Hot- fever, infection, environment Cold – Circulation trouble, aging, environment Warm

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19
Q

*Normal Eye Assessment Sclera:

A

White Conjunctiva: pink Cornea: Clear Without drainage, lesions Cleanliness Prosthesis

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20
Q

*Nasal Assessment Clean,

A

moist mucosa, drainage free Mucosa pink and intact Abnormal: drainage, crustations, dry, irritated

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21
Q

*Ear Assessment External ear:

A

free of drainage Ear lobes get larger with age May have cerumen (wax)

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22
Q

*Ear Care

A

No bobby pins, toothpicks or Q-tips Wash and dry Assess for drainage, cerumen Hearing Aids Turn off hearing aid Before inserting into ear

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23
Q

a condition that creates white patches on your tongue, gums or the inside of your cheeks.

A

Leukoplakia

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24
Q

a common form of mouth ulcer, which appears as a painful white or yellow ulcer surrounded by a bright red area

A

Canker Sores

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25
Q

The earliest stage of gum disease (periodontal disease)

A

Gingivitis

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26
Q

bad breath/ dark crusty

A

Halitosis and Sordes

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27
Q

T or F
All skin wounds are NOT pressure injuries Only pressure areas are staged .

A

T- All skin wounds are NOT pressure injuries Only pressure areas are staged

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28
Q

All skin lesions can be classified as partial thickness.

T or F

A

F
All skin lesions can be classified as partial thickness or full thickness.

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29
Q

Pressure Ulcer Prevention and Assessment

A

-Good skin care,
-lifting instead of pulling,
-using pressure-relieving device

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30
Q

Results in ischemia (insufficient supply of blood) and hyperemia (excess blood flow engorgement)

A
  1. 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

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31
Q

stages of stress ulcer (1 and 2)

A

Stage 1 ulcers have not yet broken through the skin. (RED)

Stage 2 ulcers have a break in the top two layers of skin.

32
Q

stages of stress ulcer ( 3 and 4)

A

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.

33
Q

Nanda Dx: For Partial thickness & Stage 1 and Stage 2 –

A

Impaired Skin Integrity

34
Q

Nanda Dx: For Full Thickness & Stage 3 and Stage 4

A

Impaired Tissue Integrity

35
Q

Assessment of pressure injuries includes evaluating factors like ( hint the abbreviate)

A

redness,
ecchymosis,
edema,
drainage,
approximation

36
Q

yellow indicates and clear/white indicates

A

PUS/bulla

37
Q

What are the characteristics you are looking for during the skin assessment? (8)

A
  • color
  • pigmentation
    -texture
    -moisture
  • turgor/recoil,
    -edema,
    -lesions,
    -cleanliness
    -temperature.
38
Q

Elasticity of the skin and can show the hydration status of the patient

A

Turgor

39
Q

How should you assess turgor?

A

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)

40
Q

swelling caused by excess fluid trapped in your body’s tissues (most notable in the hands, arms, feet, ankles, and legs)

A

edema

41
Q

You would assess it through the edema

A

GRADING SCALE and by pushing 8 mm on affected area

42
Q

What is the edema grading scale?

A

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+)

43
Q

___________is a condition characterized by
-usually thick, dark hair in women where it usually doesn’t grow (face, chest area, etc.)
excessive hair growth.

A

hirsutism

44
Q

What do you look for in a nail assessment? (6)

A
  • general color and marking
    -cleanliness
    -thinness/thickness
    -adherence to nail bed
    -shape and contour
    -capillary refill
45
Q

Which of the four examination techniques do we use for assessing hair, skin, and nails?

A

(inspection, percussion, palpation, auscultation)

46
Q

When inspecting the skin, what information can we get? (6)

A

-color

-uniform

-thickness

-symmetry

-hygiene

-lesions

47
Q

Why is age not something that we can tell during a skin inspection?

A

Wrinkles do not define a certain age

48
Q

What are five functions of the skin?

A
  1. protection
  2. secretory organ
  3. senses pain
  4. regulates body temp
  5. absorption of vitamins(D)
49
Q

softening of the skin from prolonged moisture making epidermis prone to injury

A

Maceration

50
Q

rubbing away of epidermal layer of skin especially over bony areas caused by friction/shearing

A

abrasion

51
Q

Skin tear or injury caused by pressure, friction, shearing force, or moisture.

A

pressure injuries

52
Q

Inflammation of sebaceous gland common among adolescence and adults.

A

acne

53
Q

Where can you best see jaundice?

A

sclerae

54
Q

Name two physiological causes of erythema.

A

Inflammation and vasodilation

55
Q

At risk for alteration in epidermis and or dermis.
(what impairment)

A

Skin Integrity Impairment

56
Q

NIC interventions fo Impaired skin/tissue

A

bathing/ perineal care/pressure management /skin surveillance and wound care

57
Q

To provide privacy and warmth during a bed bath, a(n) ____________ should be placed over the resident.

A

Bath blanket

58
Q

In addition to promoting cleanliness, comfort and a sense of well-being for the individual, a bed bath also helps prevent __________________.

A

pressure sores

59
Q

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)

A
  1. Assist bath
  2. Complete bath
  3. Partial bath
60
Q

For which type of bath will you most likely have a prescription ?

A

basin n bath

61
Q

T of F
Assessments, including skin assessments and abdominal assessments, can be done during bathing.

A

T

62
Q

what is the function of the stratum corneum?

A

outer most layers acts as a barrier it restricts water loss and prevents fluids/pathogens and chemicals from entering the body.

63
Q

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

A

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.

64
Q

What are the 6 categories of the Braden Scale?
MO, NU, F, A, M, S ( some are topics we learned in class)

A

Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and Sheer

pts with score of 16 or less are at risk for developing pressure ulcers.

65
Q

PUSH TOOL

A

pressure ulcer scale for healing

66
Q

Impaired Skin Integrity:

A

Altered epidermis and/or dermis

67
Q

“Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.” = Impairment

A

Impaired Tissue Integrity

68
Q

Wound assessment

9

A
  • 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
69
Q

pressure ulcer formation factors

6

A

a. incontinence,
b.friction and shear
c. immobility
d. loss of sensory perception,
e. level of activity,
f. poor nutrition

70
Q

How to prevent pressure ulcer formation

bring up devices/ how often to turn

A

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)

71
Q

REEDA

A

R- Redness
E- Ecchymosis
E- Edema
D- Drainage
A- Approximation

72
Q

______-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)

A

Red

Necrotic tissue

Pale

73
Q

_____* what drianage* contains little cells matter; serum is straw colored; clean wounds

A

Serous drainage
watery

74
Q

_____*drianag *edamage to capillaries; bright red or dark red-brown

A

Sanguineous drainage
bloody

75
Q

; combination of bloody and serous drainage; new wounds

A

Serosanguineous drainage

76
Q

Thick, odor; infected; pus; yellow or blue green

A

purulent drainage

77
Q

Red-tinged pus; small vessels in wound have ruptured

A

Purosanguineous drainage

Nur 111 (18 decks)

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