Hygiene Flashcards
what is personal hygiene?
cleanliness & grooming that promotes physical and psychological well being=enhances the healing process
who is responsible for patient’s hygiene?
the nurse
what is the body’s first line of defense?
INTACT skin
4 skin function principles?
-intact skin
-injury resistance varies
-nutrition and hydration of cells help prevent injury
-adequate circulation needed to maintain skin cell life
what is the braden scale?
risk assessment for pressure injuries
ranges from 6-23 lower the score=increased risk
braden scale categories?
sensory perception
moisture
activity
mobility
nutrition
friction and shear
skin in the elderly?
-thinning of SUBQ and dermal layer
-decreased gland activity: dry skin=cracks and breaks
-longer time for cell renewal/difficulty regenerating: prolonged healing
-nails: grow up and thick instead of longer
-decrease in collagen fiber: collagen requires for wound healing
*more disease processes
what is involved in morning care?
-toileting
-oral/denture care
-bathing & ROM
-back massage
-hair care
-anti embolism stockings
-shaving
-nail/foot care
-eye, ears, nose
-peri care
-linens
-comfort positioning
-organize/clean bedside
oral care gold standard?
brushing patients teeth
what can bad oral care lead to?
-cardiac disease
-renal disease
-dementia
-VAP*
why?
pathogens enter bloodstream and destroy brain cells
oral care assessment?
-lips
-color/surface gums
-teeth
-tongue
-hard/soft palates
-dentures
teeth brushing for unconscious patient?
-head up and turned to side
-use suction
-rinse them out
-don’t froth toothpaste
what medical treatments/diseases create a dry oral cavity?
-oxygen therapy
-nasogastric tubes
-med side effects
-mouth breathing (occurs with infection)
-mechanical ventilation
evidence links poor oral care to?
serious disease processes
who is oral care typically delegated to?
CNA’s or unlicensed personnel
*lack knowledge base for importance
bathing purposes?
-cleansing and conditioning
-relaxation
-promotes circulation
-self image and emotional well being improvement
-movement and exercise
-assessment opportunities
-strengthens nurse/patient relationship
types of baths?
-showers
-bathing:
complete (need everything done for them)
partial assist (can do some things themselves)
-CHG: chlorhexadine (if they have anything invasive: catheters, AV fists, ports, central lines, IVs, PICC and Mid lines) or if in ICU
-bag bath: pre moistened wipes
why is soap not good for elderly?
is drying and requires rinsing
why shouldn’t you use baby powder?
sources of bacterial infection
why use CHG baths?
daily use of CHG cloths reduce risk of MDRO and HAI’s
*if using lotion, ensure compatibility with CHG wipes
what are CHG wipes?
prepackaged: single pack contains 3 individuals packet
each packet: 2 CHG wipes
*warmed in CHG warming cabinet-required for CHG activation
warming station light indicators?
yellow: warming, not ready
solid green: ready for use
blinking green: aging out, use first
red: expired - don’t use
how to use CHG baths?
-6 wipes total
1: neck, chest, abdomen
2: back and butt
3: clean left arm
4: clean right arm
5: clean left leg
6: clean right leg
do not use on face or peri area
do not use on mucous membranes or severely abraded skin
best practice for purewick external female catheter?
-attach to LOW suction
-replace at least every 8-12 hrs
-empty urine container Q8 or more
-NO barrier cream (may impede suction)
-change suction tubing every 30 days
-not rec: agitated or frequent BM
criteria for purewick?
strictly I&O ordered
-must be incontinent AND unable to use bedpan/commode
-post surgery and requires immobilization
-approved by wound care and/or surgery
-palliative care CMO (comfort measures only)
-critically ill
peri care?
clean from LEAST contaminated to MOST contaminated
-no rinse cleaners
- peri bottles for rinsing/cleaning
-barrier creams if appropriate (urine/stool breaking skin down)
*change gloves before peri care
peri care for females?
front to back
do not put condom cath on with___?
foreskin still pulled down
*don’t push tip too far in=breakdown
foley care?
-wash peri area
-catheter attached to leg (can float in and out if not secured)
-clean 6 inches down the tubing
-clamp in place
-never lift cath over bladder level
how to label cream?
initials and expiration
when to use cream?
prior to injury/sore
what is Mepilex?
sticky cream to prevent/protect
eye, ear, nose care?
-eyes: inner to outer canthus, don’t forget glasses
-assess hearing aid function
-ONLY water soluble ointments for nares
-check 02 tubing for skin breakdown BEHIND EARS
vaseline? lips only (its occlusive)
back massage benefits?
nonpharm option for pain or anxiety
-general body conditioner
-relieves muscle tension
-promotes relaxation
-can observe skin for breakdown signs
-improves circulation
-can decrease pain, distress, anxiety
-may improve sleep quality
providing hair care?
wash & comb hair
shaving men: slow downward strokes with taut skin
women: against hair growth
foot care for diabetes?
-daily: wash feet lukewarm (decreased heat perception) water
-dry well btwn toes
-moisturizer, not btwn toes
-check for cuts, blisters, redness
-trim/file nails
-change socks daily
-never barefoot
-examine shoes for irritants
why is there special care for diabetic feet?
microvascular circulation problems
-50% amputations done on diabetics
safety checks before you leave room?
-comfort position
-TV lighting/noise
-call light in reach
-bed low position
-HOB elevated
-side rails
*organize how you would want it
environmental care for comfort and safety?
-label everything
-remove trash
-bedside bag
-curtains open
-room stocked
-sharps!
