Hygiene/Body Mechanics Flashcards
factors influencing personal hygiene
social practices personal preferences body image health beliefs and practices physical conditions/cognitive function socio-economic status culture
Opportunities to… while giving Hygiene care
spend time clarify client's perspective listening/interviewing head to toe assessment ROM/mobilization technical care (dressing change, IV site etc)
Assessment Opportunities
skin, feet & nails, oral cavity, hair/scalp, ears/eyes/nose, developmental changes, use of sensory aids, self-care ability, hygiene practices, cultural practices, risk for hygiene problems
Outcomes of poor hygiene
impaired client comfort, dignity & healing, impaired skin integrity, complications of immobility, missed diagnosis/injuries, missed treatments, medical complications, increased length of stay, colleague retribution
functions of the skin
protection, sensation, temperature regulation, excretion and secretion, produces and absorbs vitamin D
clinical observations of skin
colour (pale, blue, red); texture (smooth, rough), thickness, turgor, temperature (warm, cool), hydration (dry vs. moisturized), odours, presence, characteristics of lesions
common skin problems
abrasion, excessive dryness, acne, ammonia dermatitis, contact dermatitis, psoriasis, erythema, hirsutism
risk factor for skin imparement
immobilization, reduced sensation, nutrition/hydration alterations, secretions/excretions on the skin, vascular insufficiency, external devices
bodies first line of defence
intact, healthy skin
how does healthy skin protect the underlying tissue
the degree to which skin protects depends upon general health of cells, amount of subcutaneous tissue and dryness of the skin
moisture in contact with skin can result in increased bacterial growth & irritation
what causes body odours
skin bacteria acting on body secretions
categories of baths
cleansing : complete/self-help bed bath, partial bath, bag bath, tub bath, shower
therapeutic : physical effects
assessing feet
inspect all surfaces including between toes, soles, heels
observe for lesions, dryness, cracking
consider - gait, pain, footwear
assess - pulses (dorsalis pedis; posterior tibial; popliteal), colour, temperature, sensation, movement
assessing fingernails/toenails
explore the clients usual nail care practices and self-care abilities - impaired vision, coordination…
inspect for - lessions, dryness, inflammation, cracking, callus, corns, plantar warts, athlete’s foot, ingrown nails, feet odors or any other nail deformities
assessing oral cavity
lips, teeth/dentures,
buccal mucosa, - pinkish-red, smooth, moist
gums,- pink smooth moist, tight around each tooth, non-tender
palate (hard & soft), Uvula,
tongue, - medium or dull red, moist, slightly rough
inspect floor of mouth for nodules, ulcerations, or white patches
color, hydration, texture, lesions, localized pain, infection, halitosis
Oral cavity risks
dentures/appliances (comfort/fit) tobacco use medications stress dental hygiene practices recent appetite changes
Assessing Hair/Scalp
colour, distribution, quantity of body hair, scalp colour, dryness, dandruff, lesions, follicles, age-related changes (hormonal, medic, nutiriotnal), ticks, pediculosis (lice), scabies
Assessing Eyes
history of eye problems or related treatments
assess - free from infection/irritation/pain, pupils (size, shape, equality, accommodations, light reaction [black, round, regular & equal], selera (white), Iris colour (details clearly visible and in tact), conjunctivae (clear, pink, without inflammation or lesions), lashes turned our, eyebrows symmetrical
Assessing Ears
abnormal; excessive cerumen or drainage, local inflammation, discharge, lesions, edema, deformity, pain
Assessing Nose
nares - inflammation, discharge, lesions, edema, deformity;
nasal mucosa - pink, clear, little or no discharge
Tubing (nasogastric can cause erosion/irritation
Your client’s nail beds, lips, mouth and skin have a bluish hue. You document this as…
Pallor
he skin around your client’s ulcer is indurated which means that it is…
tunneled
When examining your client’s skin tugor your suspect that your client may be dehydrated as the skin….
remains tented
A potential complication of clients with rough dry flaky skin is…
ulcers
What is the rationale for washing and drying from ankle to knee and wrist to elbow?
promote circulation
diabetic foot care provided by the sutdent nurse involves allof the following except:
a wash feet daily in lukewarm water and dry well
b. Cut toenails weekly
c. gentle application of moisturize to dry areas
d inspect for pressure points
b. cut toenails weekly
Somatitis parasitica (thrush is:
a. characteriaxed by creamy white patches of exudate
b. treated with oral/topical anti-fungal drugs
c. caused by recent antibiotic, corticosteriod radiation therapy
d. All of the above
e. A and B only
d. all of the above
Halitosis is defined as
bad breath
Which of the following contribute to the need for frequent mouth care in the unconscious client: a. mouth breathing/oxygen therapy b. inability to eat or drink c Accumulation of saliva d All of the above e a & b only
d. All of the above
Name three common causes of alopecia
chemotherapy, childbirth, aging, genetics, illness, and hormones
Pediculosis capitus is defined as:
a. cradle cap
b. head lice
c. crab
d. Ticks
b. head lice
define body mechanics
using alignment, joint mobility, and balance in a coordinated effort to perform activities such as lifting, bending and moving
What is the correct sequence of the following nursing priorities if a fire occurs in a health care setting?
a. Remove clients from the site of danger, pull the fire alarm, contain the fire, and extinguish the fire.
b. Pull the fire alarm, contain the fire, remove clients from the site of danger, and extinguish the fire.
c. remove clients from the site of danger, pull the fire alarm, extinguish the fire, and contain the fire
d. Pull the fire alarm, contain the fire, extinguish the fire, and remove the clients from the site of danger.
a. remove clients from the site of danger, pull the fire alarm, contain the fire, and extinguish the fire.
A hospitalized 90-year-old woman who uses a walker is receiving diuretic medication and must use bathroom several times each night. To promote safety, which of the following should the nurse do?
a. leave the bathroom light on
b. withhold her diuretic medication
c. provide a bedside commode
d. keep the side rails up
c. provide a bedside commode (without wheels)
a 75-year-old man is hospitalized following a cerebrovascular accident (stroke). He is unable to ambulate without help but becomes disoriented at times and tries to get out of bed. What is the MOST appropriate safety measure the nurse must perform for thesis patient.?
a. Retraining him in bed
b asking a family member to stay with him
c. checking the patient every 15 minutes
d. using a bed exit safety monitoring device
d. use a bed exit safety monitoring device
Which of the following nursing interventions is the highest priority for a client at risk for falls in a hospital setting? a. keeping all the side rails up reviewing prescribed medications c completing the get up and go test d. placing the bed in the lowes position
d. place the bed in the lowest postion
Accreditation Canada’s client safety goals address the need to decrease the number of errors in hospitals. Which of the following practices will help increase client safety?
a. improving the nurse’s ability to multitask
b. identifying the health care practitioners who are incompetent
c. establishing strict policies and procedures
d. creating a culture of safety
d. create` a culture of safety
The nurse, at the change of shift report, learns that one of the clients in his care has bilateral soft wrist restraints. the client is confused, has been trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which of the following actions by the nurse is appropriate?
a. Keeping the wrist retraint on at all times and removing it only if it becomes soiled
b. ensuring that no fingers can be inserted between the restraint and the wrist
c. Using a square knot to ensure the client cannot get the restraint undone
d. ensuring that the restraints are tied to the part of the bed that moves to elevate the head.
d. ensure that the restraints are attached to the part of the bed that moves to elevate the head
A client is being admitted to the hospital because of a seizure that occurred at home. The client has no previous history of seizures. In planning the client’s nursing care, which of the following measures is the most essential at this time of admission
a. Placing a padded tongue depressor at the head of the bed
b. padding the bed with blankets
informing the client about the importance of wearing a medical identification tag
d. teaching the client about epilepsy.
b. Pad the bed with blankets.
Marcel, 8 years old, is admitted to the pediatric unit following a convulsive (seizure) episode at home. When entering Marcel’s room, the nurse notes that he is having a convulsion. What should the nurse do as a priority in this situation?
a. draw the curtain to provide privacy
b. place a pillow under his head to prevent trauma
c. reassure Marcel by talking to him gently
d. ensure airway patency for Marcel.
d. Ensure airway patency
Mr. Taylor, 85 years old, has a history of dementia. He is known to strike out during personal care. What is the BEST way to minimize risk to the nurse when giving Mr. Taylor a tub bath?
a. Encouraging the client to remain calm
b. Asking a colleague for assistance
c. Giving him a shower instead
d. Administering a sedative prior to his bath
b. Asking a colleague for assistance
Mr. Sanders has had Alzheimer’s disease for 3 years. He is 75 years old and lives with his 72-year-old wife. He takes little part in his care and is confused at times. The nurse suggests a prevention strategies to Mrs. Sanders, who is worried about her husband roaming at night. Which of the following suggestions by the nurse would reduce the risk of unintentional injury?
a. Install an alarm bell on the bedroom door.
B. ensure adequate lighting in the house.
c. Administer sleeping medications to mr. saunders before he retires
d. ensure that someone stays with him.
b. ensure adequate lighting in the house.
Alignment
proper body alignment and posture bring body parts into line in a manner that promotes optimal balance and body function.
Base of support
the foundation on which the body rests. feet hip with apart placed directly under you to allow the center of gravity a strong and balanced base.
Center of gravity
the central line in the body where all of the body’s supports meet.
Posture
optimum body alignment to take advantage of the center of gravity and base of support. It allows for proper lung expansion, efficient circulatory, respiratory, renal and gastrointestinal functions.
Pivot
maintaining optimum balance, base of support and posture to turn around the centre of gravity without twisting the spine
Key principles to outline when discussing proper body mechanics
the efficient, coordinated and safe use of the body to move objects and carry out the activities of daily living. avoid solo lifting, re-positioning and transferring
changes that effect the body alignment of older adults
a gradual loss of muscle tone, joint flexibility and decreasing reaction time. A decrease in bone density is common. Osteoporosis can affect the joints of the lower extremities and anterior aspects of spinal bones leading to fractured hips and vertebrae. All affect the posture, gait and balance. Gate becomes wide-based, short-stepped and shuffling. - REGULAR EXERCISE is key.
What actions would a nurse take to ensure proper body mechanics during a bed bath
position the bed at a comfortable height so that you do not have to perform undue reaching and straining. Lower the side rail closest to you. Have the client move closer to you.
Most common back injury and how to prevent it
Lower back injuries are the most common as a result of client handling.
prevention:
Understand the weight of the load. anything over 20kg is verboten
use assistive equipment, get hellp from coworkers.
be consciously aware of your posture and positioning
when standing for a long time, flex one hip and knee and rest foot on an object if possible
when sitting, keep your knees slightly higher than hips
use a firm mattress and soft pillow
exercise regularly to maintain physical condition
avoid exercise that cause pain or require spinal flexion with straight legs or spinal rotation
spread feet to provide wide base of support when moving objects
spread weight of object between large muscles of arms/legs
wear cloths that allow good body mechanics and low-heeled shoes for good support.
explain the no-lift policy of some agencies
many agencies require nurses to use assisted lift devices to prevent back injuries.
types of lifting devices
mechanical lift and a ceiling mounted lift
slipp patient mover
