hygiene personal care bed making Flashcards
Don PPE in what oder
gown, mask, goggles, gloves
Doff PPE in what order
gloves, goggles, gown, mask
early morning care includes (before breakfast)
assist to bathroom/ BSC/ bedpan, provide supplies for face washing/ comb, assist with glasses/ denture
AM care (after breakfast)
complete or partial bath (privacy, safety, warm water, top to bottom/ front to back, gentle strokes, dry, promote independence if they can)
leg, foot and nail care includes
wash feet with warm water, dry throughly in-between toes, apply lotion, removes TEDs/ SCDs before bath, avoid massage of reddened areas, provide diabetic foot care if needed
hair care includes
identify pts usual hair care/ styling preferences, wash (shampoo & water/ dry shampoo), shaving, tx any infestations (pediculosis or ticks)
mouth and oral care include
assist with brushing and flossing (pt on blood thinner use soft brush), use swabs for pts with stomatitis, pt on oxygen mucous membranes will dry out (keep moist), pt with dentures (clean mouth & dentures/ line the sink with a towel so dentures don’t fall down drain or break)
mouth and oral care for unconscious pt
place in sims position, tilt head, use kidney basin and suction to prevent aspiration
eye care includes
clean from inner to outer canthus with wet, warm cotton ball, use new cloth for each eye, removal contacts or artificial eye, clean classes
ear care includes
wash behind ears, was external ear with washcloth (do not use cotton tipped swabs), hearing aid teaching if needed
nose care includes
pay close attention if pt has NG tube…, clean secretions from around the tube, replace tape once a day to prevent nasal mucosal irritation
help with feeding includes
assess the pts ability to feed themselves, desire to make food choices/ eat, energy and muscular movements to eat, ability to safely chew and swallow
help with toileting includes
asses pts ability to assist, check ambulation orders, frequently associated with falls, if urinal is full (assess amount, color, clarity, empty and record I & O)
bed time care includes
assist with elimination, assist pt with washing hands and face, oral care, skin care, straighten/ change bed linens PRN
back massage used as
relaxant after bath or at bed time, use warm lotion, long/slow strokes (effleurage)
back massage effects
mood, pain, muscle tension, blood pressure, depth of respirations
older adult body considerations
skin less elastic/ thinner, hair is thinner, dentures, may be HOH (hard of hearing)
factors effecting self care
Environment: lack of access to facilities, poverty (water), wheelchair access; motivation; cognitive abilities; energy (illness, weakness, surgery); pain; neuromuscular function, sensory deficits
nursing diagnoses for hygiene, personal care
self care deficit, impaired skin integrity, risk for injury, impaired mobility, ineffective health maintenance
bathing rationales
provides opportunity for thorough skin assessment, eliminate perspiration, oils, dead skin(prevents body odor), enhances circulation, stimulates RR and depth, provides sensory input, allows pt teaching
perineal care is important because
greatest risk for infection (catheters, genital surgery, childbirth), clean from least contaminated to most, performed with daily bath/ after every incontinence
perineal care- male
clean form urinary meatus downward, clean crevices
perineal care- female
clean front to back (pubic bone to sacrum)
bed safety
lowest position, position safe for patient, side rails raised z(no more than 3 sides), wheels are locked, call light
