learning activity 4 & 5 Flashcards
What are the three different types of blood cells:
- Erythrocytes- first type of red blood cells
- Leukocytes – second type, white blood cells
- Thrombocytes- are the third type, these are clotting cells
LEUKOCYTES have two mononuclear cells. What are they?
•1. Granulocytes- formed in bone marrow, there are three types
oEosinophils – are active and increased in number in allergic conditions such as asthma
oBasophils – increase the healing
oNeutrophils – disease fighting
•2. Mononuclear leukocytes
oLymphocytes
oMonocytes
Never (Neutrophils) Let (Lymphocytes) Monkeys (Monocytes) Eat (Eosinophils) Bananas (Basophils
What are the functions of skin and mucosa?
Skins function is protection, secretion, excretion, temperature regulation, and sensation. Mucosa’s function is to protect against infection.
What are the factors affecting skin tissue integrity
Reduced sensation, vascular insufficiency, immobility
What is erythema?
Abnormal redness of the skin due to infection.
What is cyanosis?
Blueness of the skin
What is pallor?
Unusual or extreme paleness
What is jaundice?
Yellow discoloration of the skin, due to increase of bile pigments in the blood.
What is hyper-pigmentation?
The darkening of the skin
What is hypo-pigmentation?
The loss of colour of the skin
What is ecchymosis?
A bruise
What is petechiae?
Non- raised hemorrhage in the skin or mucous membrane
What is a primary lesion?
And pathological or traumatic discontinuity of tissue
What is a secondary lesion?
Are changes in the skin that result from primary lesions
What is diaphoresis?
Perspiration, especially when artificially
What is hyperhidrosis?
Excessive sweating
What is bromhidrosis?
Secretion of foul-smelling sweat
How do you rate edema?
Edema is rated by the length of time the skin stays pitted after you press on it.
What is decubitus ulcers?
It is a pressure sore
Describe normal urine.
Normal urine is clear, light yellow or straw coloured
Identify factors that commonly influence urinary and bowel elimination.
Adequate fluid intake, medication, diagnostic exam, surgical procedures, psychological factors
What is the primary purpose of urinary catheterization?
After a surgical procedure
What ongoing assessments of clients with retention catheters should be made?
Volume & frequency of voiding, the absence of urine, bladder distension, restlessness, diaphoresis & abdominal discomfort
List the factors affecting bowel functioning.
Age, diet, fluid intake, physical activities, psychological factors, personal habits, position during, pain, pregnancy and labour, surgery, medications, diagnostic tests
Describe the characteristics of abnormal stool: CLAY, BLACK , TERRY, RED, GREEN & PUS
,clay-coloured –absence of bile, black – iron ingestion or upper gastro bleeding, tarry – same as black, red – lower gastro bleeding, green –food has passed through the intestines too quickly or it could be disease or food poisoning , pus - infection
What aids are available to assist clients to eliminate when they cannot go to the bathroom.
The commode or bed pans
What are the Skin’s function?
- Protection
- Secretion
- Excretion
- Temperature regulation
- Sensation
What is the Oral Cavity function/ appearance
- Mucous membranes
- Salivary gland
- Teeth
- Gums
What are the Individual Factors
- Social practices
- Personal preferences
- Body image
- Socio-economic factors
- Health beliefs & motivation
- Cultural variables
- Physical condition
What Assessment: physical examination would you check for on the face and head?
- Integument: skin, hair, nails
- Oral cavity
- Eyes, ears, & nose
What are some Common Skin Problems?
- Acne
- Rashes
- Contact dermatitis
- Abrasions
What are Common Foot & Nail Problems
- Callus
- Corns
- Plantar warts
- Tinea Pedis (athlete`s foot)
- Ingrown nails
- Paronychia
- odors
What are some Hair & Scalp Problems
•Dandruff •Ticks •Lice -Pediculosis capitis - “ corporis - “ pubis •Alopecia
What are Risk Factors for Skin Impairment?
- Immobilization
- Reduced sensation
- Nutrition & hydration alterations
- Secretions & excretions on the skin
- Vascular insufficiency
- External devices
Use of Sensory Aids include?
- Eyeglasses
- Contact lenses
- Artificial eyes
- Hearing aids
ASSESSMENT of:
- Self-care ability
- Hygiene practices
- Cultural factors
- Clients at risk for problems
- Special considerations
- Client exceptions
NURSING DIAGNOSIS
(NANDA) The North American Nursing Diagnosis Association
- Ineffective health maintenance
- Impaired mobility
- Bathing/Hygiene self-care
- Risk for impaired skin Integrity
Bathing Benefits include:
- Makes a person feel relaxed & refreshed
- Cleans the skin & eliminates odors
- Exercises muscles
- Stimulates blood flow
- Meets needs of love & belonging & esteem
- Observes skin problems, builds trust, & connection with patient
Additional Hygienic Care Considerations are:
•Perineal care
- self-care ability
- reduction of embarrassment
- asepsis
Massage: Precautions include:
- Check care plan first
- Not on back injury or fractured ribs
- Not on a person who had recent back surgery
Steps for Perineal Care for Female
- Provided once daily, & PRN
- Drape with blanket
- Place washcloth at top of vulva & stroke to anus
- First clean each side & then middle
- Clean anal area by placing washcloth at the front of body & stroke down to back
Perineal Care for Males
- Provided once daily, & PRN
- Drape with blanket
- Pass washcloth in a circular motion, moving from tip of penis to base
- If uncircumcised, retract foreskin to wash, then return foreskin
- Anal area same as female
Foot & Nail Care Guidelines
- Careful inspection
- Lukewarm water temp
- No soaking
- Cutting of nails, if indicated
- Application of lotion
- Proper socks, stockings, & shoes
Oral Care for an Unconscious Person
- Breathing through open mouth leads to drying & cracking of the lips & mucous membranes
- Explain procedure to person
- Guard against aspiration by turn head to side
When BATHING BABIES what temp should the water be at?
•Water should be about 37.8-40.6
BATHING: List four benefits of bathing a patient
- Cleansing
- Relaxation
- Improves circulation
- Passive or active exercises
- Creates close relationship
List four steps to complete when preparing to give a complete bed bath.
- Ask the patient to void first
- Adjust bed height to promote good body mechanics
- Arrange supplies
- Cover patient with bath blanket
- Fill basin two thirds full with warm water
What order would you use when bathing a patient
- Eyes
- Face, ears, neck
- Arm- from fingers up to shoulders
- Chest
- Abdomen
- Legs
- Peineal area- genital, groin, pelvis, scrotum
- Shoulders
- Back
- Buttocks and anus
When giving a bath, the bath supplies should be on the side of the bed opposite to where you are working to avoid spilling of the bath water?
False
A massage shold be offered as part of the bath
True
Describe the steps for providing perineal care for a female patient.
- Ask patient to void first.
- Position patient on her back and drape the pelvis and legs with a bath blanket
- Wear gloves
- Use warm water
- Separate the labia, expose urethra and vagina
- Cleanse from the center of the urethra outward.
When providing perineal care for a female, what assessment would you make?
- Observe the skin for breakdown or irritation
* Assess for pain, redness, swelling, or discharge.
Is it necessary to wear gloves while bathing a patient?
TRUE
PERSONAL HYGIENE AND GROOMING
ORAL HYGIENE
The purpose of oral hygiene is it:
Clean the teeth and mouth
Prevent mouth odor and infection
When providing mouth care, you should observe what three things?
•Condition of lips, teeth, tongue, and gums
When providing oral care to an unconscious person, you separate the upper and lower teeth with?
A padded tongue blade is appropriate.
Which position is best for an unconscious person?
Lateral (position on the side)
What are the steps for cleaning dentures for a patient
- Wear gloves
- Handle dentures carefully to avoid dropping and breaking
- Line sink with paper towel
- Use denture cleaner or paste, clean outer teeth then inside
- Take note on cracks, loose teeth or rough edges
- Store dentures in a cup of cool water
- Label denture cup with patient’s name and room number
HAIR CARE
When caring for a patient’s hair, you should do which of the following?
- Comb small sections of hair, beginning at the ends
- Work towards the scalp
- Comb from scalp to hair ends once ends are detangled
SHAVING
How do you soften a man’s beard before shaving?
Apply warm towel compress.
How should safety razors be disposed after use?
Sharps container
When shaving a male patient, long strokes should be used when shaving the _____. Short strokes should be used when shaving the _____, _____ &______.
cheeks, jaw, lips and chin
NAIL & FOOT CARE
List four reasons why nail and foot care is important
- Prevents infection
- Maintains cleanliness
- Prevents injury
- Prevents odor
- Prevents hangnails
- Prevent ingrown nails
Should toe nails be trimmed at an angle on the side?
False
Should you soak the feet of a diabetic client
NO
DRESSING
List three indications for a patient to wear TED hose (elastic stockings).
- Inactive patients at risk for clot formation & thrombi
- Patient with heart disease and circulatory disorders who would benefit from improved venous return
- Patients confined to bed
- Women who are pregnant
What are the two lengths of TED hose?
Thigh-high TED hose & Knee-high TED hose
Ted hose worn properly should be:
- Free of wrinkles or creases
* Fitted snugly
