Skin Integrity + Hygiene Flashcards
A pt has an injured foot, which type of therapy caused vasoconstriction and less blood to the wound
Ice therapy
Hot and cold therapy have a rebound affect after how long?
30 min.
What type of infection does leukocytes indicate?
UTI
HIGH WBC COUNT
INFECTION
What are the two major functions of the nurse when it comes to skin care
Maintain skin integrity (don’t let the pt skin become impaired)
Promote wound healing
What is hygiene?
science of health and maintenance
What is the purpose of hygiene?
it is self care that is highly personal and determined by the person and their cultural values and practices
What are factors that influence individual hygienic behaviors?
Culture
Religion
Environment
Developmental age preschoolers do well independently and encouragement
Health and energy Mobility and energy levels
Personal preferences
Where do children learn their personal hygiene from?
Home (learned at an exceedingly early age)
What is the sequence of performing hygiene?
Head to toe
What is early morning care and when is it provided to the pt?
As soon as the pt wakes up
Give an opportunity to void/ urinate
Give wash cloth to wash hands and face
Give oral care
What are the nurses roles in hygiene care?
Helping the pt urinating, defecating, helping them after vomiting or becoming soiled from perspiration or wound drainage
What is morning care and when is it provided?
After the pt eats breakfast
Elimination needs
o Bath or shower.
o Perineal care.
o Back massages.
o Oral/ nail/ and hair care.
o Making pts bed.
What is hour of sleep or PM care and when is it provided?
o Elimination needs.
o Washing face and hands.
o Oral hygiene
o Back massage.
What is PRN care and when is it provided?
Provided when the pt needs it. Changing the cloths and linen. More frequent bathing.
What is the key descriptor of skin?
Good, patent, healthy skin
What is the purpose of bathing?
To remove excess oil, perspiration, dead skin cells and bacteria
STIMULATES CIRCULATION
It is an opportunity to assess skin even though you can assess skin without bathing.
To give a sense of wellness and comfort.
When a pt soils themselves or has an accident which type of care is provided?
PRN Care
If the nurse sees something present on the skin that wasnt there before, what is the doing?
Assessing the skin
What is the purpose of a cleansing bath?
Hygiene
What is the temperature for a bath?
43-46C or 110-115F
The nurse is supposed to clean pts using which method?
Rubbing ling smooth strokes from the distal to proximal parts of the extremities.
Unless contraindicated bc the pt has thrombosis.
List the types of cleansing baths
Complete
Self-help
Partial
Bag
Towel
Tub
Shower
When should the water for a bed bath be changed?
When the water is dirty or cold.
A dependent pt requires this type of bath and it includes washing what?
Complete bed bath
Washing the ENTIRE body
A pt confined to bed and able to bathe themself with the help of the nurse for washing their back and possibly their feet is what type of bath?
Self-help (assisted bed bath)
This type of bath is performed on pts in critical care and in some long term care settings
Bag bath
Describe how a bag bath is prepared
10-12 presoaked disposable wash clothes
warmed in a microwave ~1 minute but timing depends on how to get it to the correct temperature (43-46C or 110-115F)
Each area of the body is cleaned with a different cloth
Air dry skin because the emollient needs to remain on the skin (softener)
What type of bath is used for pts who are bedridden or have dementia?
Towel bath
The nurse would provide this care for a pt that can help themselves but are confined to bed by washing their back or dependent pts would receive this bath
Partial bath
Some ambulatory pts prefer to take this bath in a sink and the nurse can assist by washing their back
Partial
What areas are to be cleaned during a partial bath?
the parts that may cause discomfort or odor if neglected are washed:
Face
Hands
Axillae
Perineal area
areas that may cause odor
Dependent pts would receive these types of bath
Tub
Complete
Partial
A pt that is ambulatory and requires minimal assistance from the nurse would take this type of bath:
Shower (with the aid or a shower chair if necessary)
This type of bath omits cleaning the arms, chest, abdomen, legs and feet
partial bath
List the types of therapeutic baths
Medicated
Sitz
This bath is for mothers after child birth, pts after rectal surgery, or have hemorrhoids
Sitz
What the purpose of therapeutic baths?
physical effects
to soothe irritated skin
to treat an area (perineum)
What does a sitz bath do?
soothe and heal the perineum
Where is a therapeutic bath taken?
bathtub
disposable plastic sitz bath over a toilet bowl
What is the purpose of a medicated bath?
soothing irritated or itchy skin from sunburns, hives, or skin diseases
This bath is for pts with irritated or itchy skin, that could be from from sunburns, hives, or skin diseases
Medicated
How would the nurse prepare a medicated bath?
Fill the tub 1/3 or 1/2 full
Water at comfortable temperature (43-46C or 110-115F)
Medication is placed in the water (Na Bicarb, aveeno oatmeal, bath oils)
How long should the pt remain in the bath for a medicated bath?
20-30 minutes
If the pts arms and chest need to be treated, should these areas also be submerged in the solution?
Yes
If the window is open or air is coming into the room while the nurse is giving the pt a bath, the pt will experience which type of heat loss making them cold.
Convection
If assisting pt into shower and tub, explain how they can signal for help what is the acceptable timeframe to leave the pt alone?
2-5 minutes
What strategies would be used when bahing a pt with dementia?
Speaking soft (using low tone of voice)
Moving to their energy level
Offering two choices (letting them be independent)
The nurse needs to be organized
Play music
Cover the pt as much as possible
If a dementia pt is combative or difficult to work with or if they try to hit you, what should you do?
Stop the bath completely and come back and try again at a later time.
Who is the best source of information when it comes to bathing dementia pts or learning about their routine?
Family members or care givers
Describe the epidermis
the thinnest layer of the skin
hydrates the body
produces new skin cells by regeneration
makes melanin (skin color)
protects sublayers from damage
foul odor due to sweat pores exiting this layer
Which skin layer produces skin color/ skin pigment
epidermis
Describe the dermis
processes sensation of pain, heat/ cold (temperature), pressure, and touch
produces sweat (sweat glands are in this layer)
Produces hair (hair follicles are in this layer)
Which layer provides sensation
the dermis or dermal layer
Describe the hypodermis or SQ layer
a cushion for muscle and bone
produces connective tissue - proteins/ lipids
regulates body temperature
Describe partial thickness wounds
the dermis and epidermis heal by regeneration
describe full thickness wounds
dermis, epidermis, and hypodermis (SQ)
(all 3 layers) + muscle and bone require connective tissue repair
Which layer of the skin hydrates the body
epidermis
What is the process that controls sweat
perspiration and evaporation
In the process that controls sweat, which type of heat loss is occurring
radiation and conduction
Radiation causes the body to gain _______
heat
The body producing heat is called
conduction
Heat gain is called
radiation
Describe conduction
body heat lost to nearby objects through direct physical touch
Radiation and conduction work thorugh
vasoconstriction and vasodilation
How does the body get rid of heat
evaporation
What is the function of the hypodermis or subcutaneous tissue
is a cushion between the dermis/ epidermis and muscle and bone
produces lipids and proteins
regulates body temperature
What is the type of tissues in the hypodermis
adipose tissue
connective tissue (bone, blood, muscles, cartilage)
What are other functions of the hypodermis (subQ)
stores fat (energy)
shock absorber
regulates body temp
produces hormones
What would happen if the hypodermis was destroyed
bone and muscle would be exposed
requires connective tissue repair (bone, blood, muscles, cartilage)
Describe what muscle tissue is
fibrous connective tissue
If only two layers of the skin is damaged and they heal by regenerations, what kind of thickness is this
Partial
If 3 layers of the skin is damaged and requires connective tissue repair, what kind of thickness is this?
full thickness
The NANDA dx for 3 layers (epidermis, dermis, subQ/ hypodermis) is destroyed, what is it called?
Impaired tissue integrity
What are the 5 functions of the kin
- Protection from injuries
- Regulated body temperature (hypodermis/ subcutaneous)
- Secretes sebum
- Transmits sensation (dermis)
- Produces and absorbs vitamin D
A function of the skin is protection, what is the skin protecting the body from?
protects underlying tissue from injury or trauma
patent healthy skin = skin that is not broken
protects the body from bacteria or microorganisms
How does the body regulate body temperature as its function
evaporation and perspiration
vasoconstriction and vasodilation
Cooling the body when working out is a process of
radiation and conduction
evaporation and perspiration
vasocon. and vasod.
Describe the function of the skin secreting sebum
it is oil that softens the skin, lubricates hair, creates skin turgor and skin elasticity
Does sebum decrease in older adults
yes
True or False: Elderly adults have increased moisture on their skin?
False
Which function of the skin protects the body from humidity
Sebum - a process opens to get rid of heat loss
This is an action of sebum on the skin
bactericidal
This is condition when the epidermis does not produce color
albinism
When UV lights hit the skin it activates a receptor to produce
Vitamin D
The skin can produce and make this
vitamin D
A pt who cant bathe themself requires this type of bath
complete
Described situations when a pt would need a complete bath
brain injury (coma)
quadriplegic
unconscious
hospice
How frequently do pts need to be repositioned
every 2 hours
