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EPCC Nursing Foundations > Skin Integrity + Hygiene > Flashcards

Skin Integrity + Hygiene Flashcards

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1
Q

A pt has an injured foot, which type of therapy caused vasoconstriction and less blood to the wound

A

Ice therapy

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2
Q

Hot and cold therapy have a rebound affect after how long?

A

30 min.

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3
Q

What type of infection does leukocytes indicate?

A

UTI
HIGH WBC COUNT
INFECTION

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4
Q

What are the two major functions of the nurse when it comes to skin care

A

Maintain skin integrity (don’t let the pt skin become impaired)
Promote wound healing

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5
Q

What is hygiene?

A

science of health and maintenance

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6
Q

What is the purpose of hygiene?

A

it is self care that is highly personal and determined by the person and their cultural values and practices

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7
Q

What are factors that influence individual hygienic behaviors?

A

Culture
Religion
Environment
Developmental age preschoolers do well independently and encouragement
Health and energy Mobility and energy levels
Personal preferences

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8
Q

Where do children learn their personal hygiene from?

A

Home (learned at an exceedingly early age)

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9
Q

What is the sequence of performing hygiene?

A

Head to toe

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10
Q

What is early morning care and when is it provided to the pt?

A

As soon as the pt wakes up
Give an opportunity to void/ urinate
Give wash cloth to wash hands and face
Give oral care

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11
Q

What are the nurses roles in hygiene care?

A

Helping the pt urinating, defecating, helping them after vomiting or becoming soiled from perspiration or wound drainage

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12
Q

What is morning care and when is it provided?

A

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.

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13
Q

What is hour of sleep or PM care and when is it provided?

A

o Elimination needs.
o Washing face and hands.
o Oral hygiene
o Back massage.

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14
Q

What is PRN care and when is it provided?

A

Provided when the pt needs it. Changing the cloths and linen. More frequent bathing.

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15
Q

What is the key descriptor of skin?

A

Good, patent, healthy skin

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16
Q

What is the purpose of bathing?

A

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.

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17
Q

When a pt soils themselves or has an accident which type of care is provided?

A

PRN Care

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18
Q

If the nurse sees something present on the skin that wasnt there before, what is the doing?

A

Assessing the skin

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19
Q

What is the purpose of a cleansing bath?

A

Hygiene

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20
Q

What is the temperature for a bath?

A

43-46C or 110-115F

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21
Q

The nurse is supposed to clean pts using which method?

A

Rubbing ling smooth strokes from the distal to proximal parts of the extremities.
Unless contraindicated bc the pt has thrombosis.

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22
Q

List the types of cleansing baths

A

Complete
Self-help
Partial
Bag
Towel
Tub
Shower

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23
Q

When should the water for a bed bath be changed?

A

When the water is dirty or cold.

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24
Q

A dependent pt requires this type of bath and it includes washing what?

A

Complete bed bath
Washing the ENTIRE body

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25
Q

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?

A

Self-help (assisted bed bath)

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26
Q

This type of bath is performed on pts in critical care and in some long term care settings

A

Bag bath

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27
Q

Describe how a bag bath is prepared

A

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)

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28
Q

What type of bath is used for pts who are bedridden or have dementia?

A

Towel bath

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29
Q

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

A

Partial bath

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30
Q

Some ambulatory pts prefer to take this bath in a sink and the nurse can assist by washing their back

A

Partial

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31
Q

What areas are to be cleaned during a partial bath?

A

the parts that may cause discomfort or odor if neglected are washed:
Face
Hands
Axillae
Perineal area
areas that may cause odor

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32
Q

Dependent pts would receive these types of bath

A

Tub
Complete
Partial

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33
Q

A pt that is ambulatory and requires minimal assistance from the nurse would take this type of bath:

A

Shower (with the aid or a shower chair if necessary)

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34
Q

This type of bath omits cleaning the arms, chest, abdomen, legs and feet

A

partial bath

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35
Q

List the types of therapeutic baths

A

Medicated
Sitz

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36
Q

This bath is for mothers after child birth, pts after rectal surgery, or have hemorrhoids

A

Sitz

37
Q

What the purpose of therapeutic baths?

A

physical effects
to soothe irritated skin
to treat an area (perineum)

38
Q

What does a sitz bath do?

A

soothe and heal the perineum

39
Q

Where is a therapeutic bath taken?

A

bathtub
disposable plastic sitz bath over a toilet bowl

40
Q

What is the purpose of a medicated bath?

A

soothing irritated or itchy skin from sunburns, hives, or skin diseases

41
Q

This bath is for pts with irritated or itchy skin, that could be from from sunburns, hives, or skin diseases

A

Medicated

42
Q

How would the nurse prepare a medicated bath?

A

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)

43
Q

How long should the pt remain in the bath for a medicated bath?

A

20-30 minutes

44
Q

If the pts arms and chest need to be treated, should these areas also be submerged in the solution?

A

Yes

45
Q

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.

A

Convection

46
Q

If assisting pt into shower and tub, explain how they can signal for help what is the acceptable timeframe to leave the pt alone?

A

2-5 minutes

47
Q

What strategies would be used when bahing a pt with dementia?

A

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

48
Q

If a dementia pt is combative or difficult to work with or if they try to hit you, what should you do?

A

Stop the bath completely and come back and try again at a later time.

49
Q

Who is the best source of information when it comes to bathing dementia pts or learning about their routine?

A

Family members or care givers

50
Q

Describe the epidermis

A

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

51
Q

Which skin layer produces skin color/ skin pigment

A

epidermis

52
Q

Describe the dermis

A

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)

53
Q

Which layer provides sensation

A

the dermis or dermal layer

54
Q

Describe the hypodermis or SQ layer

A

a cushion for muscle and bone
produces connective tissue - proteins/ lipids
regulates body temperature

55
Q

Describe partial thickness wounds

A

the dermis and epidermis heal by regeneration

56
Q

describe full thickness wounds

A

dermis, epidermis, and hypodermis (SQ)
(all 3 layers) + muscle and bone require connective tissue repair

57
Q

Which layer of the skin hydrates the body

A

epidermis

58
Q

What is the process that controls sweat

A

perspiration and evaporation

59
Q

In the process that controls sweat, which type of heat loss is occurring

A

radiation and conduction

60
Q

Radiation causes the body to gain _______

A

heat

61
Q

The body producing heat is called

A

conduction

62
Q

Heat gain is called

A

radiation

63
Q

Describe conduction

A

body heat lost to nearby objects through direct physical touch

64
Q

Radiation and conduction work thorugh

A

vasoconstriction and vasodilation

65
Q

How does the body get rid of heat

A

evaporation

66
Q

What is the function of the hypodermis or subcutaneous tissue

A

is a cushion between the dermis/ epidermis and muscle and bone
produces lipids and proteins
regulates body temperature

67
Q

What is the type of tissues in the hypodermis

A

adipose tissue
connective tissue (bone, blood, muscles, cartilage)

68
Q

What are other functions of the hypodermis (subQ)

A

stores fat (energy)
shock absorber
regulates body temp
produces hormones

69
Q

What would happen if the hypodermis was destroyed

A

bone and muscle would be exposed
requires connective tissue repair (bone, blood, muscles, cartilage)

70
Q

Describe what muscle tissue is

A

fibrous connective tissue

71
Q

If only two layers of the skin is damaged and they heal by regenerations, what kind of thickness is this

A

Partial

72
Q

If 3 layers of the skin is damaged and requires connective tissue repair, what kind of thickness is this?

A

full thickness

73
Q

The NANDA dx for 3 layers (epidermis, dermis, subQ/ hypodermis) is destroyed, what is it called?

A

Impaired tissue integrity

74
Q

What are the 5 functions of the kin

A
  1. Protection from injuries
  2. Regulated body temperature (hypodermis/ subcutaneous)
  3. Secretes sebum
  4. Transmits sensation (dermis)
  5. Produces and absorbs vitamin D
75
Q

A function of the skin is protection, what is the skin protecting the body from?

A

protects underlying tissue from injury or trauma
patent healthy skin = skin that is not broken
protects the body from bacteria or microorganisms

76
Q

How does the body regulate body temperature as its function

A

evaporation and perspiration
vasoconstriction and vasodilation

77
Q

Cooling the body when working out is a process of

A

radiation and conduction
evaporation and perspiration
vasocon. and vasod.

78
Q

Describe the function of the skin secreting sebum

A

it is oil that softens the skin, lubricates hair, creates skin turgor and skin elasticity

79
Q

Does sebum decrease in older adults

A

yes

80
Q

True or False: Elderly adults have increased moisture on their skin?

A

False

81
Q

Which function of the skin protects the body from humidity

A

Sebum - a process opens to get rid of heat loss

82
Q

This is an action of sebum on the skin

A

bactericidal

83
Q

This is condition when the epidermis does not produce color

A

albinism

84
Q

When UV lights hit the skin it activates a receptor to produce

A

Vitamin D

85
Q

The skin can produce and make this

A

vitamin D

86
Q

A pt who cant bathe themself requires this type of bath

A

complete

87
Q

Described situations when a pt would need a complete bath

A

brain injury (coma)
quadriplegic
unconscious
hospice

88
Q

How frequently do pts need to be repositioned

A

every 2 hours

EPCC Nursing Foundations (43 decks)

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