Test 2 Flashcards
Factors that influence personal hygiene
-Culture
-Religion
-Income and Social Status
-Physical Environment
-Developmental Level
-Personal Health Practices
Cultural Influences on Hygiene
-Maintain privacy, especially for women from cultures who value female modesty
- in some cultures touch has many different meanings, touching the should of a japanese man can cause feelings of humiliation; some asian women do not shake hands with other women or men; for some indigenous people touch can mean a prevention of harm
-Be aware that to patients of Asian descent, silence can be interpreted as a sign of respect
-Provide gender-congruent caregivers as needed or requested
-Do not cut or shave a patient’s hair or beard without prior discussion
-Some some cultures discourage bathing for 7-10 days after childbirth (Chinese, Filipino)
-Some cultures consider the top parts of the body cleaner then the lower parts (Chinese, Japanese, Korean, Hindu)
-Among Hindus and Muslims, the left hand is used for cleaning and the right hand is used for eating and praying
Benefits of Hygeine
-Promotes health
-Maintains skin integrity
-Regular bathing promotes circulation and hydration
-Allow for assessment and education
-Socialization and pleasure for clients
Safe Practices for Hygiene
-Place client’s personal hygiene care items within patient’s reach
-PPE
-Perform client hygiene moving from cleanest to less clean or dirty
-Test the temperature of water/solutions
-Use proper body mechanics and safe patient handling
-Assess client before, during, and after bathing
AM care (Morning)
Offer bedpan/urinal/assist to bathroom; wash hands and face;Mouth care; Assist with breakfast; Bath back massage, oral care, shave, hair care, nail care, change linens, ambulate
PM Care (Afternoon)
Washing hands and face; back care; oral care; toileting, straighten bed linen
HS Care (Evening)
Washing hands and face; changing into pjs, straightening linen; toileting; offering a snack/drink/; oral hygiene; back massage
Steps before bath
-Bed in low position and bed rails up when not at bedside
-Oberserve standard precautions, including wearing clean gloves. Other PPE may be necessary, depending on the patient’s condition
-Check the floor for spills, and make sure equipment is working properly
-Gather all necessary equipment and supplies
-Adjust the room temperature and ventilation for the patient’s comfort
-Explain the procedure and ask the patient for suggestions on how to prepare supplies
Assessment during hygeine
-client’s tolerance of the activity, comfort level, cognitive ability, musculoskeletal function
-patient’s visual status, ability to sit without support, hand grasp, and ROM to the extremities
-The presence and position of external medical devices or equipment
-The patient’s bathing preferences and self-care abilities
-Pain (0-10). Premidicate
-Condition of skin
-Any special needs specific to the client and assessed for any allergies
-Client’s knowledge of skin hygiene
-Potential client incontinence or excess drainage on linen
-If the patient has notice any problems related to the condition of the skin and genitalia
-Physician orders (for specific precautions, therapeutic bath, special products, etc)
-Institutions policies on changing linen
Hygiene for skin issues
Dry skin-Warm water for baths not hot, rinse well and apply moisturizers
Acne-Wash hair and skin each day to remove oil
Hirsutism-Excessive growth of body or facial hair
Rashes-Wash area, apply antiseptic as ordered
Contact dermatitis-Remove cause, apply medication as ordered, tepid bath
Abrasion (scraping of epidermis)-Wash with soap and water
Risk factors for skin impairment
-Immobilization
-Reduced sensation
-Nutrition and hydration alterations
-Secretions and excretions on the skin
-Vascular insufficiency
-External devices
Oral Issues
-Dental Cavities
-Gingivitis
-Halitosis
-Mucositis
-Dry, cracked, tongue
-Thrush
Risk Factors for Oral Hygiene
-Dehydration (inability to take fluids by mouth or NPO)
-Presence of NG tubes or oxygen tubes: mouth breathers
-Chemo medications
-Radiation therapy to head and neck
-Presence of airway (ET tube)
-Blood clotting disorders (leukaemia)
-Oral surgery, trauma to mouth
-Aging
-Chemical injury
-Diabetes
Steps in oral hygiene
-Wear gloves
-Position patient with head of bed at 30-45 degrees
-Soft toothbrush
-Clean all 3 surfaces
-Tickle gums and clean tongue
-Brush at 45-degree angle to gum line
-Floss between all teeth
-Rinse
Why do you brush at 45 degree angle to the gumline?
Angle allows brush to reach all tooth surfaces and clean under gum line where plaque and tarter accumulate.
Performing Oral Hygiene on an unconscious or debilitated patient
-Risk for:
alterations of the oral cavity
infection
aspiration
-Assess gag reflex
-Position patient in Sim’s position or side-lying
-Two care providers provide care: 1 provides oral care and 1 suctions oral secretions
Problems of the Hair and Scalp
-Dandruff
-Ticks
-Head lice
-Hair loss
-Pediculosis (crab lice)
-Body lice
Hair Care:Combing
Position in 45-90 position if tolerated
Moisten hair and use wide tooth comb
Start on one side of head
Move fingers through hair to loosen tangles
Comb hair from scalp toward hair ends
Comb hair in circular motion by turning wrist while lifting up and out
Shaving
Electric razor-shave across side of face and downward direction of hair growth. Use non-dominant hand to keep skin taunt
Disposable razor-Place bath towel over patient’s chest and shoulders. Place warm washcloth to face for several seconds, apply cream and hold razor at a 45 degree angle to face. Shave across one side of face in short, firm strokes. Shave toward chin. Use non dominant hand to keep skin taunt
Why should patients with diabetes no soak their hands or feet
Skin Breakdown & Infection Risk – Prolonged soaking can weaken the skin’s protective barrier, making it more susceptible to infections, such as fungal or bacterial infections.
Peripheral Neuropathy – Many diabetics have reduced sensation in their hands and feet due to nerve damage. They may not feel water that is too hot, leading to burns, or they may not notice small cuts or sores that can become infected.
Delayed Wound Healing – Diabetes can impair circulation, especially in the extremities. Soaking can lead to maceration (softening) of the skin, increasing the risk of ulcers that heal slowly and may lead to serious complications.
Increased Risk of Dry Skin & Cracking – Soaking can strip the skin of its natural oils, leading to dryness and cracking, which provides an entry point for infections.
Benefits of back massage
Promotes relaxation, relieves muscular tension, stimulates circulation, improves sleep
Massage is associated with reduction in BP, reduction in pain, a decrease in anxiety and depression
Massages communicate caring
Nail and Foot care
-Soak hands and feet prior to cleaning nails, use a plastic applicator stick to clean under nails, use a soft cuticle brush to clean around cuticles, clean between toes, dry feet, apply lotion to feet but do not use lotion between toes, apply lotion to hands
Stomas
Opening in the abdominal wall
For fecal or urinary elimination
It is essential that a pouch be placed over the stoma correctly so that the output from the stoma is contained
The skin around the stoma is protected, and a patient is free from odour or leakage
Colostomy
A surgical procedure in which a part of the colon (large intestine) is diverted to an opening on the abdomen, called a stoma, to allow waste to exit the body when the normal bowel function is impaired
Ileostomy
A stoma placed in the last part of the small intestine called the ileum, which drains fecal effluent that is watery to thick and contains digestive enzymes
Catheter-Associated urinary tract infection (CAUTI) prevention practices
-Secure indwelling catheters
-Maintaining closed drainage system
-Maintaining free flow of urine
-Perform routine perineal care daily, after soiling
IVAPS
I-Introduce self, 2 patient identifiers
V-Void
A-Allergies (latex or soap_
P-Pain and privacy
S-Safety (bed rails, wheels locked)
Female Perineal Care
-Encourage self care
-Dorsal recumbent positon
-Use bath sheet, upper thighs
-Non-dominant hand, pull back labia majora
-Expose urinary meatus and vaginal orifice
-perineum to rectum (outer, outer, inner)
-Assess for skin breakdown, discharge, pain
-Always front to back
Male Perineal Care
-Encourage self care
-Supine or low fowlers
-Provide privacy
-Retract foreskin if uncircumcised
-Meatus outward
-Assess for redness and discharge
-Penis shaft
-Under penis and scrotum
-Rinse and dry thoroughly
-Return foreskin
Fowlers
Head of the bed raised to an angle of 45 degrees or more; semi sitting position, foot of bed may also be raises at knee
Preferred while patient eats. Is used for nasogastric tube insertion and nasogastric tracheal suction. Promotes lung expansion
Semi-Fowlers
Head of bead raised approximately 30 degrees: inclination less than Fowler’s position: foot of bed may also be raised at knee
Promotes lung expansion. Is used when patient receives gastric feeding to reduce regurgitation and risk of aspiration
Trendelenburg’s
Entire bed frame tilted with head of bed down
Is used for postural drainage. Facilitates venous return in patients with poor peripheral perfusion.
Reverse trendelenburg
Entire bed frame tilted with foot of bed down.
Used infrequently. Promotes gastric emptying. Prevens esophageal reflux
Flat
Entire bed frame horizontally parallel with floor
Is used for patients with vertebral injuries and in cervical traction; Is used for patients who are hypotensive; Is generally preferred by patients for sleeping
Function of the Urinary System
Removes waste from the blood, maintains the body’s water balance
3 terms used for process of emptying the bladder
Voiding, urination, micturition
Challenges related to incontinence
-Incontinence is embarrassing
-The client is uncomfortable
-Skin irritation, infection and pressure ulcers are risks
-Falling is a risk because the client may rush to the washroom
-The client’s pride, dignity, and self-esteem are affected
-Good skin care and dry garments and linens are essential
When Catheters are used
-Before, during and after surgery to keep bladder empty
-For clients who are too weak or disabled to use the bedpan, urinal, commode, or toilet
-To protect wounds and pressure ulcers from contact with urine
-To allow hourly urinary output measurements
-As a last resort for incontinence
-For certain diagnostic purposes
-high infection risk
Skin Integrity
Refers to the skin being a complete structure, in unimpaired condition
Impaired skin integrity
Altered epidermis and/or dermis, destruction of skin layers (dermis), and disruption of skin surface (epidermis)
Risks of altered skin integrity
-Increases the chance of infection, impaired mobility, and decreased function and may result in loss of limb or sometimes life
3 layers of skin
Epidermis-provides a waterproof barrier and creates our skin tone
Dermis-contains tough connective tissue, hair follicles, and sweat glands
Subcutaneous layer or hypodermic-fat and connective tissue
Factors affecting skin integrity
-Age
-Genetics
-General health
-Hygiene
-Living conditions
-Mechanical forces
Assessment of Skin Integrity
-Skin diseases
-Previous bruising
-General skin condition
-Skin lesions
-Usual healing of sores
-Inspection and palpation
-Skin color
-Temperature
-Texture and turgor
-Presence of edema
-Vascularity
-Characteristics of any lesion
Rashes
Skin eruption that may result from overexposure to sun or moisture from an allergic reaction
-If skin is continually scratched inflammation and infection may occur
-Wash the area thoroughly and apply antiseptic lotion to prevent further itching and aid in the healing process. Apply warm or cold compresses to relieve inflammation, if indicated
Dry Skin
-Flaky, rough texture on exposed areas such as hands, arms, legs or face
-Skin may become infected if the epidermal layer is allowed to crack
-Bathing should be less frequent, rinsed well
-Increase and encourage fluid intake
-Use nonallergenic moisturizing cream to perform a protective barrier and keep fluid in
-Use creams to cleanse skin that is dry
Acne
Inflammatory, papulopustular skin eruptions, usually involving bacterial breakdown of sebum; appears on face, neck, shoulders and back
-Infected material within the pustule can spread if the area is squeezed or picked. Permanent scaring can result
-Wash hair and skin thoroughly each day with soap and water to remove excess oil and prevent secondary infections
-Use cosmetics sparingly
-Use prescribed topical or oral antibiotics
Contact Dermatitis
-Inflammation of skin characterized by abrupt onset with erythema, pruritus, pain, and appearance of scaly oozing lesions
-Often difficult to eliminate because the person is usually in continual contact with the substance causing the skin reaction, and it may be hard to identify this substance
-Avoid causative agents
Psoriasis
A non contagious, chronic skin condition characterized by an abnormal growth or keratinocytes and an inflammatory reaction that results in the formation of thick, silvery, scaly, inflamed patches of skin; commonly seen on the scalp, knees, elbows and chest
-The cause is unknown and there is no cure. It is often difficult to diagnose as it has similar symptoms to eczema and atopic dermatitis
-Treatment options are aimed at reducing the extent and severity of the condition and improving quality of life. The patient should avoid trigger agents such as smoking, stress, excessive alcohol, and skin injury
Impetigo
A bacterial skin infection characterized by red sores that can break open, ooze fluid, and develop a yellow-brown crust. The sores can occur anywhere on the body. It is one of the most common skin infections in children. While it can occur in adults, it is more common in children. Impetigo is contagious and can be spread to others through close contact or by sharing linens and clothing. Scratching can also spread sores to other parts of the body
-Is cause by one of two kinds of bacteria, strep or staph. It can occur in healthy intact skin, but more often bacteria enter the body when the skin has already been irritated through other skin conditions, such as eczema, poison ivy, insect bites, burns, or cuts
Is treated with antibiotics. For mild cases a topical antibiotic is prescribed. For more serious cases oral antibiotics may be prescribed
Hand-Foot-and-Mouth-Disease
An illness cause by the enterovirus; manifest as sores or blisters in or on the mouth and on the hands, feet, and sometimes the buttocks and legs. The sores can be painful, and the illness usually lasts approximately 1 week. It is most common in children and most often occurs in the summer or fall
-Symptoms may begin with fatigue, a sore throat, or a fever. Within 1-2 days, blisters or sores can appear. The virus spreads easily through coughing and sneezing, or through contact with infected stool or blister fluid
-Usually, medical treatment is not required, Interventions are focused on symptom management, which includes offering cool fluids, analgesics, and antipyretics
Abrasion
Scraping or rubbing away of the epidermis that may result in localized bleeding and later weeping of serous fluid
-Infection occurs easily because of the loss of this protective skin layer
-Caregivers should trim their fingernails and not wear jewelry
-clean the area and dry thoroughly and gently
-Observe for retained moisture in dressings and bandages, excess moisture can increase the risk of infection
-Lift-do not pull-When transferring or repositioning a patient
-Consider the use of a lift, as needed, for immobile or heavy patients
What are pressure injuries
A pressure injury develops when blood supply to the skin is cut off for more than 2 to 3 hours. As the skin dies, the bedsore first starts as a red, painful area, which eventually turns purple. Left untreated, the skin can break open and the area can become infected
A bedsore can become deep. It can extend into muscle and bone. Once a pressure injury develops, it is often very slow to heal. Depending on the severity of the pressure injury, the person’s physical condition, and the presence of other diseases (such as diabetes), pressure injuries can take days, months, or even years to heal. They may need surgery to help the healing process
Suspected Deep Tissue Injury
Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discolouration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discolouration may appear differently in darkly pigmented skin. This injury results from intense or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or it may resolve without tissue loss
Stage 1 Pressure Injury
Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanch able erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discolouration; these may indicate deep tissue pressure injury
Stage 2
Parital thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum, filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage, including incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds
Stage 3
Full-thickness loss of skin, in which adipose tissue (fat) is visible in the ulcer and granulation tissue and epibole
(rolled wound edges) are often present. Slough, eschar, or both may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and bone are not exposed
Stage 4
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough, eschar, or both may be visible. Epibole, undermining, tunnelling, or a combination of these often occur. Depth varies by anatomical location
Unestageable
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar on th wheel or ischemic limb should not be softened or removed
Braden Scale
Assessment tool used to recognize clients at risk for skin breakdown/pressure ulcers
Widely used in adult population
Based on a number scoring system
6 categories are assessed
Total score ranges from 6-23
Lower Braden score indicates higher risk for pressure ulcer development
Categories of the Braden scale
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
Sensory
1-Completely Limited, or limited ability to feel over most of the body
2-Very limited-responds to painful stimuli only, or limited ability to feel over 1/2 of the body
3-Slightly limited-responds to verbal commands but cannot always communicate discomfort or need to be turned, or limited ability to feel pain or discomfort in 1 or 2 extremities
4-No impairment-responds to verbal commands, no limit to feel or voice pain
Moisture
1-Constantly moist-Skin moist most of the time, dampness detected every time patient is moved
2-Very moist-Skin of often moist (not always), requires linen change-once per shift
3-Occasionally moist-Skin occasionally moist, requires linen change once per day
4-Rarely Moist-Skin usually dry, requires linen change at routine intervals
Activity
1-Bedfast-Confined to bed
2-Chairfast-Cannot bear own weight, requires assistance. Ability to walk limited or non-existent
3-Walks occasionally-Spends majority of time in bed/chair. Walks occasionally for short distances with or without assistance
4-Walks frequently-Walks outside room at least 2 times per day, walks in room at least q 2 hours
Mobility
1-Completely Immobile-No independent changes in position
2-Very limited-Occasional slight changes independently, but requires assistance for frequency significant changes
3-Slightly limited-frequent, slight changes without assist
4-No limitation-Able to make major and frequent position changes without assist
Nutrition
1-Very Poor-Never eats complete meal/rarely more then 1/3, 2 or less proteins per day. NPO, clear liquids, IVs for more then 5 days
2-Probably inadequate-Rarely eats complete meal, approximately 1/2, 3 proteins. Occasionally take dietary supplements. Receives less than optimum liquid diet or tube feeding
3-Adequate-Eats over 1/2 of meals, 4 proteins. Usually takes a supplement, tube feeding or TPN probably meets nutritional needs
4-Excellent-Eats most of every meal, never refuses, 4 or more proteins. Occasionally eats between meals. Does not require supplements
Friction and Shear
1-Problem-Moderate to maximum asset with moving. Freq likes down in bed/chair. Spasticity, contractures or agitation leads to almost constant friction
2-Potential Problem-Maintains relatively good position in bed/chair most of the time, but occasionally slides down. Moves feebly, requires min assist. Skin probably slides against sheets
3-No apparent problem-Maintains good position in bed/chair/ Moves independently in bed/chair. Sufficient muscle strength to lift completely during move
Braden scale scoring
6-9 Very high risk
10-12 High risk
13-14-Moderate risk
15-18 Low risk
19-23 Not at risk
Preventative Interventions for skin breakdown
-Assess client skin at least once per shift
-Regular turning/repositioning schedule, reposition frequently
-Offload client heels
-Use pillows or foam wedges to keep bony prominences from direct contact with each other
-Encourage activity when possible
-Use pressure redistribution surfaces, ie air mattress
-Manage moisture, friction and shear
-change briefs ASAP
-Use sliding sheets when moving client in bed
-Encourage proper nutrition
-Position clients in bed at 30 degrees to prevent sliding down in the bed
Blanchable Hyperemia
Redness of the skin due to dilation of the superficial capillaries. When pressure it applied to the skin, the area blanches or turns a lighter color
Nonblanchable hyperemia
Redness of the skin due to dilation of the superficial capillaries. The redness persist when pressure is applied to the area, indication tissue damage
Epibole
Rolled would edges
Erythema
Redness or inflammation of the skin or mucous membranes that is a result of dilation and congestion of superficial capillaries. Examples of erythema are nervous blushes and mild sunburn
Eschar
A scab or dry crust that results from trauma, such as a thermal or chemical burn, infection, or excoriating skin disease
