Unit 7 Flashcards
Guidelines for Personal Care
Safety Medical Asepsis Body Mechanics Resident Rights Communication
AM Care
before Breakfast
Morning Care
after Breakfast
Afternoon Care
after Lunch/before Supper
PM Care
Evening/bedtime
Observations
ability to respond movement pain/discomfort skin Ear, Nose, Throat & Mouth Respiration Bowel & Bladder Appetite & ADL's
Hygiene
keeping body clean
ADL’s
grooming dressing bathing eating & drinking transferring bathroom
Bedpans
bedrest
Urinals
for men urinating
Bedside Commodes
able to get out of bed but not walk far
Fracture pan
Residents cannot roll onto regular bedpan
handle towards foot of bed
Cleaning bedpan
rinse with water in bathroom
wash with soap & dry
put back in place
Observations
color, clarity, odor amount complaints color & consistency of stool blood
Oral hygiene
Increases comfort
keeps mouth & teeth clean
provide tid
offer lip moisture after
Oral care is given to
unresponsive Oxygen NPO Nasogastric tube Don't have teeth
Foot Care
report breaks or redness of skin
DON’T ever cut toe or finger nails
Shaving
Shave direction of hair growth
Use electric razor on those who take anticoagulants
dispose of razors in sharps container
Pediculosis
Head lice
don’t share personal items
S/S of pediculosis
itching of scalp
scratch marks on scalp
visible eggs on hair, behind ears
Dressing and Undressing
Assist as needed
dress weak side first
undress weak side last
Decubitus Ulcers
localized injury to skin and/or underlying tissue
S/S- pale or reddened skin
Patients who are at risk for Ulcers
anemia obesity undernourished paralysis chronic illness (diabetes)
Causes of Ulcers
Pressure
Shearing
Friction
Moisture
Pressure
over body prominence
ischemia- obstructed blood flow
oxygen & nutrients don’t reach tissue
tissue death- necrosis
Moisture
Urine
Feces
Wound drainage
Perspiration
Stage I
Intact skin
pale or red not relieved by change of position
Stage II
Partial skin loss
Blister or shallow ulcer
Stage III
Full skin loss
fat exposed
Stave IV
Full tissue loss
muscle/tendon/bone exposed
Prevention
Skin care Pressure relief Friction relief Nutritional Support Preventing Contractures
Factors affecting pain
- past experience
- anxiety
- rest & sleep
- Attention
- personal & family duties
- meaning of pain
- support from others
- culture
- illness
- age
Pain scale rating
0-10
Measures to promote comfort
good alignment -> straighten blankets -> assist with bathroom -> give blankets -> calm environment -> gentle handling -> no sudden movements
Benefits of Bathing
cleans skin relaxing stimulates circulation exercise observations communication
Frequency
personal choice
weather
activity ability
health
Types of bathing
partial (face, pits, hands, pari)
shower
tub bath
bed bath
Steps before bathing
identify patient introduce self inform patient of what doing offer bedpan or toilet gather supplies
Order of bathing
eyes face ears neck farthest then nearest arm chest farthest then nearest leg back peri butt
temperature of water
105
Back of massage
relaxes muscles stimulates circulation keep hands of their skin 3-5 minutes rub lotion between hands
Don’t give back rub to patients with
certain heart diseases back injuries back surgery some lung d/o skin disease
