Unit 7 Flashcards

1
Q

Guidelines for Personal Care

A
Safety
Medical Asepsis
Body Mechanics
Resident Rights
Communication
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2
Q

AM Care

A

before Breakfast

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3
Q

Morning Care

A

after Breakfast

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4
Q

Afternoon Care

A

after Lunch/before Supper

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5
Q

PM Care

A

Evening/bedtime

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6
Q

Observations

A
ability to respond
movement
pain/discomfort
skin
Ear, Nose, Throat & Mouth
Respiration
Bowel & Bladder
Appetite & ADL's
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7
Q

Hygiene

A

keeping body clean

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8
Q

ADL’s

A
grooming
dressing
bathing
eating & drinking
transferring
bathroom
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9
Q

Bedpans

A

bedrest

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10
Q

Urinals

A

for men urinating

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11
Q

Bedside Commodes

A

able to get out of bed but not walk far

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12
Q

Fracture pan

A

Residents cannot roll onto regular bedpan

handle towards foot of bed

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13
Q

Cleaning bedpan

A

rinse with water in bathroom
wash with soap & dry
put back in place

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14
Q

Observations

A
color, clarity, odor
amount
complaints
color & consistency of stool
blood
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15
Q

Oral hygiene

A

Increases comfort
keeps mouth & teeth clean
provide tid
offer lip moisture after

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16
Q

Oral care is given to

A
unresponsive
Oxygen 
NPO
Nasogastric tube
Don't have teeth
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17
Q

Foot Care

A

report breaks or redness of skin

DON’T ever cut toe or finger nails

18
Q

Shaving

A

Shave direction of hair growth
Use electric razor on those who take anticoagulants
dispose of razors in sharps container

19
Q

Pediculosis

A

Head lice

don’t share personal items

20
Q

S/S of pediculosis

A

itching of scalp
scratch marks on scalp
visible eggs on hair, behind ears

21
Q

Dressing and Undressing

A

Assist as needed
dress weak side first
undress weak side last

22
Q

Decubitus Ulcers

A

localized injury to skin and/or underlying tissue

S/S- pale or reddened skin

23
Q

Patients who are at risk for Ulcers

A
anemia
obesity
undernourished
paralysis
chronic illness (diabetes)
24
Q

Causes of Ulcers

A

Pressure
Shearing
Friction
Moisture

25
Q

Pressure

A

over body prominence
ischemia- obstructed blood flow
oxygen & nutrients don’t reach tissue
tissue death- necrosis

26
Q

Moisture

A

Urine
Feces
Wound drainage
Perspiration

27
Q

Stage I

A

Intact skin

pale or red not relieved by change of position

28
Q

Stage II

A

Partial skin loss

Blister or shallow ulcer

29
Q

Stage III

A

Full skin loss

fat exposed

30
Q

Stave IV

A

Full tissue loss

muscle/tendon/bone exposed

31
Q

Prevention

A
Skin care
Pressure relief
Friction relief
Nutritional Support
Preventing Contractures
32
Q

Factors affecting pain

A
  1. past experience
  2. anxiety
  3. rest & sleep
  4. Attention
  5. personal & family duties
  6. meaning of pain
  7. support from others
  8. culture
  9. illness
  10. age
33
Q

Pain scale rating

A

0-10

34
Q

Measures to promote comfort

A

good alignment -> straighten blankets -> assist with bathroom -> give blankets -> calm environment -> gentle handling -> no sudden movements

35
Q

Benefits of Bathing

A
cleans skin
relaxing
stimulates circulation
exercise
observations
communication
36
Q

Frequency

A

personal choice
weather
activity ability
health

37
Q

Types of bathing

A

partial (face, pits, hands, pari)
shower
tub bath
bed bath

38
Q

Steps before bathing

A
identify patient
introduce self
inform patient of what doing
offer bedpan or toilet
gather supplies
39
Q

Order of bathing

A
eyes
face
ears
neck
farthest then nearest arm
chest
farthest then nearest leg
back 
peri
butt
40
Q

temperature of water

A

105

41
Q

Back of massage

A
relaxes muscles
stimulates circulation
keep hands of their skin
3-5 minutes
rub lotion between hands
42
Q

Don’t give back rub to patients with

A
certain heart diseases
back injuries
back surgery
some lung d/o
skin disease