Week 2 (09/01/15) - Hygiene and Related Comfort Measures

Question 1

Personal hygiene

Answer 1

• Measures for personal cleanliness and grooming
• Promotes physical and psychological well-being
• Nurses should respect individual patient preferences
• Nurses should only give care that patients cannot or should not provide for themselves
• Helps prevent infections (skin, respiratory, etc.)

Question 2

Bedside cleaning

Answer 2

Bathing cloths, bathing wipes, no-rinse body wash/shampoo, body foam, anti-bacterial soap (if out of surgery)

Question 3

Coloplast (Bedside Care Foam)

Answer 3

• Anti-microbial
• No-rinse body wash/shampoo
• Incontinent/perineal cleanser

Question 4

Hibiclens (Foaming Skin Cleanser)

Answer 4

• Surgical and ICU pts.

- 3-5 days time limit

Question 5

Baza (Spray and Protect)

Answer 5

• Spray moisturizer cleanser
• Protective, breathable dimethicone barrier
• For incontinence

Question 6

Critcaid Paste

Answer 6

• Peri-rectal and peri-anal skin protection from incontinence
• Pharmacy prescription required

Question 7

Rules for bathing pt.

Answer 7

• Face washing = no soap
• From distal to proximal (increase venous return)
• Least contaminated to most
• Skin turgor assessment (for hydration; elasticity; sternum/back of hand)
• Check mobility assessment

Question 8

Bathing Dementia pts.

Answer 8

• Comfort, safety, autonomy, self-esteem, cleanliness
• Stay calm
• Don’t push, argue, fight back

Question 9

Lifespan considerations

Answer 9

• People of extreme ages are prone to issues with thermoregulation
• Keep covered with bath blanket

Question 10

Rules for oral care

Answer 10

• Pt.’s preferences (frequency, time of day, type of products)
• Oral cavity and dentition
• Lips (dryness/cracking)
• Ability to perform own care (any limitations)
• Prevents infections
• Boosts morale

Question 11

Oral care of pts. with decreased level of consciousness

Answer 11

• Prevent aspiration (choking)
• Position to the side (towards you)
• HOB low
• Suction available
• Make multiple attempts/be persistent

Question 12

Rules for cleaning dentures

Answer 12

• Denture or regular toothbrush
• Soak in water (if pt. wants)
• VERY CAUTIOUS
• Avoid extreme water temps.
• Washcloth/basin in sink in case they fall
• Check in pt.’s bed

Question 13

Numeric pain scale

Answer 13

• 0 (no pain) to 10 (worst pain of life)

- Greater than or equal to a 4 leads to an intervention

Question 14

Wong-Baker faces

Answer 14

• Pictograms

- Ages 3 and up

Question 15

FLACC pain scale

Answer 15

• Babies

- Cannot communicate feeling of pain

Question 16

PAINAD pain scale

Answer 16

• “Pain Assessment in Advanced Dementia”

- Cannot communicate feeling of pain

Question 17

Supine

Answer 17

On back

Question 18

Prone

Answer 18

Face-down

Question 19

Side-lying

Answer 19

On side

Question 20

Semi-Fowler’s

Answer 20

30 degree incline

Question 21

Fowler’s

Answer 21

45-60 degree incline

Question 22

High-Fowler’s

Answer 22

80 degree incline

Question 23

Knee gatch

Answer 23

Knees bent

Question 24

Trendelenburg

Answer 24

Head declined

Question 25

Shampooing pt.'s hair

Answer 25

- Shampoo caps - Coloplast - Shampooing tray

Question 26

When making an occupied bed

Answer 26

- After a bed bath - Use gloves if necessary - Throw in hamper (NOT floor) - Bed = flat, raise to waist

Question 27

TEDs/PCDs

Answer 27

- Prevent blood clots - Measure thickest part of leg - Take off when bathing - TEDs come off at least once per day to check skin - PCDs come off every shift

Question 28

Rules for perineal care

Answer 28

- Only for helpless pts. - Anywhere a diaper would touch - Clean body secretions - Least contaminated to most - Clean portion of cloth for each stroke

Question 29

Oral temps (electronic)

Answer 29

- Usually 10-15 seconds - Left or right sublingual pocket - Lips closed - If pt. drank liquids, wait at least 15 minutes

Question 30

Axillary temps (electronic)

Answer 30

- Usually 10-15 seconds - Deep in armpit with arm against body - Temp = 1 degree lower than core

Question 31

Tympanic temps

Answer 31

- Use probe cover - Usually 3-5 seconds - Gently pull ear up and back (adults); gently pull ear down and back (peds)

Question 32

Rectal temps (electronic)

Answer 32

- Usually 10-15 seconds - Use rectal lubricant - Mostly used on newborns and peds

Question 33

Respiration counting

Answer 33

- Breathing in and out = one | - Be stealthy

Question 34

Gingivitis

Answer 34

Inflammation of the gingivae or gums