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NSG 111 - Test #1 > Week 2 (09/01/15) - Hygiene and Related Comfort Measures > Flashcards

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

1
Q

Personal hygiene

A
  • 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.)
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2
Q

Bedside cleaning

A

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

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3
Q

Coloplast (Bedside Care Foam)

A
  • Anti-microbial
  • No-rinse body wash/shampoo
  • Incontinent/perineal cleanser
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4
Q

Hibiclens (Foaming Skin Cleanser)

A
  • Surgical and ICU pts.

- 3-5 days time limit

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5
Q

Baza (Spray and Protect)

A
  • Spray moisturizer cleanser
  • Protective, breathable dimethicone barrier
  • For incontinence
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6
Q

Critcaid Paste

A
  • Peri-rectal and peri-anal skin protection from incontinence
  • Pharmacy prescription required
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7
Q

Rules for bathing pt.

A
  • 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
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8
Q

Bathing Dementia pts.

A
  • Comfort, safety, autonomy, self-esteem, cleanliness
  • Stay calm
  • Don’t push, argue, fight back
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9
Q

Lifespan considerations

A
  • People of extreme ages are prone to issues with thermoregulation
  • Keep covered with bath blanket
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10
Q

Rules for oral care

A
  • 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
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11
Q

Oral care of pts. with decreased level of consciousness

A
  • Prevent aspiration (choking)
  • Position to the side (towards you)
  • HOB low
  • Suction available
  • Make multiple attempts/be persistent
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12
Q

Rules for cleaning dentures

A
  • 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
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13
Q

Numeric pain scale

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

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

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14
Q

Wong-Baker faces

A
  • Pictograms

- Ages 3 and up

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15
Q

FLACC pain scale

A
  • Babies

- Cannot communicate feeling of pain

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16
Q

PAINAD pain scale

A
  • “Pain Assessment in Advanced Dementia”

- Cannot communicate feeling of pain

17
Q

Supine

A

On back

18
Q

Prone

A

Face-down

19
Q

Side-lying

A

On side

20
Q

Semi-Fowler’s

A

30 degree incline

21
Q

Fowler’s

A

45-60 degree incline

22
Q

High-Fowler’s

A

80 degree incline

23
Q

Knee gatch

A

Knees bent

24
Q

Trendelenburg

A

Head declined

25
Q

Shampooing pt.’s hair

A
  • Shampoo caps
  • Coloplast
  • Shampooing tray
26
Q

When making an occupied bed

A
  • After a bed bath
  • Use gloves if necessary
  • Throw in hamper (NOT floor)
  • Bed = flat, raise to waist
27
Q

TEDs/PCDs

A
  • 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
28
Q

Rules for perineal care

A
  • Only for helpless pts.
  • Anywhere a diaper would touch
  • Clean body secretions
  • Least contaminated to most
  • Clean portion of cloth for each stroke
29
Q

Oral temps (electronic)

A
  • Usually 10-15 seconds
  • Left or right sublingual pocket
  • Lips closed
  • If pt. drank liquids, wait at least 15 minutes
30
Q

Axillary temps (electronic)

A
  • Usually 10-15 seconds
  • Deep in armpit with arm against body
  • Temp = 1 degree lower than core
31
Q

Tympanic temps

A
  • Use probe cover
  • Usually 3-5 seconds
  • Gently pull ear up and back (adults); gently pull ear down and back (peds)
32
Q

Rectal temps (electronic)

A
  • Usually 10-15 seconds
  • Use rectal lubricant
  • Mostly used on newborns and peds
33
Q

Respiration counting

A
  • Breathing in and out = one

- Be stealthy

34
Q

Gingivitis

A

Inflammation of the gingivae or gums

NSG 111 - Test #1 (4 decks)

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