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Therapeutic Skills > Week 2: Hygiene and Comfort > Flashcards

Week 2: Hygiene and Comfort Flashcards

1
Q

Nursing Diagnosis

A
  • Not a medical diagnosis
  • Clinical judgment about responses to actual or potential health problems within the domain of nursing
  • Helps communicate thinking among nurses, to other practitioners, and to the public

Examples:

  • [Self-care deficit in bathing] related to [upper extremity weakness and generalized fatigued].
  • [Descriptor of the issue] linked to [health problems]
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2
Q

Nursing Process

A

Cognitive framework that systematically guides intellectual reasoning and critical thinking processes

  1. Assessment
  2. Nursing Diagnosis
  3. Planning
  4. Implementation
  5. Evaluation
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3
Q

Types of Bed Baths (4)

A
  1. Complete
  2. Partial
  3. Bag bath
  4. Shower or tub
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4
Q

Benefits of Bed Baths (6)

A

Bed baths improve:

- Skin integrity (infection)
- Opportunity for assessment/ROM exercises
- Improve self-image
- Improve circulation
- Promote relaxation
- Promote nurse/client relationship
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5
Q

Importance of Patient Hygiene

A
  • Contributes to sense of comfort, well being, self-esteem, identity
  • Contributes to IPAC
  • Mitigates risk factors for skin impairments
  • Valuable opportunity to connect
  • Important to follow the schedule, but adapt schedule to circumstantial factors (e.g., patient needs to rest)
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6
Q

Common bed positions (5)

A
  1. Fowler’s (45 degrees)
  2. Semi-Fowler’s (30 degrees)
  3. Trendelenburg (slight angle with elevated feet)
  4. Reverse Trendelenburg (slight angle with elevated head
  5. Flat
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7
Q

Complete bed bath

A

Client is totally dependent

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8
Q

Partial bed bath

A

Bathing only body parts that client can’t do independently

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9
Q

Bag bath

A

Bathing without water (higher risk of infection from clean but not sterile wash basins)

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10
Q

Shower/tub

A

More thorough, but we need to consider falls risks, safety, client comfort/ability, check orders if it’s appropriate, supportive equipment available, etc.

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11
Q

Fowler’s position

A
  • Head and shoulders at 45 degree angle

- Good for eating, helps lung expansion

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12
Q

Semi-fowler’s position

A
  • Head and shoulders at 30 degree angle
  • Good for eating, helps lung expansion
  • A bit less aggressive than Fowler’s
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13
Q

Trendelenburg position

A
  • The entire bed is angled with feet higher than head
  • Used for postural drainage
  • promotes venous return
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14
Q

Reverse-Trendelenburg position

A
  • The entire bed is angled with feet lower than head

- Promotes gastric emptying, prevents reflux

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15
Q

Factors influencing hygiene habits (7)

A
  1. Social practices
  2. Personal preferences
  3. Body image
  4. Socioeconomic Status
  5. Health Beliefs and Motivation
  6. Cultural Variables
  7. Physical Condition/mobility
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16
Q

Risk factors for skin impairment (6)

A
  1. Immobilization
  2. Reduced Sensation
  3. Nutrition and Hydration Alteration
  4. Secretions and Excretions on the skin
  5. Vascular Insufficiency
  6. External Devices
17
Q

Perineal care

A

Usually part of a complete bed bath

Pts most in need are those at greater risk of acquiring infection:

  • catheterized patients
  • incontinent patients
  • morbidly obese patients
18
Q

Benefits of back rubs (4)

A
  • promotes relaxation
  • relieves muscle tension
  • stimulates circulation
  • improves sleep
19
Q

Risk of Immobilization

A
  • impacts circulation, causes pressure injuries
20
Q

Risk of reduced sensation

A
  • cannot sense injury to skin
21
Q

Risk of Nutrition and Hydration alterations (4)

A
  • thinning of skin
  • loss of skin elasticiy
  • loss of subcut. tissue
  • delayed wound healing
22
Q

Risk of Secretions and Excretions on the skin

A
  • moisture on skin causes bacterial growth, irritation, skin breakdown, infection
23
Q

Risk of Vascular Insufficiency

A
  • ischemia and tissue breakdown

- infection resulting from lack of nutrients, oxygen, WBCs to damaged tissue

24
Q

Risk of External Devices (casts, bandages, etc.)

A
  • cause pressure/friction on skin
25
Q

Importance of oral care (3)

A
  • enhances well-being and comfort
  • stimulates appetite
  • prevents pneumonia
26
Q

Linens should be… (3)

A
  • clean
  • dry
  • wrinkle-free
27
Q

Medical asepsis in bed-making (4)

A
  • hold soiled linen away from body
  • never shake soiled linen
  • place soiled linen in appropriate bag
  • do not let linen touch the floor
28
Q

Comfort factors (4)

A
  • room temperature
  • good ventilation
  • control noises
  • adjust lighting
29
Q

Flat bed position (3)

A

Used for pt’s with:

  • spinal injuries
  • hypotension
  • sleeping pts

Therapeutic Skills (11 decks)

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