Week One Flashcards
what is the process of hygiene
assessment plan implementation evaluation document
what is in assessment
data collection, subjective and objective data
what is in planning
nursing diagnoses
what is in implementation
action
what are the 5 functions of the skin
protection, secretion, excretion, temp regulation and sensation
what are the primary layers of the skin
epidermis
dermis
subcutaneous tissue
shields underlying tissue
epidermis
contains bundles of collagen, nerve fibers, blood vessels, sweat glands, sebaceous glands and hair follicles
dermis
lies just beneath the skin; contains blood vessels, nerves, lymph, and loose connective tissue filled with fat cells
subcutaneous
what helps heat or cool you
subcutaneous
what requires special attention to prevent infection, odor, and injury
feet hands and nails
the condition of a patients hands and feet influences his or her abilities to
perform hygiene care
who do you NOT cut nails on
diabetic patients
what do you do if your patients toe nails are yellow and thick
get orders to refer patient to a podiatrist
what is the oral cavity lined with
mucous membranes
what does normal mucosa look like
light pink, soft, moist, smooth, and without lesions
what impairs salivary secretion
medications, exposure to radiation and mouth breathing
xerostomia
dry mouth
gingivitis
inflammation of gums
dental caries
tooth decay
why is oral care important
helps with digestion and nutrition (if sores in mouth it is difficult to eat)
what do you always need to secure in storage cup
dentures, artificial eye, hearing aid
what indicates general health status of hair
growth, distribution
what affect hair characteristics
hormonal changes, aging, infection and other illnesses
what causes changes in hair color or condition
hormonal and nutrient deficiencies
scaling of scalp
dandruff
how do you check patient for head lice
glove, section hair with tongue blade and if lice is present notify head nurse
what requires the most careful attention in hygiene
eyes, ears and nose
no soap on
eyes- face (ask patient if they would like face wash or something)
talking to patient means getting to know your patient=
therapeutic communication
during hygiene what do you assess
emotional status
health promotion practices
health care education needs
what factors influence the way a patient handles hygiene
religion and mobility
why should you ALWAYS raise side rails
for patients safety
what they can and cannot do for themselves
developmental stage
able to afford products for hygiene
socioeconomic status
let patient be apart of whatever it is that you are doing
autonomy (participation)
during assessment of hygiene what should you ask
what kind of hygiene/grooming do they prefer
what are common nursing diagnosis with hygiene
activity intolerance
bathing self deficit
dressing self care deficit
impaired physical mobility
when assessing always check where blood is coming _____
from
in the nursing process of Planning what are 2 goals and outcomes
partner with patients family
and
measurable, achievable, individualized care
have to decide what assistance is required based on patient
physical ability
what is important when figuring out when to give patient hygiene
timing
what should you teach a patient
signs and symptoms of infection and when they should call
always ask patient to verbalize back what you just _______ them
educated
what happens if patient refuses hygiene
ultimately it is patients choose BUT if their condition warrants a certain hygiene skill, educate them about why it needs to be done
who is responsible for hygiene of patients
RN and CNA
what are the key points of implementation
make instruction so they understand
find out preferences and health benefits
include safety risks
determine that patient understands by repeating
what are the bath guidlines
provide privacy maintain safety maintain warmth promote independence anticipate needs
what are the patients with special needs of hygiene
diabetes, artificial airways, unconscious, chemotherapy
when dentures are in container always have
luke warm water and lid
what prevents tangles in hair
brushing and braiding hair
what permission should you obtain when doing hair hygiene
before cutting or braiding
why should you always wear gloves when shaving patient
bleeding could occur
during hygiene always ask patient what they
prefer
if patient is using oxygen what should you check while preforming hygiene
ears for redness and nose as well
steps of bed bath before touching patient
collect equipment privacy explain procedure offer bed pan or urinal hand hygiene gloves lock wheels raise bed place bath blanket on pt obtain water (pt check water)
what is the process of washing the patients body in bed bath
wash eyes from inner to outer (dif side of towel) then dry
face then dry
upper body to lower body long strokes then dry
keep cleaned areas covered
when getting to perineal care change water and gloves and towel then dry
when done with hygiene always ask the patient if they feel
clean and comfortable
what are 6 important guidelines for nursing skills in hygiene
- identify patient with two identifiers
- move from cleanest to less clean area
- use clean gloves for contact with non-intact skin, secretions,blood
- test temp of water or solutions
- use body mech to take car of your back
- give proper direction to NAP when delegating
