NUR 372 CLASS 2 HYGIENE Flashcards Preview

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Flashcards in NUR 372 CLASS 2 HYGIENE Deck (21)
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1
Q

BASIC PRINCIPLES OF BATHING

A
  • provide Privacy
  • maintain safety
  • maintain warmth
  • promote the patient’s independence as much as possible
  • infection prevention (wash cleanest to dirtiest area)
  • consider personal choice (family can bring in special soaps, deodorant, etc.)
  • body mechanics (the pt and yours too; bending at the knees, assistive devices)
  • appropriate Equipment
2
Q

ROUTINE OF SELF-CARE

A
  • feet and nail care
  • hair care
  • oral care: patient’s with dry mouth or lips need care every 2 hours. usually done twice a day or after each meal; dentures need to be cleaned, can also brush gums to increase blood supply to gums
  • eye, ear and nose Care: inner canthus and move out
  • perineal Care
  • feeding
  • toiling: 2 h schedule to prevent urine incontinence
  • dressing: ask what they want to wear, give choices
3
Q

IMPEDING PATIENTS FROM PARTICIPATING IN SELF CARE

A
  • cultural / religious
  • developmental stage
  • mobility
  • emotional
  • physical Illness: stroke, febrile, more individualized type of care
  • personal Preference
  • sensory deficits: not be able to feel temperature of water, etc
4
Q

BENEFITS OF BATHING

A
  • cleansing the skin: removes perspiration, bacteria, which minimizes skin irritation and reduces chance of infection
  • stimulation of circulation: warm water and gentle strokes from distal to proximal increase circulation and promote venous return
  • improve self-image: promotes feeling of being refreshed, relaxed
  • reduction of body odors: especially in axillae and pubic areas
  • promotion of ROM: movement of extremities while bathing
5
Q

NURSING INTERVENTIONS DURING BATHING

A
  • develop a meaningful nurse-patient relationship
  • assessment (sub/obj) of the patient including condition of patient, psychosocial and learning needs.
  • skin assessment, listening to heart, lung and bowel sounds before getting ready for the day
  • edema, color, pulses, etc.
6
Q

TYPES OF BATHS

A
  • complete bath: nurse baths entire body of dependent patient in bed
  • partial bath: parts of the body are washed by the patient and some by the nurse
7
Q

BATHING ORDER/TECHNIQUES

A
  • collect necessary equipment: washcloth, shampoo, skin care product (aloe, soap not often used due to drying of skin)
  • consider if you need additional help
  • use gloves
  • does your patient need a shave? shave down; moisten face with warm water and apply shaving cream
  • cover patient with bath blanket and remove gown or pajamas
  • wash face first, encourage resident to participate
  • wash upper body next and continue on to lower body
  • use long strokes from distal to proximal to assist with circulation (promotes venous return).
  • keep resident covered
  • perineal care is last
8
Q

SCHEDULE OF CARE

A
  • early morning care: comfort measures and prep for day; brush teeth, wash face, etc.
  • morning care: after breakfast; morning hygiene and grooming
  • afternoon care; after tests, after lunch, and before visitors
  • hour of sleep care: comfort measures and bedtime activities
9
Q

HOW TO GIVE BACKRUBS

A
  • warm lotion in your hands
  • position prone or side-lying
  • expose only the back, shoulders, upper arms. - cover remainder of body
  • start in the sacral area, moving up the back
  • massage in a circular motion over the scapula.
  • move upward to shoulders, massage over the scapula
  • continue in one smooth stroke to upper arms and laterally along side of back down to iliac crests.
  • end by telling your patient that you are finished
10
Q

ORAL ASSESSMENT/BRUSHING TECHNIQUE

A
  • assessment of tongue and mucous membrane condition
  • report signs of thrush: white, patchy spots on tongue
  • gentle brushing at 45 degrees
  • side lying position for unconscious person
  • suction available for dysphagia or unconscious patients
  • swabs alone not adequate for long term oral care
11
Q

SKIN ASSESSMENT/HYGIENE

A
  • subjective: issues, itching or pain
  • objective:
    high risk skin areas, skin folds: dark, moist, areas harbor bacteria
  • pannus: large, skin hanging over belly
    pull area up and wash and dry it well
  • can put wash clothes between folds and it can help to dry area and keep skin apart
  • drug rashes
12
Q

PERINEAL CARE

A
  • females: cleanse labia majora then labia minora; wipe from pubis to anal area (front to back)
  • males: uncircumcised: retract foreskin and cleanse glans penis, replace foreskin after cleansing (phimosis); wash and dry scrotum
13
Q

PATIENTS WHO MAY NEED ASSISTANCE WITH PERINEAL CARE

A
  • vaginal or urethral discharge
  • skin irritation
  • catheter
  • surgical dressings
  • incontinent of urine or feces
14
Q

CATHETER CARE

A
  • if catheter in place, clean around catheter in circular fashion, using clean surface of wash cloth for each swipe.
  • carefully secure, clean from meatus
  • start at the urethra opening and clean outward.
  • for male pt be sure to replace foreskin after cleansing
15
Q

NAIL/FOOT CARE

A
  • nail care: warm water soaks, push back cuticles, filing, no nail cutting
  • assess lesions, abnormal color, presence of paronychia (skin infection around nails)
  • foot care: warm water soaks, gently rub callused areas
  • assess presence of lesions, moles, infection, heels
16
Q

TEACHING POINTS FOR FOOT CARE IN A DIABETIC PATIENT

A
  • assess feet every day for cuts, redness, swelling or blisters, dryness
  • keep feet soft and smooth: may apply thin coat of lotion to tops and bottoms of feet, but not between toes.
  • in the hospital, we do not trim toenails of diabetic patients
  • cutting skin can cause severe infection.
  • wear shoes and socks at all times while OOB
  • protect feet from cold or hot
  • never put feet in hot water (may not feel and can result in burns)
  • never use hot bottles, heating pads on feet
  • keep blood flowing: wiggle toes and move ankles throughout day when sitting
  • don’t cross legs
17
Q

PRINCIPLES OF DRESSING

A
  • techniques used depends on disability or degree of inability to dress
  • donning: dress affected extremity first
  • doffing: undress affected extremity last
18
Q

PURPOSE OF ANTIEMBOLIC MEASURES

A
  • promote circulation of blood from legs back to the heart (increase venous return) decrease venous stasis
  • support valves within peripheral leg veins so that blood is less likely to pool in a dependent position - decreases dependent edema (prevent venous stasis)
  • prevent thrombus formation
19
Q

NURSING INTERVENTIONS TO PREVENT EMBOLISM

A
  • leg and foot exercises: alternately flex/extend foot 5 times Q 1-2 hours, circular movement with feet, bend the knee and draw the foot up to the thigh, and then extend the leg
  • antiembolism stockings
  • sequential compression devices
  • avoiding compression of leg vessels-no tight fitting clothing.
  • educate pt not to cross legs
20
Q

NURSING CARE WHILE WEARING TED HOSE

A
  • assess lower extremities QS: toe area has an opening that can be pulled back for CMS assessment;
    toes should be warm, pink, brisk capillary refill, can wiggle toes, has feeling in toes with no tingling
  • should be removed twice a day
21
Q

HOW TO MEASURE FOR TED HOSE

A
  • measure calf circumference at the widest part of your calf to determine size
  • measure distance from base of the heel to the back of bend of knee to determine length