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55 Cards in this Set

  • Front
  • Back
The loss of scalp hair (baldness) or body hair.
Apocrine glands-
Sweat glands located largely in the axillae and anogenital areas; they begin to function at puberty under the influence of “androgens”.
A thickened portion of the skin.
The wax-like substance secreted by glands in the external ear canal.
Dental Caries
Tooth decay.
Artificial teeth. Dentures can come in the form of a plate (a complete set of teeth for one jaw), or they may come in the form of a bridge (only a few artificial teeth).
Connective tissue underlying the epitheliium of the skin.
Eccrine glands
Glands that produce sweat. They are the most numerous sweat gland found over most of the body. The sweat that they produce cools the body through evaporation.
Periodontal disease. Red, swollen gingiva (gums), tissues that surround teeth
Inflammation of the tongue, can be caused by lack of B12
Bad breath, strong mouth odor or persistent bad taste in mouth
The science of health and its maintenance.
(Lice) Lice are parasitic insects that infest mammals. Infestation with lice is called pediculosis.
An invisible soft film that adheres to the enamel surface of teeth.
An unpleasant cutaneous sensation that provokes the desire to rub or scratch the skin to obtain relief.
Tinea pedis
(aka. Athletes foot) Usually caused by a fungus. Sometimes called “ringworm of the foot”.
Factors affecting personal hygiene
Culture, Religion, Environment (homeless), Developmental Level, Health and Energy, Personal Preferences ( may need dr order for shower)
Functions of the skin condition and personal hygeine
1. Protection of tissue from injury (stops microorganisms
2. Regulates body temp
3. Secretes Sebum (oil) lubricates
4. transmits sensation thru nerve receptors (pain, touch, temp, pressure)
5. Produces/stores Vitamin D
UV rays activate Vit D
What does the skin secretion, sebum, do?
Softens, lubricates hair (won't become brittle
Decreases water loss from skin during low humidity
Lessons the amount of heat loss from skin
Bacterial killling action
Describe the three functional levels of care.
0-completely independant
+1 requires use of equipment or device but manages care without another person
+2 semi independent requires another person for assist.
+3 Moderately dependent person plus equipment
++4 totally dependent, total care
Identify NANDA’s four self-care deficit diagnoses.
• Bathing/Hygiene
• Dressing/Grooming
• Toileting
• Feeding
Assessing skin and hygiene practices.
- A nursing health history to determine the client’s skin care, practices, self-care abilities, and past or current skin problems
B. Physical assessment of the skin.
C. Identification of clients at risk for developing skin impairments.( diabetes immobility)
Discuss the following skin problem and related nursing implications: abrasions
Superficial layers of skin scraped/rubbed away, with reddening, localized bleeding, serious weeping.
Implications: infection-should be kept clean/dry; Don't wear jewelry to prevent further damage; Lift, do not pull client across bed
Discuss the following skin problem and related nursing implications: excessive dryness
Skin appears flaky and rough.
Nursing Implications: Bath less frequently, no or non irritating soap; rinse thoroughly; encourage increased fluid intake, dry well encourage PO's
Discuss the following skin problem and related nursing implications: ammonia dermatitis
diaper rash, caused by bacteria reacting with urea in urine; skin becomes red and sore.
Implications: dry clean skin... apply preventive ointment containing zinc oxide to buttocks and perineum
Discuss the following skin problem and related nursing implications ACNE
Inflammatory condition with papules and pustules
Implication: keep skin clean, other treatments vary widely.
Discuss the following skin problem and related nursing implications: erythema.
Redness associated with a variety of conditions: rashes, exposure to sun, elevated body temp.
Implications: wash carefully to remove microorganisms; apply antiseptic to prevent itching, promote healing, and prevent skin breakdown
Identify factors considered when planning personal hygiene for a client.
Planning to assist a client with personal hygiene includes:
• Consideration of the client’s personal preferences, health, and limitations
• The best time to give the care.
• The equipment facilities and personnel available.
Discuss general guidelines for implementing skin care.
1. An intact, healthy skin is the body’s first line of defense. 2.Skin protection is based upon healthy cells 3. Moisture on skin increases bacteria 4. BO caused by resident skin bacteria + body secretions 5. Skin sensitivity varies among individuals and with health 6. Skin care agents have selective purposes.
Discuss the nursing activities associated with the following: complete bed bath
Nurse washes whole body of a dependent client in bed
Discuss the nursing activities associated with the following: self-help bed bath
Clients confined to bed are able to self-bath with assistance for necessary areas
Discuss the nursing activities associated with the following: partial bath
Certain body parts that are infected or odor, may be done at sink
Discuss the nursing activities associated with the following: tub bath
Bathed in tub
Discuss the nursing activities associated with the following: shower.
many ambulatory clients are able to use showers with minimum assistance. Long term care center often have showers
Physical Assessment of the Skin:
document when assessing, cleanliness, color, texture, tep., lesions, describe exactly what is observed and palpated, head to toe,good source of light,compare bi-lateral parts,
document type, color, size, distribution or grouping, location and consistency,
Physical Assessment Skin
Identify any variables known to cause skin problems- deficient self care abilities, immobility, malnutrition, decreased hydration,decreased sensation, sun exposure, vascular problems, presence of irretants
Physical Assessment of Oral Cavity
any unusual odors, mastication ( chewing), and swallowing, Examine Lips color, moisture, lumps, ulcers, lesions, and edema
Physical Assessment of Oral Cavity cont...
movement of the uvula and conditions of the tonsils, Tongue, color, symmetry, movement, texture, lesions, teeth- decay, caries
Periodontitis or periodontal disease
is a marked inflammation of the gums also involves degeneration of the dental tissues (periosteum)
inflammation of the oral mucosa (virus, bacteria, trauma) heat pain increased flow of saliva, hallotosis
ulceration of the lip, lack of vitamin B , cracks in edges of lips
Physical Assessment

Eyes, Ears, Nose
position, alignment, appearance, eye lashes, presence of cerumen ( redness, edema, crusting, tearing,bleeding,secretion, tenderness
Physical Assessment

texture,cleanliness,oilness,lesions, inflammations, infection Ex. dandruff, loss of hair or none, lice(pediculous), ticks Ex. Lyme disease, Rocky Mountain fever
Physical Assessment

Nails and Feet
capillary refill, contour of nail bed, intactness of skin, swelling inflammation, lesions, tenderness, orthopedic problems
Physical Assessment

Perineal and Vagina
males for lesions, swelling, inflammation,excoriation, tenderness, and d/c
woman -color, size, masses almost the same
Physical Assessment

Anal area
cracks, nodules, distended veins, masses or polyps. Note odors
Nursing Diagnosis
a careful assessment of the skin, mucous, membranes, and other body, areas may lead, to the identification numerous pt problems that can be classified as a nursing diagnosis
Early morning Care
upon wakening providea bedpan/urinal, wash face and hands give oral care oral
Morning Care
usually after breakfast Bath, shower, elimination perineal care, back massage, oral mail and hair care, make bed
Afternoon Care
elimination, wash hands and face
Hour of Sleep
HS care-provided prior to retiring for the night, provides bedpan/urinal, wash hands and face, oral care and back massage
As needed rquired by the pt
excessive hair on a person's body or face, particulary in woman Implications: shaving, tweezing,electrolysis, Enhance self concept
Back Massage
1. To relieve muscle tension ,2. promote physical and mental relaxation3. relieves insomnia
Can do assessment then planning
prone or side lying