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119 Cards in this Set
- Front
- Back
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What is a person's unit?
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the personal space, furniture, and equipment provided for the person by the agency. The room is a private area, and is designed to provide comfort, safetly, and privacy
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Privacy
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According to OBRA and CMS each person has the right to full visual privacy. Agencies provide privacy curtains or screens in order to ensure privacy
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How is privacy maintained?
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The curtain should always be pulled completely around the bed before giving care. The curtains will provide visual privacy but sounds, conversations, and odors are not blocked.
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What is full visual privacy?
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Having the means to be completely free from public view while in bed.
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What things are controlled to provide room comfort?
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Temperature, ventilation, noise, odors and lighting are controlled to help meet the persons needs for comfort
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What is required when controlling temperature and ventilation?
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Most people are comfortable between 68-74 degrees, but OBRA requires rooms to be kept between 71-81 degrees, and each room must have at least 1 window to the outside.
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What should be done to help protect people from drafts?
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Make sure they wear proper clothing, they wear enough clothing, offer lap robes to those in chairs and wheelchairs, provide enought blankets for warmth, cover with bath blankets when giving care, move from drafty areas.
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What are some causes of odors?
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bowel movments, urine, draining wounds, vomitus, body odor, breath, and smoking,
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How can odors be controlled?
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empty, clean, and disinfect bedpans, urinals, comodes, and kidney basins promptly, keep toilets flushed, check incontinent patients often, , clean people who are wet or soiled, change wet/soiled linens and clothing, keep laundry containers closed, dispose of incontinence products and ostomy products promptly, use room deodorizers.
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Noise
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Ill and older people are sensitive to noises and sounds. people want to know the cause and meaning of new sounds.
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How can you decrease noise?
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control your voice, handle equipment carefully, keep equipment in good working order, answer phones, signal lights, and intercoms promptly
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Lighting
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Many older people have problems with glares and shadows, and light improves a persons overall mental health. Good lighting is needed for safety and comfort, always adjust light to meet persons changing needs, keep light controls near the patient
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What furniture is required in a patient/resident room?
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a closet space with racks and shelves, toilet facilities nearby, bed of proper height and size, clean comfortable mattress, drawers and shelves for persons personal items, an overbed table, a bedside stand, a chair, and privacy curtains.
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Name the six basic bed positions.
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Flat, fowlers position, high-fowlers position, semi-fowlers psoistion, trendelenburgs position, reverse trendelenburgs position
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When would a flat position be used?
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the usual position for sleeping, after spinal cord injury, and for cervical traction.
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When would semi-Fowlers position be used?
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this is comfortable and prevents sliding down in bed. the raised knee portion can interfere with circulation in the legs, take care if this position is used
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When is trendelenburgs position used?
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it is used if ordered by the physician, could be used for a patient in shock, or while moving a person
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When is reverse trendelenburgs position used?
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Ordered by the physician, could be used for acid reflux, hernia, copd
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The overbed table
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is placed over the bed by sliding the base under the bed, it is raised and lowered for the person in bed or in a chair, used for meals, writing, reading, and other activities, nursing team uses the overd table as a work surface, only clean and sterile items are places on the table.
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Signal Lights
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allows the patient to signal for help, when an intercom system is used remember confidentiality, people with limited hand mobility may need a signal light that can be turned on by tapping it with hand or fist
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What is done for patients that are unable to use signal lights?
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check the care plan for special communication measures, check the person often
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When using a signal light you must...
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keep the signal light withing the person's reach, place signal light on person's strong side, remind person to signal when help is needed, answer signal lights promptly, answer bathroom and shower or tub room signal lights at once.
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Neat and Clean Beds
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straighten linens whenever loose or wrinkled, straightened loose or wrinkled linens at bedtime, check for and remove food and crumbs after meals, check linen for dentures, eyeglasses, hearing aids, sharp objects, and other items, change linens when wet, soiled or damp, follow standard precautions and bloodborne pathogen standard.
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Closed bed
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is not in use. The bed is ready for a new patient, or resident, the bed is made for a resident who is up most of hte day
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open bed
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is in use, the top linenes are fan-folded back so the person can get into bed
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occupied bed
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a bed with someone in it
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surgical bed
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made to transfer a person from a stretcher, and for persons who arrive by ambulance
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Linens
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When handling linens and making beds, practice medical asepsis. the uniform is considered dirty so hold linens away from body and uniform. never shake linens, and place clean linens on a cleans surface, NEVER place clean or dirty linens on the floor
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Linen etiquette
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collect enough linens, do not bring uneeded linens to a persons room, collect linens in oder that you will use them, place clean linene ona clean surface, remove dirty linen away from you one piece at a time, wet,damp or soiled linens are changed right away
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When are linens changed in a hospital
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In a hospital the top/bottom sheets, the cotton deawsheet, and pillowcases are changed daily. the mattress pad, plastic drawsheet, blanket, and bedspread are re-used for the same person. linens are also changed whenever wet or soiled
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When are linens changed in Long-term care?
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complete linen changes are usually done on the person's bath day once or twice a week. Pillowcases, top and bottom sheets, and drawsheets are changed twice a week, and whenever wet or soiled
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drawsheets
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a small sheet placed over the middle of the bottom sheet. it helps ti keep mattress and bottom linens clean. plastic drawsheet can be placed between bottom sheet, and cotton drawsheet, are often used without plastic drawsheets, and can be used as assistive devices to move and transfer persons in bed
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Why are beds made daily?
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Clean, dry, and wrinkle free linens promote comfort, prevent skin breakdowns, prevent pressure ulcers.
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When is a closed bed made?
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after a person is discharged, for a new patient or resident, after the bed frame and mattress are cleaned and disinfected
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When is an open bed made?
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For newly admitted person's arriving by wheelchair, persons who are getting ready for bed, persons whoa re out of bed for a short time
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When is an occupied bed made
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When the person stays in bed. Be sure to keep the person in good alignment, follow restrictions or limits in persons movements or position, explain each procedure step to the person before it is done
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when is a surgical bed made?
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for persons returning to their rooms from surgery, who arrive at the agency by ambulance, who are taken by stretcher to treatment or therapy areas, using portable tubs
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Importance of Hygeine
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promotes comfort, safetly, and health. Intact skin-is the body's first line of defense against disease, prevents microbes from entering the body and causing an infection, mucous membranes of hte mouth, genital area, and anus must be clean and intact.
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Purpose of Hygiene
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good hygiene cleanses the body, prevents body and breath odors, is relaxing, increases circulation. Culture and personal choice affect hygiene and the nurse uses the nursing process to meet the person's hygiene needs.
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Daily Care
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Most people have hygiene routines and habits, routine care is given during the day and evening. before breakfast, after breakfast, after lunch,before sleet, assist with hygiene whenever it is needed
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Before breakfast care/early morning care/am care
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get patients ready for breakfast and morning tests. assist with elimination needs, cleaning incontinent people, changing wet or soiled linens and garments, assising with hygiene-face/hand washing and oral care, assising with dressing and hair care, positioning person for breakfast, making beds and straightening units
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After breakfast/morning care
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given after breakfast, and hygiene measures are more thorough at this time. assist with elimination, change incontinent persons, change wet/soiled linens and garments, assist with hygiene-hand/face washing, oral hygiene, bathing, back massage, and perineal care, assisting with grooming-haircare, shaving, dressing, and undressing, assisting with activity-amublation/ROM exercises, making beds and straightening units
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Afternoon care
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done after lunch and before the evening meal. assis with elimination before and after naps, cleaning incontinent people before and after naps, changing wet/soiled linen before and after naps, shaning wet/soiled garments before and after naps, assisting with hygiene and grooming-=face/hand washing, oral care, hair care, assisting with activity, straightening beds and units
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evening care/pm care
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given in the evening at bedtime. it is relaxing and promotes comfort. assist with elimination, cleaning incontinent people, changing soiled/wet linens and garments, assisting with hygiene-face/hand washing, oral hygiene, and back massages, helping person change into sleepwear, straightening beds and units
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What does oral hygiene do?
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Keeps the mouth and teeth clean, prevents mouth odors and infections, increases comfort, makes food taste better, reduces the risk for cavities (dental caries) and periodontal disease
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Illness, disease, and some drugs can affect our oral cavity causing what?
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a bad taste in the mouth, a whitish coating in the mouth and on the tongue, redness or swelling in the mouth and on tongue, dry mouth (is also common from oxygen, smoking, decreased fluid intake, and anxiety)
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What is the purpose of flossing?
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removes plaque and tarter from the teeth, and removes food from between the teeth
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Teeth brushing
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many people perform oral hygiene themselves, some people need help gathering supplies and setting up, you may need to brush teeth for people who are weak, cannot use their arms, and are too confused to brush their teeth
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unconsious person mouth care
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is very important because unconscious people may have dry mouth and crusting on the tongue and mucous membranes. the care plan will tell you what cleaning agent to use, but sponge swabs are used to apply the agent. apply lubricat to the lips after cleaning to prevent them from cracking. protect person from choking/aspiration by positioning them on their sides, using only a small amount of fluid, and keeping dentures out. keep mouth open with a padded tongue blade. tell the person what you are doing assume that they can hear you
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How often is mouthcare done for the unconscious person?
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At least every 2 hours, follow the directions and the care plan
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Dentures
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an artificial tooth or set of artificial teeth, can be full or partial dentures. Dentures are slippery when wet som make sure to use a gauze pad when removing dentures
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Denture Care
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Mouth care is given and dentures are cleaned as often as natural teeth, use a cleaning agent for dentures and follow manufacturers instructions, hot water warps dentures, use cool water, do not wrap dentures in tissues or napkins, clean dentures for those who cannot do so, dentures are fragile so place a towel in the sink when cleaning.
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Benefits of bathing
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cleans the skin, cleans the mucous membranes of the genital and anal areas, a bath is refreshing and relaxing, circulation is stimulated and body parts exercised, observations are made, have time to talk to the person
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Types of baths
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complete or partial baths, tub baths, or showers are given
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What type of bath is needed?
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bathing method depends on the person's condition, self-care abilities, and personal choice
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When is a bath given?
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The person's choice of bath time is respected whenever possible, but bathing frequency is a matter of person preference.
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complete bed bath
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involves washing hte entire body in bed. usually needed for persons who are unconscious, paralyzed, in casts or traction, weak from illness or surgery. for a towel bath an oversized towel is used, and bag baths are commerically prepared or prepared at agency
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partial bath
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involves washing face, hands, axillae, back, buttocks, and perineal area. Some people bath themselves in bed or at the sink, assist as needed
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tub baths and showers
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falls, burns, and chilling from water are risks, safety is important, protect person's privacy, follow directions and care plan
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back massage
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relax muscles and stimulate circulation, are given after the bath and with evenign care, can be given after repositioning or to help person relax. last 3-5 minutes.
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Rules for back massage
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observe skin before massage, lotion reduces friction during massage, use firm strokes, and after massage apply lotion to elbows, knees and heals.
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What is Perineal Care?
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Perineal care (pericare) involves cleaning genital and anal areas. Cleaning prevents infection and odors, and promotes comfort. Perineal care is done daily during the bath and whenever the area is soiled with urine or feces
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When is Peri-care provided?
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Is important for people who have urinary catheters, have had rectal or genital surgery, have given birth, are menstruating, are incontinent of urine or feces, are uncircumcised.
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Giving Peri-care
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The person does perineal care is able, the procedure embarrassess many people and nursing staff, standard precautions, medical asepsis, and bloodborne pathogen standard are followed
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When giving perineal care
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use warm water, not hot; use washcloths, towelettes, cotton balls, or swabs according to agency policy, rinse thoroughly, pat dry after rinsing
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reporting Peri-care
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Report observations at once: bleeding, signs of skin breakdown, discharge from vagina or urinary tract, unusual odors, changes from prior observations, report and record care given ( if not recorded it is assumed it was not given)
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Grooming measures
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are important to many people, prevent infection and promote comfort, affect love, belonging, and self-esteem needs.
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Grooming
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people differ in their grooming measures, person should tend to his/her own to extent possible, person may use adaptive devices for hair caire and dressing
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hair care
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how the hair looks and feels affects mental well-being. assist with hair care whenever needed. Process reflects persons culture, choices, skin/scalp condition, health history, and self-care ability
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Causes of Alopecia
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hair loss due to male pattern baldness with aging, thinning hair in some women with aging, cancer treatments, skin diseases, stress, poor nutrition, pregnancy, some drugs, and hormone changes
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Causes of Hirsutism
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excessive body hair in women and children due to heredity and abnormal amounts of male hormones
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Signs/symptoms of pediculosis
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complaints of tickling feeling or something moving in the hair, itching, irritability, sore on teh head or body cause by scratching, rash
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Scabies
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caused by a female mite that burrows into the sckin andlays eggs, person has rash and intense itching, highly contagious, people at risk live in crowded livign settings and those with weakened immune systems
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brushing/combing hair
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Encourage patient to do their own hair care and assist as needed. person chooses how to brush, comb, and style hair, brushing prevents tangles and matting, start brushing from the scalp to the ends, do not braid hair without patients permission, never cut hair, special measure for curly, coarse, dry hair, and normal practices and products are part of care plan
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shampoo methods
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shampoo during shower or bath, shampoo at the sink, shampoo on a stretcher, shampoo in bed/ The method is determined by persons condition, safety factors, personal choice.
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Shampooing
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factors which affect frequency-condition of hair and scalp, hairstyle, personal choice. do not shampoo hair unless told to do so. hair is dried and styled ASAP after the shampoo, check before rolling or curling hair
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Shaving
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many men shave for comfort and mental well-being and women shave their legs and underarms, coarse facial hari, and use other hair removal methods
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razors and shavers
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Safety razors or electric shavers are used. soften the beard before using an electic shaver or safety razor. do not use a safety razor for people who have healing problems, who take anticoagulant durgs.
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Mustaches and beards
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need daily care, ask person how to groom beard and mustache, never trim without persons permission
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nail and foot care
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prevents infection, injury, and odors. hang nails, ingrown nails, and nails torn away from the skin cause skin breaks; long or broken nails can scratch skin or snag clothing, dirty feet, socks, or stockings harbor microbes and cause odors
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Nail and foot injuries
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stubbing toes, stepping on sharp objects, being stepped on, shoes that fit poorly. Poor circulation prolongs healing. infections and foot injuries are serious for older people and people with healing problems.
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Trimming nails
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can result in injury, must practice caution. use nail clippers to cut fingernails, NEVER use scissors, clip nails straight across.
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changing gowns and clothing
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provide for privacy, encourace person to do as much as possible, let person choose what to wear, remove clothing from strong side first, put on clothing from weak side first, support arm or leg when removing or putting on a garment
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Changing hospital gowns
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gowns are usually worn for iv therapy. if ther eis injury or paralysis the gown is removed from strong side first, support weak arm while removing gown, put clean gown on weak side first
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Risks from poor diet and eating habits
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increase the risk of infection, increase the risk of acute and chronic diseases, cause chronic illnesses to become worse, cause healing problems, affect physical and mental function, increasing risk for accidents and injuries.
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Dietary Guidlines description of healthy diet
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high in fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products. includes lean means, poultry, fish, beans, eggs, and nuts, is low in fats, cholesterol, salt, and added sugars
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Nutrients
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no food/group has every essential nutrient, protein is the most important nutrient (needed for tissue growth and repair), carbs are neede dfor energy and fiber for bowel elimination, fats provide fast energy add flavor to food and help body use certain vitamins, vitamins are needed for certain body functions (do not provide calories), minerals are used for many body processes, and water is needed for all body processess
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What factors affect eating and nutrition?
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age (taste changes), culture influences dietary practices, food choices, and food preparation, selecting, preparing, and eating food often involves religious practices, people with limited income usually buy cheaper carbohydrate foods, loos of appetite can occur from illness, drugs, anxiety, pain, and drepression and unpleasent sights, thoughts, and smells
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My Pyramid
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Is based on Dietary Guidlines for Americans 2005. shows steps to healthier "you". The kind and amount of foods to eat daily depends on age, gender, and activity level, gradual improvement, physical activity, variety, moderation, the right amount from each food group band
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What are the food group bands found in My Pyramid?
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grains, vegetables, fruits, milk,meats and beans, and oils
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Food labels
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use to make informed choices for a healthy diet. Contain serving size and number of servings, calories and calories from fat, nutrients, how a serving fits into daily diet (DV), and DV is expressed as a percent of a 2000calorie diet
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Diet and Appetite
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food likes and dislikes are person, but food likes usually expand with age and experience, body reactions affect eating and nutrition, disease or injury can effect can affect hands, wrists and arms requiring adaptive equipment, and illness and recovery decrease appetite while nutritional needs increase.
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What are special diets used for?
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doctors order special diets for nutritional deficiency or disease, for weight control, to eliminate or decrease certain substance in diet.
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Regular,general and house diets
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diest that have no limits or restrictions
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What is a sodium-controlled diet?
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Sodium causes body to retain water, and control decreases the amount of sodium in body. A doctor orders the amount of sodium allowed. The diet involves: omitting high sodium foods, no adding salt to food at table, limiting hte amount of salt used in cooking, diet planning
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When is a Sodium-controlled diet ordered?
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for patients with heart disease, fluid retention, liver disease, and some kidney diseases.
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What is the average amount of sodium in the daily diet?
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between 3000-5000 mg per day. The body needs no more than 2300 per day.
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Diabetes Diet
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used for people with diabetes. the dietitian and person develop a meal plan, and consistency is the key. The meal plan involves: persons food preferences, calories needed, and eating meals and snacks at regular times
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What special care must be given for those patients on a Diabetes diet?
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Serve the person's meals and snacks on time, always check the tray to see what was eaten, tell nurse what person did and didn't eat, tell nurse about changes in persons eating habits.
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Dysphagia Diet
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Food thickness is changed to meet person's needs. Doctors, speech-language pathologists, occupational therapist, dietitian and nurse chhoose the right food thickness
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How can you promote safety for patients with dysphagia?
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know the signs and symptoms of dysphagia, feed the person according to the care plan, follow aspiration precautions, report changes in how person eats, report choking, coughing, or difficulty breathing during or after meals at once, report abnormal breathing or respiratory sounds at once.
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What are the different types of dysphagia?
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Slow swallow-the person has difficulty getting enough food and fluids for good nutrition and fluid balance.
Unsafe Swallow- food enters the airway (aspiration) |
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Fluid Balance
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death can result from too much or too little water. is needed for health (amount in/amount out should be almost equal). if intake exceeds output body tissues swell with water (edema). if output exceeds intake dehydration occurs.
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Normal fluid requirements
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adults need 1500 ml of water daily to survive. 2000-2500 ml of fluid per day are neede for normal fluid retention.
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What are some common special fluid orders?
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Encourage fluids, restrict fluids, nothing by mouth (NPO), thickened liquids.
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Encourage fluids
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the person drinks an increased amount of fluids
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restrict fluids
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fluids are limited to a certain amount
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Nothing by mouth (NPO)
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Non per os, cannot eat or drink anything
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thickened liquids
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all liquids are thickened, including water
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Why are I & O records kept?
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to evaluate fluid balance and kidney function, to help in evaluation and planning medical treatments, when person has special fluid orders
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What fluids are included in intake?
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all fluids taken by mouth, foods that melt at room temperature, IV fluids and tube feedings
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What fluids are include in output?
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urine, vomitus, diarrhea, and wound drainage
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What factors can affect appetite and ability to eat and therefore maintain food and fluid needs?
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weakness, illness, and confusion; unpleasant odors, sights, and sounds; uncomfortable position; need for oral hygiene; need to eliminate; pain
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foodborne illness
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caused by pathogens in food and fluids. food is not sterile it has pathogens when purchased, can become contaminated from other foods, food handlers with poor hygiene can contaminate foods, pathogens grow between 40-140 degress F. this is called the danger zone
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Protein
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needed for tissue growth and repair. sources include, meat, fish, poultry, eggs, milk and milk products, creals, beans, peas, and nuts.
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carbohydrates
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provide energy and fiber for bowel elimination. sources include fruits, vegetables, breads, cereals, and sugar.
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fats
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provide energy, add flavor to food, and help cody use certain vitamins. sources include meats, lard, butter, shortening, oils, milk, cheese, egg yolks, and nuts
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vitamins
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needed for certain body functions. teh body stores vitamins a,d,k,e. the vitamin c and b complex are not stored and must be ingested daily
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minerals
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needed for bone and tooth formation, nerve and muscle function, fluid balance, and other body processes
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