Nur 111 Lab Review

Front 1

Self Care and Hygiene : Bathing
- Purpose

Back 1

1. Cleanse the skin, control body odors, and promote self-esteem
2. Stimulate circulation
3. Provide an opportunity to assess skin and physical mobility
4. Provide range-of-motion exercises for joints
5. Promote relaxation and comfort

Front 2

Self Care and Hygiene : Bathing
- Equipment

Back 2

* Two bath towels
* Two washcloths
* Bath blanket
* Washbasin with warm water (110°-115°F; 43.3°-46.1°C); test by measuring with bath thermometer or by placing several drops on your inner forearm
* Soap, soap dish, or liquid (nonsoap) cleanser or Bag bath packet removed from warmer just before bathing
* Clean gown or pajamas
* Laundry bag
* Disposable clean gloves for perineal care

Front 3

Self Care and Hygiene : Bathing
- Assessment

Back 3

* Assess client's ability to perform self-care and amount of assistance he or she needs. Evaluate activity tolerance, cognitive function, musculoskeletal function, and level of discomfort to determine type of bath.
Note: Encourage the client to be as independent as possible but not to become excessively fatigued. Pain should not be intensified.
* Assess the client's preferences for bathing (i.e., frequency, time of day, type of skin-care products).
* Review chart to determine other procedures or therapies the client is receiving to coordinate scheduling and prevent fatigue.
* Identify clients with special considerations for bathing:
o Older clients: Susceptible to dry skin
o Immobilized clients: Pressure areas on dependent and bony parts; need for range-of-motion exercises to joints
o Clients with altered sensation: Risk for burns from hot water
o Obese or diaphoretic clients: Excessive perspiration or moisture on skin surfaces that rub against each other and provide medium for excoriation and bacterial growth
* Review history for precautions regarding movement or positioning.
* Assess client's knowledge and practice of hygiene to determine learning needs.

Front 4

Female/Male Pericare
-Purpose & Assessment

Back 4

1. To promote cleanliness.
2. To prevent infection.
3. To remove irritating and odorous secretions.

* Assess the client's tolerance for bathing: comfort during movement, respiratory status during activity.
* Assess the client's ability to perform care independently or with assistance.
* Assess the urethral opening for drainage or irritation if a urinary drainage catheter is in place.
* Assess the rectal area for irritation and presence of feces.

Front 5

Female/Male Pericare
- Equipment

Back 5

* Gloves
* Toiletry items: deodorant, lotion, powder
* Washcloths and towels
* Clean hospital gown
* Clean basin
* Perineal cloths-disposable (facility dependent)
* Mild soap
* Bath blanket
* Toilet tissue
* Linen-saver pad
* Laundry hamper for reusable linens
* Trash bag for disposable supplies
* Optional: bedpan, perineal bottle, antiseptic soap, petroleum jelly, zinc oxide cream, vitamin A and D ointment,
* abdominal pad

Front 6

Female/Male Pericare
- Special Considerations

Back 6

* Give perineal care to a client of the opposite gender in a matter-of-fact way to minimize embarrassment.
* If the client is incontinent, first remove excess feces with toilet tissue. Use a small amount of antiseptic soap and water to help eliminate odor. If necessary, irrigate the perineal area to remove any remaining fecal matter.
* After cleaning the perineum, apply a thin layer of ointment or cream (petroleum jelly, zinc oxide cream, or vitamin A and D ointment) to reduce skin breakdown by providing a barrier between the skin and excretions.
* To reduce the number of linen changes, tuck a water-proof pad between the client's buttocks to absorb oozing feces.

Front 7

Performing Foot and Hand Care
- Assessment

Back 7

* Note client's gait for limping or unusual position. Unnatural gait can be caused by painful feet or bone and muscle disorders.
* Assess footwear worn by client. Socks should be worn and changed daily to absorb excess perspiration and avoid fungal infections.
* Identify clients at risk for foot or nail problems:
o Diabetes is associated with changes in microcirculation to peripheral tissues. The client with diabetes is at high risk for infection from breaks in skin integrity and may have decreased sensation to pain as a result of neuropathy.
o Older adult clients' ability to perform foot and nail care may be impeded by poor vision, obesity, or musculoskeletal conditions that limit their ability to bend and maintain balance.
o Cerebrovascular accident may alter the client's gait due to foot drop, muscle weakness, or paralysis.
o Conditions associated with foot and ankle edema (renal failure, congestive heart failure) interfere with blood flow to surrounding tissues and impede proper shoe fit.
* Determine client's ability to perform self-care.
* Inspect nails and skin of fingers, toes, and feet. Assess areas between toes for dryness and cracking.
* Assess client's knowledge of foot and nail care practices.
* Review agency policy for trimming nails. Many agencies require a physician's order to perform nail trimming on high-risk clients.

Front 8

Performing Foot & Hand Care
- Purpose and Equipment

Back 8

1. Maintain skin integrity
2. Provide for client's comfort and sense of well-being
3. Maintain foot function and ability to ambulate
4. Encourage self-care

* Waterproof pad
* Washcloth, towels
* Washbasin, warm water, soap
* Lotion
* Disposable gloves
* Nail clippers, file
* Cuticle stick

Front 9

Self Care and Hygiene : Oral Care
- Purpose & Equipment

Back 9

1. Cleanse tooth surfaces to prevent odor and caries
2. Maintain hydrated, intact oral mucosa
3. Promote self-esteem and comfort
* Soft toothbrush (sponge-ended swabs may be used for clients at risk for bleeding)
* Toothpaste
* Cup with water, straw
* Emesis basin
* Washcloth, towel
* Mouthwash (optional; nonalcohol-based is preferable)
* Dental floss
* Disposable gloves (if the nurse provides oral care)

Front 10

Self Care and Hygiene : Oral Care
- Assessment

Back 10

* Inspect lips, buccal membrane, gums, palate, and tongue for lesions or inflammation.
* Assess for presence of caries or halitosis (bad breath).
* Identify clients at risk for oral hygiene complications:
o Dehydration, NPO status, nasogastric tubes dry the oral mucosa.
o Oral airways accumulate secretions and irritate the mucosa.
o Chemotherapy often results in stomatitis and ulcerations.
o Anticoagulant therapy or clotting disorders predispose the client to gum bleeding.
o Oral surgery or trauma may contraindicate tooth brushing; special rinses may be ordered.
* Assess client's desire for back massage.
* Determine any limitations to positioning.

Front 11

Self Care and Hygiene : Oral Care
- Procedure Tips

Back 11

# Place towel under client's chin.
Rationale: Protects bed linens and gown from soiling.
# Moisten toothbrush with water. Apply small amount of toothpaste (Fig. 1). If client is anticoagulated or has a clotting disorder, use a very soft toothbrush or a sponge-ended swab to prevent gum bleeding.
Rationale: Limits trauma to oral mucosa that could cause bleeding.

Front 12

Self Care and Hygiene : Oral Care
- Procedure Tips for Unconscious Patient

Back 12

# Place client in a side-lying position.
Rationale: Side-lying position prevents aspiration.
# Place towel or waterproof pad under client's chin.
# Place emesis basin against client's mouth or have suction catheter positioned to remove secretions from mouth
Use padded tongue blade to open teeth gently (Fig. 7). Leave in place between the back molars. Never put your fingers in an unconscious client's mouth.
Rationale: Unconscious clients often respond to oral stimulation by biting down.
Brush teeth and gums as directed previously, using toothbrush or soft sponge-ended swab. Cleanse oral cavity using toothette
# Use a small bulb syringe or syringe without needle to rinse oral cavity (Fig. 10). Swab or use oral suction to remove pooled secretions
Apply thin layer of petroleum jelly to lips to prevent drying or cracking

Front 13

Self Care and Hygiene : Oral Care
- Procedure Tips for Unconscious Patient

Back 13

Using a padded tongue blade, gently open the client's mouth.

Front 14

Making an Occupied Bed
- Purpose and Assessment

Back 14

1. Provide clean linen for client who is unable to get out of bed
2. Promote comfort
* Assess pain level and need for analgesia to ensure comfort during linen change.
* Note any position precautions (i.e., elevation of body parts).
* Assess client's potential for excessive perspiration, drainage, or incontinence in determining special linen requirements.
* Assess agency protocol for linen change. In some long-term care facilities, linen changes occur when the client gets a bath, weekly or biweekly.

Front 15

Making an Occupied Bed
- Equipment

Back 15

* Bottom sheet
* Top sheet
* Draw sheet
* Blanket (change only if soiled)
* Bedspread (change only if soiled)
* Mattress pad, if used by facility (change only if soiled)
* Pillowcases
* Waterproof pads or bath blanket (optional for incontinent or diaphoretic clients)
* Linen bag
* Bedside table or chair

Front 16

Making an Occupied Bed
- Procedure Tips

Back 16

Help client to roll onto side facing away from you (Fig. 2). Client may grasp side rail to assist. Additional personnel may be needed to assist with client positioning. Adjust pillow under head.
Tightly fanfold soiled linens (Fig. 3). Tuck under buttocks, back, and shoulders (Fig. 4). Do not fanfold mattress pad unless it is soiled.

Front 17

Making an Occupied Bed
- Fitted Sheet

Back 17

Place draw sheet on bed with center fold at center of bed. Position sheet so it will extend from the client's back to below the buttocks (Fig. 7). Fanfold the top edge and place next to client. Tuck excess under mattress. Some agencies use a cloth waterproof pad instead of a draw sheet.
Position top sheet and draw sheet under soiled sheets (Fig. 8).
Rationale: Positioning clean sheet under soiled sheets makes it easier to remove linens.