Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
25 Cards in this Set
- Front
- Back
|
Types of Hygienic Care (4) |
Early morning (after waking) toilet, wash face/hands, oral care Morning care (after b'fast) toilet, shower, wash face/hands, back massage, oral, nail,hair PM Care ( before sleep) toilet, wash face/hands, oral care, back massage PRN (as needed) ex: a client who sweats a lot will need frequent baths |
|
|
Major Functions of Skin (5) |
protects underlying tissue regulates body temp secretes sebum transmits sensations Produces and absorbs vitamin D |
|
|
Sudoriferous glands (2) |
sweat glands- Appocrine- under arms and around genitals, produces body odor causing sweat Eccrine- all over body, cools body |
|
|
Assessing Skin (5) |
Nursing History- assess clients self care ability, past or current skin problems, important considerations ex: diabetic at risk for foot ulcers Physical assessment- does client have difficulty bathing, difficulty toileting |
|
|
Guidelines for skin care (6) |
1. healthy skin is bodies 1st line of defense 2.how much skin can protect body depend on skin health 3. prolonged contact with moisture can result in bacterial growth and irritation 4. B.O cause by bacteria acting on body secretions 5.skin sensitivity and injury proneness varies among people 6.skin care products have specific effects on the body and purposes |
|
|
Bathing facts (4) |
1. excessive bathing especially bad for older ppl b/c it removes sebum. 2. stimulates circulation 3. produces sense of well-being 4. opportunity for nurse to assess clients. |
|
|
Categories of Baths (2) Types of baths (9) |
Cleansing- complete bed bath, self help bed bath, partial bath, bag bath, tub bath, sponge bath, shower. Therapeutic baths. pg. 756 |
|
|
Bathing an adult client |
Purpose- clean skin, circulation, emotional benefit Assessment- physical / emotional factors( tired, in pain, cold). Condition of skin, range of motion of joints, mobility (balance, strength) Planning- nurse will likely delegate bath, tell uap, type of bath, report skin changes, client should be as self sufficient as possible, get report from uap after. Preformance-introduce self, ask client prefrences, wash hands, ensure client privacy evaluation- note how client tolerated procedure, re check skin, note range of motion, circulation, check against prior data |
|
|
Perineal - Genital care |
Purpose- remove secretions and odors, client comfort Assessment- look for, irritation, inflimation, swelling, discharge, odor, pain, urinary or fecal incontinence. client hygiene practices, self care ability Planning- get equipment together implementation- introduce self, wash hands, client privacy, put knees up, block view with towel Female- outside to inside, spread labia to wash inside, check for secretions, use separate corner of cloth for each part to prevent moving bacteria. for post-delivery or menstruating clients put on a pad after dry. Male- clean penis and scrotum, clean under foreskin, back of scrotum, perineal, ect. evaluation- look at previous data, possible follow up ex; ointment, report abnormalities |
|
|
Feet |
At birth foot unformed / at 5 years old arches and pads take shape / feet fully grown at 20. as clients age feet become, wider, longer, arches settle and padding deteriorates. Joint cartilage also shrinks deteriorating range of motion. older clients need special attention b/c of reduced blood flow / possible self care deficit. Nursing history of feet- normal care/ shoes worn, self care ability, risk for foot problems, problems with foot mobility Physical assessment- inspect for size, shape presence of lesions ( tissue abnormality). palpate to assess, tenderness, edema, circulation. |
|
|
Common foot problems |
callus- Thick skin due to pressure. usually filed down corn- build up of keratin ( a fiberous material found in hair and nails) caused by friction. usually surgically removed Plantar warts- appear on side and sole of foot, caused by virus, can freeze them off or use acid to remove. Fissures- deep grooves, mostly between toes, due to dryness and cracking of skin. treatment is foot hygiene and antiseptic to prevent infection. in grown toenail- toe has grown into skin arround it, frequent soaks and surgical removal athlete's foot- caused by fungus, small fluid filled blisters form, anti fungal powders, keep dry. |
|
|
Providing foot care |
purpose- clean skin on feet, prevent odors, infections, assess foot Assessment- history of or current foot problems, usual foot care practices, skin, temperature, circulation planning- diabetic client's feet need more care. implementation- introduce self, wash hands, client privacy, wash and soak foot, dry foot, maybe do nails, maybe put on powder, document problems evaluation- inspect nails and skin after, compare to prior data, report abnormalities. |
|
|
Nails |
nursing health history- usual practices, self care ability, physical inspection- color, shape, surrounding tissue cut straight across and file to round corners clients with diabetes or circulatory problems at risk when trimming nails. do not cut , file. |
|
|
Teeth |
Teeth have 3 parts, crown, root, and pulp cavity teeth appear five to eight months after birth at age 7 children lose their 20 deciduous teeth which are gradually replaced by 33 permanent teeth. by 25 most people have all their teeth. periodontal disease increases during pregnancy. teeth turn yellow due to the aging process. lack of fluoride in water and poor dental care leads to tooth and gum problems in older adults. as a result many have periodontal ( gum disease) the main cause of tooth loss and dental carries ( cavities) saliva production decreases with age which can turn gums brown. |
|
|
Assessing / caring for teeth |
Interview- what are normal practices, self care, do you see a dentist purpose- remove plaque, prevent sores, well being assessment- self care ability, inspect mouth, see if client has mouth problems or dentures implementation- introduce self, wash hands, client privacy, prepare client(sit up in bed ect) brush, floss, document, if unconscious lay on side to prevent liquid from going down throat evaluation- look for ongoing problems, report deviations, refer to dentist if possible |
|
|
tooth problems |
plaque- invisible soft film, made of bacteria, saliva, old food. tartar- visible hard deposit of plaque gingivitis- red swollen gums pyorrhea- advanced gingivitis, pus is evident when teeth are pressed additional problems halitosis- bad breath glossitis- inflammation of tongue |
|
|
good oral hygiene |
includes daily, stimulation of gums, brushing flossing, and flushing of mouth |
|
|
oral health through lifespan |
toddlers- when first tooth appears clean after each feeding pre-school- brush teeth after eating, not too much sugar, visit dentist adults- proper diet and mouth care older adults- may have problems due to self care deficits, can cause serious problems |
|
|
special oral hygiene needs |
xerostomia- saliva supply is reduced, possible side effect of medication. |
|
|
Hair |
Lanugo- fine hair on body of a fetus usually disappears with age older people's hair is thinner, drier and loses color chemotherapy may cause alopecia- hair loss |
|
|
Physical assessment of hair |
may uncover: dandruff- scaling of the scalp hair loss- usually hereditary ticks- can cause diseases, remove with tweezers lice ( pediculosis)- three kinds, head, body , and pubic hair lice. Test ?- use nix to remove lice because it is the least toxic scabies- contagious skin infestation by itch mite. brown burrows into skin creases. itches more at night. clean body and then use scabicide lotion hirsutism- excessive body hair, ( a problem when on face of women) lifespan considerations- infants- shampoo hair daily school age- check for lice, ect older adults- ensure warmth when washing hair |
|
|
Eyes |
unconscious clients may not have blink reflex so may need care eye trauma / infection patients may need to remove eye discharge nursing health history- eyewear, last eye exam, history of eye problems physical assessment- inspect external eye assessment interview- when do you wear glasses, what is your vision like without them, do you have eye problems eye care- wipe away dried secretions, if unconscious may need to use eye drops. unconscious client- cover eyes with moist compress every 2-4 hours, use artificial tears to lubricate eyes, watch for redness, ect contact lenses- hard- remove every 12 hours, soft- can wear 1-30 days, gas permeable- between soft and hard if dirt gets in eyes, clean with tepid water |
|
|
ears |
cerumen- earwax clean auricles ( visible part of outer ear) Test ? do not use anything smaller then a pinkie finger, move finger up and back around outer ear removing a hearing aid- turn it off, rotate it forward and pull out, clean ear mold, put it back in, make sure it works, compare hearing to previous assesment |
|
|
nose |
blow nose, clean secretions with saline / water and a cotton applicator. |
|
|
Hygienic environment |
environment- light, cleanliness of room, ventilation, warmth, noise, bedding. room temp- 68-74 ventilation- removes odors and stale air noise- excess noise causes stress hospital beds- 3 sections, allows head or feet to be raised separately. can moce up and down mattresses- usually water resistant to resist soiling side rails- precautions- raised side rails do not prevent clients from getting out of bed, they increase fall risk restraint- if all side rails are up and client did not request it, then it is a restraint entrapment- when client gets caught in openings around a hospital bed alternatives- low height bed, bed alarms, sensors footboard- immobilize foot at right angle to prevent them from moving feet bed cradle- keeps covers off feet, legs, or abdomen. bed can be either open ( covers pulled back) or closed ( not pulled back) bed spreads are mitered at corners to prevent them from moving intravenous rods- support iv infusion containers making an occupied bed- remove top bedding, roll 1/2 of bottom bedding as close to the client as you can, put clean sheet on 1/2 the bed, roll them onto clean side, finish. maintain good body alignment, move client gently and smoothly, explain what you are going to do before you do it, use bed making time to assess client. |
