Reading...
Play button
Play button
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;
38 Cards in this Set
- Front
- Back
|
What are the purposes of a bath?
|
cleansing the skin
condition the skin relaxation promote circulation exercise stimulate rate and depth of respirations promote comfort through muscle relaxation and skin stimulation providing sensory input improve self-image strenghten nurse-pt relationship |
|
|
What are shower and tub baths?
|
shower is preferred method for hospitalized pts who are ambulatory and can tolerate activity
check for non skid mats provide soap, towel, gown, etc shower chair needed? assist to and from shower and in and out of shower as needed check water temp (110-115) call ligh handy unlock door help wash hard to reach areas |
|
|
What are bed baths?
|
may be able to bathe themselves yet remain in bed or may require partial or complete assistance
provide articles for bathing and basin within easy reach privacy remove top linens and cover w/ bath blanket |
|
|
What is the bag bath?
|
alternative to traditional bed bath
premoistened washcloths that require no rinsing |
|
|
What are the principles and purposes of giving a back rub?
|
generally follows the pt's bath
conditions the body, relieves muscle tension, promotes relaxation, improves circulation 4-6 min w/ warmed lotion contraindicated for pts having had back surgery or fractured ribs position on stomach if possible |
|
|
Who to administer oral hygiene?
|
modify to meet pt needs
especially important for pt's who are NPO moisten lips w/ lubricant good mechanical cleaning! |
|
|
How to promote skin health?
|
topical emollients, bath additives and soap substitutes promote barrier function of the skin
apply moisturizers after bathing or at least twice a day |
|
|
How to provide eye care?
|
position pt on same side as the eye to be cleaned so that solution does not cross bridge of nose and contaminate the other eye
use water or NS w/ cotton ball or washcloth from inner canthus to outer canthus of eye wipe eyelashes clean matted eyelashes by applying warm compress for 3-5 mins to lossen debris |
|
|
How to provide eye care to a pt w/ diminished or absent blink refex?
|
at least every 4 hrs
corneal ulceration can occur if not kept moist use eye lubricants or eye shields as ordered artifical tears for comatose pts |
|
|
How to provide ear care?
|
clean outer ear
check batteries on hearing aids clean ear pieces or ear mold daily w/ mild soap and water |
|
|
How to provide nose care?
|
best way to clean is blow gently w/ both nostrils open wide
avoid irrigations b/c dnager of forcing material into sinuses clean external nares w/ mineral oils |
|
|
How to provide hair care?
|
brushing stimulates circulation to the scalp and helps keep the hair shaft clean
braid long hair w/ permission cutting may b enecessary which requires written consent brush and comb scalp and undo tangles before shampooing no-rinse shampoos |
|
|
How to provide foot care?
|
particularly important w/ aging and conditions such as circulatory disturbances of diabetes
good documentation needed |
|
|
How to provide perineal care?
|
sitz bath may be used to clean and irrigate perineal or anal areas
use perineal cleansers, mositurizers, and mositure barriers for foley care- cleanse 6-8 inches of the catheter- inspect meatus and characteristics of urine use plain soap and water for vaginal care |
|
|
How to provide environmental care?
|
ensure equipment at BS is working properly
request permission before opening a bedside stand or overhead table compartment always ask if there is anything the pt needs before leaving the room call light w/in reach at all times bed in low position with wheels locked side rails up as needed employ principles of medical asepsis electrical equpiment safely grounded uncluttered walk space decrease odor by emptying bedpans, BSC, emesis basins, urinals, etc ASAP remove odorous trash from room room deodorizers may be used room temp shoudl generally be bbetween 68-74 |
|
|
How to teach pts about soaps and detergents?
|
soaps often made from vegetable and animal fat, whereas most detergents are made from petroleum derivatives
expensive cleansing products aren't necessarily better non-soap cleansing products if dry skin |
|
|
How to teach pts about deodorants and antiperspiratns?
|
deodorants mask odors, whereas antiperspirants reduce the amount of perspiration by acting as stringents, closing the exits of the sweat glands
contraindicated prior to mammography, post-mastectomy and w/ radiation to the pits |
|
|
How to teach pts about cosmetics?
|
purity enforced by the FDA
discard after about 4 months as often become contaminated keep applicators clean and replace as needed don't share cosmetics |
|
|
What is a physical assessment of the skin?
|
overall inspection of skin's surface
inspect skin color- range from pinkish-white to shades of brown is the skin color constant? changes in pigmentation? changes in skin color? |
|
|
What is erythema?
|
redness of skin
seen most often in the face and neck associated w/ sunburn, inflammation, fever, trauma, and allergic reactions |
|
|
What is cyanosis?
|
a bluish or grayish discolorization of the skin in response to inadequate oxygenation
|
|
|
What is jaundice?
|
a yellow color of the skin resulting from liver and gallbladder disease, some types of anemia and hemolysis
|
|
|
What is pallor?
|
paleness of the skin, often resulting from an inadequate amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues
may be visible over the entire skin or only in the lips, nailbeds, mucous membranes and conjunctiva |
|
|
How to inspect for skin vascularity?
|
inspect for vascularity, bleeding, bruising, which could be from cardiovascular, hematologic, or liver dysfunction
|
|
|
What is ecchymosis?
|
ecchymosis is a collection of blood in the subcutaneous tissue casuing a purplish discolorization
|
|
|
What is petechia?
|
small hemorrhagic spots caused by capillary bleeding
|
|
|
What are skin lesions?
|
lesions are areas of diseased or injured tissue
not any bruising, scratches, cuts, insect bites, & wounds |
|
|
How are skin lesions categorized?
|
primary which arise from previously normal skin
secondary which results in changes in primary lesions |
|
|
How to inspect skin lesions?
|
assess wounds (breaks on continuity of skin) for size, shape, depth, location, and presence of drainage or odor
scars are healed wounds describe rashes (skin eruptions) in terms of type, size, elevation, coloring, and presence of drainage or itching document!! |
|
|
What is diaphoresis?
|
an excessive amount of perspiration
|
|
|
What is turgor?
|
is the fullness or elasticity of the skin and is usually assessed on the sternum or under the clavicle
normal elasticity results in a skin fold slowly returning to normal decreased w/ dehydration or as a normal finding in the elderly |
|
|
What is edema?
|
excess fluids in the tissues
characterized by swelling, with taut and shiny skin over the edematous area |
|
|
What is pitting edema & what may be the result of it?
|
palpation of the area with the fingers that results in an indentation
may be a result of overhydration, heart failure, kidney failure, trauma, or peripheral vascular disease |
|
|
Who would be at risk for pressure ulcer development?
|
older adults, individuals w/ spinal cord injuries, traumatic brain injuries, or neuromuscular disorders
|
|
|
What is stage I of a pressure ulcer development?
|
stage 1: an ovservable pressure related alteration of intact skin whose indicators as compared w/ the adjacent or opposite area of the body may include changes in one or more of the following: skin temp, tissue consistency, & sensation
may appear w/ persistent red, blue, or purple hues |
|
|
What is stage II of a pressure ulcer development?
|
partial thickness skin loss involving epidermis and or dermis
ulcer is superficial and presents clinically as abrasion, blister, or shallow crater |
|
|
What is stage III of a pressure ulcer development?
|
full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia
ulcer presents clinically as deep crater w/ or w/o undermining of adjacent tissue |
|
|
What is stage IV of a pressure ulcer development?
|
full thickness skin loss w/ extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
|
