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Ch 30: Hygiene
Terms in this set (41)
physical examination of hygiene
Evidence of lesions
guidelines for assessing skin
Allow data obtained to direct skin assessment.
Proceed systematically in head-to-toe sequence.
Use a good source of light, preferably daylight.
Compare bilateral parts for symmetry.
Use standard terminology to report and record findings.
Identify variables known to causes skin problems.
Does it bother you?
How does it bother you (itching)?
How long have you had this problem?
Have you found anything helpful in relieving these symptoms?
assessing the oral cavity
Color and surface of gums
Hard and soft palates
Which one of the following gum diseases manifests as a marked inflammation of the gums that also involves a degeneration of the dental tissues and bone?
Which of the following oral problems involves an ulceration of the lips usually caused by vitamin B complex deficiencies?
The formation of cavities in the teeth by the action of bacteria; tooth decay.
inflammation of the gums
A serious gum infection that damages gums and can destroy the jawbone.
inflammation of the mucosa of the mouth
inflammation of the tongue
a disorder of the lips characterized by crack-like sores at the corners of the mouth
caused by Vit B deficiency
calcified deposit at the gingival margin of the teeth
are most likely to develop in the buccal cheek mucosa
done before oral care
denture care steps
With gloved hands, remove the dentures.
Place the dentures in the emesis basin or denture cup.
Line the sink with a washcloth or soft towel.
Run cool or room temperature water. Rinse the dentures.
Gently brush the dentures using a toothbrush and toothpaste while holding them safely and firmly in your hand.
May be soaked in commercial preparations.
Rinse the dentures under the running water.
Place the dentures in a denture cup or emesis basin with cool water
early morning hygiene care
Assist patient with toileting.
Wash face and hands.
Provide mouth care.
Provide comfort measures to refresh patient to prepare for day.
After breakfast, nurse completes morning care:
Special skin measures
Hair care, cosmetics
Positioning for comfort
Refreshing or changing bed linens
Tidying up bedside
Ensure patient's comfort after lunch:
Offer assistance with toileting, handwashing, oral care.
Straighten bed linens.
Help patient with mobility to reposition self.
Before patient retires to sleep:
Offer assistance with toileting, washing, and oral care.
Offer a back massage.
Change any soiled bed linens or clothing.
Position patient comfortably.
Ensure that call light and other objects patient requires are within reach.
Clean from inner to outer canthus with wet, warm cloth, cotton ball, or compress.
Use artificial tear solution or normal saline every 4 hours if blink reflex is absent.
Care for eyeglasses, contact lens, or artificial eye if indicated.
ear and nose care
Wash external ear with washcloth-covered finger
Perform hearing aid teaching and care if indicated.
Remove crusted secretions around nose by washcloth
Clean nose by having patient blow it if both nares are patent.
Identify patient's usual hair and scalp care practices and styling preferences.
Note any history of hair or scalp problems such as dandruff, hair loss, or baldness.
Treat any infestations, such as pediculosis and ticks.
Groom and shampoo hair.
Care for beards and mustaches.
Assist with unwanted hair removal.
diabetic foot care
Wash your feet every day
Keep your skin soft and smooth.
If you can see and reach your toenails, trim them
Wear shoes and socks at all times.
Protect your feet from hot and cold.
Keep the blood flowing to your feet.
perenial and vaginal care
Perform a physical assessment of male and female genitalia.
Perform perineal care in matter-of-fact and dignified manner according to procedure.
Cleanse with plain soap and water.
Proceed from the least contaminated to the most contaminated area.
A nurse is scheduling hygiene for patients on her unit. What is the most important consideration when planning a patient's personal hygiene?
A. When the patient had his or her most recent bath
B. The patient's usual hygiene practices and preferences
C. Where the bathing fits in the nurse's schedule
D. The time that is convenient for the patient care assistant
A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply.
A. It promotes the patient's sense of well-being.
B. It prevents deterioration of the oral cavity.
C. It contributes to decreased incidence of aspiration pneumonia.
D. It eliminates the need for flossing.
E. It decreases oropharyngeal secretions.
F. It compensates for an inadequate diet.
A, B, C
Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases
A nurse assisting with a patient bed bath observes that an older female patient has dry skin. The patient states that her skin is always "itchy." Which nursing action would be the nurse's best response?
A. Bathe the patient more frequently.
B. Use an emollient on the dry skin.
C. Massage the skin with alcohol.
D. Discourage fluid intake.
A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply.
A. A patient who is taking antibiotics for chronic bronchitis
B. A patient diagnosed with type II diabetes
C. A patient who is obese
D. A patient who has a nervous habit of biting his nails
E. A patient diagnosed with prostate cancer
F. A patient whose job involves frequent hand washing
B, C, D, F
Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply.
A. Compare bilateral parts for symmetry.
B. Proceed in a toe-to-head systematic manner.
C. Use standard terminology to report and record findings
D. Do not allow data from the nursing history to direct the assessment.
E. Document only skin abnormalities on the patient record.
F. Perform the appropriate skin assessment when risk factors are identified.
A, C, F
A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply.
A. Wash the skin twice a day with a mild cleanser and warm water
B. Use cosmetics liberally to cover blackheads.
C. Use emollients on the area.
D. Squeeze blackheads as they appear.
E. Keep hair off the face and wash hair daily.
F. Avoid sun-tanning booth exposure and use sunscreen
A, E, F
A nurse observes a marked inflammation of the gums, along with recession and bleeding of the gums, and documents this observation using which term?
An unresponsive patient is wearing gas-permeable contact lenses. How would the nurse remove these lenses?
A. Gently irrigate the eye with an irrigating solution from the inner canthus outward.
B. Grasp the lens with a gentle pinching motion.
C. Don sterile gloves before attempting the removal procedure.
D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release it.
The lens must be situated on the cornea, not the sclera, before removal. To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean, not sterile, gloves are used.
Mr. James has an eye infection with a moderate amount of discharge. Which action would be most appropriate for the nurse to use when cleaning his eyes?
A. Using hydrogen peroxide
B. Wiping from the outer canthus to the inner canthus
C. Positioning him on the same side as the eye to be cleansed
D. Using only one cotton ball per eye
A nurse is providing foot care for patients in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply.
A. Bathe the feet thoroughly in a mild soap and tepid water solution.
B. Soak the feet in warm water and bath oil.
C. Dry feet thoroughly, including the area between the toes.
D. Use an alcohol rub if the feet are dry.
E. Use an antifungal foot powder if necessary to prevent fungal infections.
F. Cut the toenails at the lateral corners when trimming the nail.
A, C, E
A nurse is caring for an 80-year-old patient who has become weak and fatigues easily. He is unable to wash his body and always asks the nurse to brush his teeth. Based on this information, what is an appropriate nursing diagnosis for this patient?
A. Risk for Impaired Skin Integrity related to immobility
B. Bathing/Hygiene Self-Care Deficit related to decreased strength and endurance
C. Social Isolation related to lack of visitors
D. Impaired Oral Mucous Membrane related to inability to brush his teeth
A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? Select all that apply.
A. For male and female patients, wash the groin area with a small amount of soap and water and rinse.
B. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area.
C. For male and female patients, always proceed from the most contaminated area to the least contaminated area.
D. For male and female patients, use a clean portion of the washcloth for each stroke.
E. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward.
F. In an uncircumcised male patient do not retract the foreskin (prepuce) while washing the penis.
A, D, E
An older patient with an unsteady gait requests a tub bath. Which action would be most appropriate?
A. Add Alpha-Keri oil to the water to prevent dry skin.
B. Allow the patient to lock the door to guarantee privacy.
C. Assist the patient in and out of the tub to prevent falling.
D. Keep the water temperature very warm because the patient chills easily.
A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What should the nurse do?
A. Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve.
B. Cut the gown with scissors to allow arm movement.
C. Thread the bag and tubing through the gown sleeve, keeping the line intact.
D. Temporarily disconnect the tubing from the IV container, threading it through the gown.
A nurse is caring for a 25-year-old male patient who is comatose following a head injury. The patient has several piercings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this patient's piercings?
A. Do not remove or wash the piercings without permission from the patient.
B. Rinse the sites with warm water and remove crusts with a cotton swab.
C. Wash the sites with alcohol and apply an antibiotic ointment.
D. Remove the jewelry and allow the sites to heal over.
The nurse should then apply a dab of liquid medicated cleanser to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene.
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