Upgrade to remove ads
Only $35.99/year

Fundamentals of Nursing Chapter 40- Hygiene

Terms in this set (35)

Discuss conditions that place patients at risk for impaired skin integrity
Immobilization, Bariatric patient, Reduced sensation caused by stroke, spinal cord injury, diabetes, local nerve damage, Altered cognition resulting from dementia, psychological disorders, or temporary delirium, Limited protein or caloric intake and reduced hydration (e.g., fever, burns, gastrointestinal alterations, poorly fitting dentures), Excessive secretions or excretions on skin from perspiration, urine, watery fecal material, and wound drainage, Presence of external medical devices (e.g., cast, restraint, bandage, dressing), Vascular insufficiency
Immobilization
Dependent body parts are exposed to pressure from underlying surfaces. The inability to turn or change position increases risk for pressure ulcers.
Bariatric patient
Patient cannot visualize skin properly and keep it clean and dry. Excessive adipose tissue creates pressure from weight, lack of air circulation, and an increase in moisture with poor tissue perfusion
Reduced sensation caused by stroke, spinal cord injury, diabetes, local nerve damage
Patient unable to sense skin injury. Does not receive normal transmission of nerve impulses when applying excessive heat or cold, pressure, friction, or chemical irritants to skin.
Altered cognition resulting from dementia, psychological disorders, or temporary delirium
Patient unable to verbalize skin care needs. Does not realize effect of pressure or prolonged contact with excretions or secretions, requiring more vigilant assessment.
Limited protein or caloric intake and reduced hydration (e.g., fever, burns, gastrointestinal alterations, poorly fitting dentures)
Predispose to impaired tissue synthesis. Skin becomes thinner, less elastic, and smoother with loss of subcutaneous tissue. Poor wound healing results. Reduced hydration impairs skin turgor.
Excessive secretions or excretions on skin from perspiration, urine, watery fecal material, and wound drainage
Moisture is medium for bacterial growth and causes local skin irritation, softening of epidermal cells, and skin maceration.
Presence of external medical devices (e.g., cast, restraint, bandage, dressing)
Devices such as casts, cloth restraints, bandages, tubing, and orthopedic devices exert pressure or friction against surface of skin.
Vascular insufficiency
Arterial blood supply to tissues is inadequate, or venous return is impaired, causing decreased circulation to extremities. Tissue ischemia and breakdown often occur. Risk for infection is high.
nursing assessment questions used to determine the patient's awareness of hygiene problems and ability to perform hygiene measures.
Cultural and/or Religious Practices, Tolerance of Hygiene Activities, Assistance with Hygiene, Skin Care, Mouth Care, Foot and Nail Care, hair and Scalp Care
Cultural and/or Religious Practices
Do you have preferences for how you bathe or clean your teeth? How comfortable are you with someone helping you, with how we care for you? In what way can I best help you with your bath, hair care. ...?
Tolerance of Hygiene Activities
Does bathing cause any symptoms such as shortness of breath, pain, or fatigue? What can I do to minimize these symptoms? Which aspects of bathing or toothbrushing cause discomfort or fatigue?
Assistance with Hygiene
Do you use any aids to help you with your bath such as grab bars in your tub or shower? Do you prefer someone of the same gender to help in your hygiene care? Which parts of the bath, toothbrushing, and foot care can you do for yourself? With which parts of hygiene care do you need help?
Skin Care
Which type of bath do you prefer? How often and when do you usually bathe? What kind of soap and lotion do you use? Have you noticed any skin changes or irritation? Do you have any known allergies or reactions to soaps, cosmetics, or skin care products?
Mouth Care
Do you have any mouth pain or toothaches, have you noticed any sores in your mouth, do your gums bleed during brushing or flossing? Do you wear dentures or a partial plate?
Foot and Nail Care
How do you usually care for your feet and nails? Do you soak your feet? Do you file or trim your own fingernails and toenails?
Hair and Scalp Care
Have you recently experienced itching of the scalp or noticed flaking or dandruff? Have you noticed any changes in the texture or thickness of your hair?
Discuss different approaches used in maintaining a patient's comfort and safety during hygiene care.
provide privacy, maintain safety, maintain warmth, promote independence, anticipate needs
provide privacy
Close the door and/or pull room curtains around the bathing area. While bathing a patient, expose only the areas being bathed by using proper draping.
maintain safety
Keep side rails up when away from a patient's bedside when patients are dependent or unconscious. NOTE: When side rails serve as a restraint, you need a health care provider's order. Place the call light in the patient's reach if leaving the bedside even temporarily.
maintain warmth
Keep the room warm because the patient is partially uncovered and easily chilled. Wet skin causes an excessive loss of heat through evaporation. Control drafts and keep windows closed. Keep the patient covered. Expose only the body part being washed during the bath.
promote independence
Encourage the patient to participate in as much of the bathing activities as possible. Offer assistance when needed.
anticipate needs
Bring a new set of clothing and hygiene products to the bedside or bathroom.
Peripheral Neuropathy
Muscle wasting of lower extremities • Absence of deep tendon reflexes • Foot deformities • Infections • Abnormal gait
Vascular Insufficiency
Decreased hair growth on legs and feet • Absent or decreased pulses • Infection in the foot • Poor wound healing • Thickened nails • Shiny appearance of the skin • Blanching of skin on elevation
Fowler's position
a semi-sitting position; the head of the bed is raised between 45 and 60 degrees
Semi-Fowler's Position
the head of the bed is raised 30 degrees; or the head of the bed is raised 30 degrees and the knee portion is raised 15 degrees
Trendelenburg position
A position in which the patient's feet and legs are higher than the head
Reverse Trendelenburg's position
The head of the bed is raised and the foot of the bed is lowered
Flat bed position
Entire bed frame horizontally parallel with floor
uses of Fowler's position:
While patient is eating, During nasogastric tube insertion and nasotracheal suction, Promotes lung expansion, Eases difficult breathing
uses of Semi-Fowler's position:
Promotes lung expansion, especially with ventilator-assisted patients, Used when patients receive oral care and for gastric feedings to reduce regurgitation and risk of aspiration
uses of Trendelenburg's position:
Used for postural drainage, Facilitates venous return in patients with poor peripheral perfusion
uses of reverse Trendelenburg's position:
Used infrequently, Promotes gastric emptying, Prevents esophageal reflux
uses of flat bed position:
Used for patients with vertebral injuries and in cervical traction, Used for patients who are hypotensive, Patients usually prefer for sleeping
Other sets by this creator