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Terms in this set (68)
loss of hair on body or scalp.
thickened portion of the skin.
type of bath given chiefly for hygiene purposes.
dry or greasey, scaly material shed from the scalp.
red, swollen gums.
the science of health and its maintenance.
the growing inward of the nail into the soft tissues around it, most often results from improper nail trimming.
infestation with head lice.
disorder of the supporting structures of the teeth.
an invisible soft film consisting of bacteria.
purulent peridontal disease.
a contagious skin infestation caused by an arachnid, the itch mite.
the oily, lubricating secretion of sebaceous glands in the skin.
a visible, hard deposit of plaque and dead bacteria that forms at the gum lines.
given for physical effects, such as to soothe irritated skin or to treat an area.
small gray brown parasites that bite into tissue and suck blood.
ADL's involved in personal hygiene
maintenance of personal hygiene
hygiene promotes: (3)
decreases infection and disease
nursing role in hygiene (4)
assess self-care abilities
provide assistance with ADLs
promote self-care in ADLs
delegate appropriate parts of hygiene care
factors that influence hygiene and self-are practices: (7)
culture and religion
psychosocial factors that influence hygiene
when to bathe
what products to use
culture and religion factors that influence hygiene
beliefs about hygiene and cleanliness
economic factors that influence hygiene
availability of facilities
developmental level factors that influence hygiene
physical and health factors that influence hygiene
pain: limits mobility and energy
limited mobility: decreased range of motion, weakness, bedrest
sensory deficits: decreased independence and increased safety concerns
cognitive impairments that influence hygiene
cannot determine need for hygiene
cannot problem-solve ADL processes
forgets when last performed hygiene and ADLs
emotional disturbances that affect hygiene
profound lack of energy for ADLs
altered reality does not include hygiene
which factor would be most likely to influence the hygiene practice of the homeless client?
a. degree of mental illness
b. cultural beliefs
c. living environment
d. knowledge level
c. the clients living environment
early morning care
wash face and hands, mouth care
bathing, toileting, hair, skin, bedmaking
toileting, hand washing, oral care, readying for visitors
prior to sleep
relaxation activities, readying environment to facilitate sleep
types of scheduled hygiene care: (4)
early morning care
assess prior to delegating hygiene care, instruct CNA regarding:
amount of assistance needed
use of assitive devices
presence and care of tubes
observations to make during hygiene care
assessment of the integumentary system during a bath:
color: pallor, erythema, jaundice
conditions that affect the skin: maceration, pruritus, acne
alteration in skin integrity: abrasions, pressure ulcers
assess functional abilities and status
bathe areas hard to reach
bathe only those areas absolutely necessary, including perineum
bed bath can be: (3)
other types of baths
bag or packaged bath
shower tub bath
oral care facilitates
removal of food particles and secretions
assessment of clients oral status
care of dentures
while giving oral care, assess:
condition of the teeth, cavities, gingivitis
conditions affecting the mouth: stomatitis, glossitis, oral lesions/malignancies
inflammation of the mucous membrane lining the mouth
Inflammation of the tongue. The tongue is painful, sometimes covered with ulcers, and swallowing is difficult.
when providing oral care for the unconscious patient, the nurse should:
a. place the patient on his side with the head of the bed in a lowered position
b. skip brushing the teeth as the patient could aspirate
c. swab the patients lips and oral cavity with lemon glycerin swabs at least hourly
d. place the patient in an upright position and brush his teeth with a sponge brush.
a. place the patient on his side with the head of the bed in a lowered position
when caring for feet/diabetics
special condiderations for the diabetic clients should be made
when performing hair care keep in mind:
special consideration for cultural variations in hair
care for mustaches and beards
when performing care of the eyes, keep in mind:
special considerations for clients with contact lenses
care of an artificial eye
The nurse is planning to meet the hygiene needs of a patient. Which is the first assessment to be performed by the nurse?
1. Determine the patient's preferences about hygiene practices
2. Assess the patient's ability to assist in hygiene activities
3. Collect the patient's toiletries needed for the bath
4. Recognize the patient's developmental stage
1. Hygiene is a personal matter determined by individual beliefs, values, and practices. Hygiene practices are influenced by culture, religion, environment, age, health, and personal preferences. When personal preferences are supported, the patient has a sense of control and usually is more accepting of care.
The nurse gives a bed-bound patient a bed bath. The primary reason the nurse provides hygiene to this patient is to:
1. Support a sense of well-being by increasing self-esteem
2. Remove excess oil, perspiration, and bacteria by mechanical cleansing
3. Promote circulation by stimulating the skin's peripheral nerve endings
4. Exercise muscles by contraction and relaxation of muscles when bathing
2. The removal of accumulated oil, perspiration, dead cells, and bacteria from the skin limits the environment conducive to the growth of bacteria and skin breakdown. An intact, healthy skin is one of the body's first lines of defense.
The nurse is providing hygiene to a patient with peripheral neuropathy. The nurse should:
1. Seek a physician's order for foot care
2. File the toenails straight across the nail
3. Wash the feet with lukewarm water and dry well 4. Apply moisturizing lotion to the feet, especially between the toes
3. Lukewarm water is comfortable and limits the potential for burns. Drying the feet limits moisture that promotes bacterial growth.
The nurse must make the decision to give a patient a full or partial bed bath. This decision depends on the:
1. Physician's order for the patient's activity
2. Immediate needs of the patient
3. Time of the patient's last bath
4. Wishes of the patient
2. A total patient assessment with an analysis of the data identifies the needs of the patient and the appropriate intervention to meet those needs.
The nurse is caring for a patient who wears eyeglasses. The nurse should:
1. Encourage use of artificial tears while hospitalized
2. Dry the glasses with a paper towel after cleaning the lenses
3. Limit the time that glasses are worn in an effort to rest the eyes
4. Use warm water to clean the lenses of glasses at least once a day
4. Eyeglasses should be cleaned at least once a day because dirty lenses impair vision. Warm, not hot, water is used to prevent distortion of the lens or frame, particularly if it is made of a plastic compound.
The nurse is giving a patient a bed bath. Which nursing action is most important?
1. Lower the side rail on the working side of the bed
2. Ensure that the bath water is at least 110° F
3. Fold the washcloth like a mitt on the hand
4. Raise the bed to the highest position
2. The temperature of bath water should be between 110 and 115 degrees F to promote comfort, dilate blood vessels, and prevent chilling. A lower temperature can cause chilling, and a higher temperature can cause skin trauma.
The nurse is responsible for providing hair care for a patient. To distribute oil evenly along hair shafts the nurse should:
1. Brush from the scalp toward the hair ends
2. Lift opened fingers through the hair
3. Apply a conditioner to wet hair
4. Use a fine-toothed comb
1. Brushing the hair from the scalp to the ends of the hair massages the scalp and distributes oils secreted by the scalp down along the length of the hair shaft.
Which condition identified by the nurse places a person at the greatest risk for self-care toileting and elimination problems?
1. Amputation of a foot
2. Early dementia
3. Fractured hip
3. Discomfort due to the proximity of the fracture to the pelvic area and the limitations placed on the positioning of, or weight bearing on, the affected leg impact on a patient's ability to use a bedpan or transfer to a commode.
The nurse is planning to shampoo the hair of a patient who has an order for bed rest. What should the nurse do first?
1. Tape eye shields over both eyes
2. Brush the hair to remove tangles
3. Encourage the use of dry shampoo
4. Wet hair thoroughly before applying shampoo
2. It is easier and causes less trauma to the hair to brush out tangles when the hair is dry rather then wet.
The nurse is providing for the hygiene and grooming needs of an obese patient with an activity intolerance. Which is the most important nursing intervention?
1. Maintaining the bed in a high-Fowler's position 2. Administering oxygen during provision of care 3. Providing rest periods every ten minutes
4. Assessing response to activity
4. Evaluation of a patient's response to care allows the nurse to alter care to meet the patient's individual needs.
The nurse must bathe the feet of a patient with diabetes. What should the nurse do before bathing this patient's feet?
1. File the nails straight across with an emery board
2. Ensure a physician's order for hygienic foot care is obtained
3. Teach the patient that daily foot care is essential to healthy feet
4. Assess for additional risk factors that may contribute to foot problems
4. A thorough assessment of the patient is the first step of the nursing process. People with diabetes frequently have thick, hardened toenails, peripheral neuropathy, impaired arterial and venous circulation in the feet, and foot or leg ulcers.
The nurse is caring for a patient with an excessively dry mouth. Which nursing action is most important when providing mouth care for this patient?
1. Swabbing with a sponge-tipped applicator of lemon and glycerin
2. Cleansing four times a day with a water pick
3. Rinsing frequently with mouthwash
4. Providing oral care every two hours
4. Mouth breathing, oxygen use, unconsciousness, and debilitation, among other conditions, can lead to dry oral mucous membranes. The nurse should provide oral hygiene with saline rinses frequently to keep the oral mucosa moist.
Which common problem with the hair should the nurse anticipate when patients are on complete bed rest?
1. Dry hair
2. Oily hair
3. Split hair
4. Matted hair
4. Bed rest causes matted, tangled hair because of friction and pressure related to the movement of the head on a pillow.
A patient is incontinent of loose stools and is mentally impaired. What should the nurse do to help prevent skin breakdown?
1. Wash the buttocks with strong soap and water 2. Frequently check the rectal area for soiling
3. Gently put a pad under the buttocks
4. Place the call bell in easy reach
2. Loose stool contains digestive enzymes that are irritating to the skin and should be cleaned from the skin as soon as possible after soiling.
The nurse understands that there are actions common to both a bed bath and a tub bath. Identify all that apply.
1. _____ Helping the patient wash parts that cannot be reached
2. _____ Exposing just the part of the body being washed
3. _____ Providing for privacy throughout the bath
4. _____ Obtaining an order from the physician 5. _____ Ensuring that the call bell is in reach
1. Patients can provide self- care within their abilities. When they have limitations, such as an inability to reach a body area, an activity intolerance, a decreased level of consciousness, or dementia, it is the nurse's responsibility to assist the patient regardless of the type of bath.
3. Bathing is a private matter and an invasion of personal space. The nurse provides privacy by pulling a curtain, closing a door, and keeping the patient covered as much as possible. These interventions maintain the patient's dignity.
a painful condition of the nerves of the hands and feet due to damage to the peripheral nerves; also known as peripheral neuritis
People with diabetes frequently have: (5)
thick, hardened toenails
venous circulation in the feet, and foot
what causes xerostomia? (4)
debilitation, among other conditions, can lead to dry oral mucous membranes.
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