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Hygiene and care
Hygiene and care of the patient's environment
| Question | Answer |
|---|---|
| the self-care measures people use to maintain their health | Personal Hygiene |
| the science of health | hygiene |
| at all times the nurse will need to teach health promotion practices, and hygiene care provides an excellent opportunity for this. the nurse must project an attitude of acceptance. | during the bath the nurse noted the pt's physical and emotional state. |
| also known as clean technique, this is a technique that inhibits the growth and spread of pathogenic microorganisms. | medical asepsis |
| disease-producing | pathogenic |
| tiny living plants or animals that can be seen only through a microscope. | microorganisms |
| a nurse should stay within the rules of touch that are culturally prescribed. | the nurse should ask pt's what will make them most comfortable during a bath. |
| the nurse must also consider the individual pt's beliefs, values, and habits | keeping the room clean, neat, and orderly contributes to a sense of well-being. |
| the nurse will want to consider the pt's age, severity of illness, and activity tolerance to maintain pt comfort. Recommended room temp should be 68 degrees to 74 degree F. Infants, older adults and acutely ill may need warmer temperatures. | Good ventilation is necessary to keep stale air and odors from lingering in the room. The nurse must be aware of protecting the pt from drafts. |
| Factors that influence a pt's personal hygiene | Social practices, body image, socioeconomic status, knowledge, personal preference (nurse should not try to change the pt's preferences unless pt's health is affected), physical condition, and cultural variables. |
| the nurse must do everything possible to control stimuli within the pt's personal environment. | the lounge chair can be used by both the pt and visitor. straight chairs are more maneuverable and can be used to transfer pt's for bed (i.e. bed-making). |
| hospital bed usually have removable headboards just in case they need easy access to the pt's head during cardiopulmonary resuscitation. | the back rub is contraindicated if the pt has such conditions as fractures of the ribs or vertebral column, burns, pulmonary embolism, or open wounds. monitor pulse and blood pressure of those pt's with a history of hypertension or dysrhythmias. |
| this bath cleanses & aids in reducing inflammation of the perineal & anal areas of the pt who has undergone rectal or vaginal surgery or childbirth. discomfort from hemorrhoids or fissures is relieved by this bath. water temp 110 F for affected area 20-30 | SITZ BATH |
| dizziness | vertigo |
| fainting | syncope |
| bath may be given to relieve tension or lower body temperature. the water temperature is tepid, not cold 98.6 degrees F | COOL WATER BATH |
| bath is given chiefly to reduce muscle tension. the recommended water temperature is 109.4 degrees F | WARM WATER TUB BATH |
| bath given to assist in relieving muscle soreness and muscle spasms. Not recommended for children. Water temp for adults should be 113-115 degrees F. Not used for pt's w/ neurological disorders or circulatory impairment because of danger of burning. | HOT WATER TUB BATH |
| A complete bath is for pt's who are totally dependent. the seriously or critically ill pt may need towel bath. the nurse assists the pt to bathe those body parts that are inaccessible to the pt. | when bathing pt with dementia, nurses may need to adjust their style of interaction. |
| this bath may include agents such as oatmeal, cornstarch, Burrow's solution, and soda bicarbonate (alkaline bath). this is ordered to reduce tension and relax pt & relieve pruritis. | MEDICATED BATH |
| When a person's physical condition changes , the skin often reflects this by alternations in skin color, thickness, texture, turgor, temperature, and hydration. | obesity increases the risk because fate tissue has decreased vascularity and resilience and increases weight and pressure on bony prominence. underweight increases the risk because of lack of cushion over the bones and muscles. |
| normal skin has the following characteristics; | intact without abrasions, warm and moist, localized changes in texture across surface. good turgor (elastic and firm); generally smooth and soft, skin color variations from body part to body part |
| good nursing interventions for skin integrity include; optimal healing of the impaired skin without complication, decrease in the pt's discomfort, decrease in length of hospitalization, decrease in the cost of ongoing care. | two mechanical factors can result in pressure ulcers; 1. Shearing force- tissue layers of skin slide on each other, kinking or stretching of subq blood vessels, results of in interruption of blood flow to skin. 2. friction- rubbing skin over a surface |
| bony prominence- heels, ankles, knees, sacral area, ischial area, spinal area, shoulders, and elbows | dentures should be stored in an enclosed, labeled cup for soaking or when they are not worn (e.g. during surgery or a diagnostic procedure) |
| oral hygiene helps maintain a healthy state of the mouth, teeth, gums, and lips. Brushing the teeth removes food particles, plaque, and bacteria, massage the gums, and relieves discomfort resulting from unpleasant odors and tastes. | oral care must be provided on a regular basis. frequency of hygience measures will depend on the condition of the pt's mouth. the beneficial outcomes of oral hygiene may not be seen for several days. |
| repeated cleansing is often needed to remove tenacious, dried exudate of the tongue and to restore the mucosa's hydration to normal. | use a rolled bath blanket as a pressure-reducing devices |
| conditions that place pts at risk for oral disorders: lack of knowledge about oral hygiene, inability to perform oral care, alteration in the integrity of teeth mucosa resulting from disease or treatments, pts who don't receive aggressive care | the nurse should remember pts taking anticoagulants should use a electric razors A pts beard, mustache,or sideburns are never removed without written consent, except for emergency purposes. |
| the elderly are also at risk for foot disorders because of poor vision or decreased mobility. | pts at risk for acquiring an infection, for example pts with indwelling catheters, pts recovering from rectal or genital surgery, or postpartum pts. |
| catheter care is done at least two times daily on all pts with indwelling catheters unless otherwise ordered by the physician. | catheter care include cleansing of the meatal-catheter junction with a mild soap and water and sometimes application of a water-soluble microbicidal ointment (Betadine or Neosporin may be ordered) |
| pts who cannot grasp small ojects, have limited mobility in the upper extremities, have reduced vision, or are seriously fatigued will require assistance from the nurse. | the eyes, ears, and nose are sensitive, and therefore extra care should be taken to avoid injury to these tissues |
| circular area around the eye | circumorbital |
| the eye is cleansed from the inner to outer canthus, a separate section of the washcloth is used each time to prevent speared of infection. | Eyeglasses should be stored in the case and placed in the drawer of the bedside stand when not in use to avoid accidental damage. |
| NEVER USE BODDY PINS, COTTON-TIPPED APPLICATORS, because they might cause damage to the tympanic membrane (eardrum) or cause cerumen (wax) to become impacted in the canal. | determine if the pt can hear by talking slowly and clearly in a normal voice tone. When not in use, the hearing aid should be stored where it will not become damaged. |
| harsh nose blowing causes pressure capable of injuring the tympanic membrane (eardrum), nasal mucosa, and even sensitive eye structures. | when the pt receives oxygen per nasal cannula or has a nasogastric tube, the nurse should cleanse the nares every 8 hours with a cotton tipped app moistened with saline |
| different bed positions can be used to promote lung expansion, postural drainage, and other interventions. the pt bed is usually made in the morning after the bath. when possible the bed is made while not occupied. comfort and privacy are most important | if linens are soiled w/feces, blood, or emesis, they should be changed. Use chux (waterproof pads) with caution. accumulation of moisture creates a risk for skin maceration and impairment. |
| an unoccupied bed may be made open or closed. in the open bed the top linens are fan-folded toward the foot of the bed to allow the pt to return to the bed more easily. | a closed bed is prepared following a pt's dismissal, transfer, or when the pt dies, before another pt is admitted. the postoperative bed is a form of the open bed. |
| device for receiving feces or urine from either the male or female pts confined to bed | bedpan |
| device for collection urine from male pts, urinals for female pts also are available its used when a pt cant get up to go to the bathroom. | urinal |
| flow sheets are used to document normal voiding and stools. abnormalities are recorded in the nurses notes | bedpans are metal and plastics. there are two types of bedpans. one type has a high back. the second type is flat and smaller and is called a fracture pan |
| a urinal is metal or plastic. two types are; 1. used by the male pt for voiding 2. female urinal, which has an adapter that accommodates the female anatomy. | the bedpan and urinal should be emptied immediately after use. cleansed, and stored properly. liquid stool is estimated on the appropriate form according to the agency's policy. |
| for pt unable to assume the normal squatting position, there are stool risers, which require less effort to sit or stand. | normal urine- ranges from pale, straw color to amber, is transparent at time of voiding, has a characteristic odor; faintly aromatic, negative of protein, glucose, ketone bodies, red & white BC, and bacteria |
| normal stool- brown, odor is affected by food types, has soft formed consistency, frequency ranges from once a day to two or tiw, resembles the shape of the rectum, contains undigested food, dead bacteria, fat, bile pig, living cells, intestinal mucosa, w | pelvic floor exercises (kegel exercises) involve tightening the ring of muscle around the vagina and anus and holding it for several seconds. this should be done a minimum of 10 times, tid |
| this occurs because pressure in the bladder is too great, because the sphincters are weak, or because the innervation has been compromised due to illness or injury | urinary incontinence |
| alert pts need an incontinence product that is discreet and promotes self-care. | persistent urge, stress, or overflow incontinence may need referral for urologic evaluation. |
| incontinence characterized by urine or fecal flow at unpredictable times requires the use of disposable adult undergarments or underpads as the primary means of management. | when urinary incontinence results from decreased perception of bladder fullness or impaired voluntary motor control, bladder training can be helpful. |
Created by:
Nicknack10
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