NUR 2206 Exam 2
- Factors affecting hygiene
Answer -developmental level (infants and older adults have fragile skin) -disease (impacts patient's ability to maintain hygiene routine) -culture (ask about practices) -socioeconomic status (access, ability to purchase hygiene supplies) -personal preferences (routine, usual products)
- hygiene assessment
Answer -Daily hygiene practices -Factors interfering with hygiene -History of skin or mucous membrane problems
- while bathing, the nurse should perform a assessment
Answer skin
- types of interventions for hygiene
Answer -early morning care -AM care -HS care -PRN (as needed)
- self care
Answer patient able to perform own hygiene
- partial care 1 / 4
Answer patient needs some assistance with hygiene
- complete care
Answer patient needs total assistance with all aspects of hygiene
- shower
Answer -safety considerations
-use shower chair
- bed bath/bag bath
Answer -wash extremities DISTAL to PROXIMAL (promote venous return)
-head to toes (start with eyes and face, end with feet) -only expose area you are washing -keep patient covered with warm bath blanket
- additional nursing interventions after bathing
Answer -application of skin emol- lients/protectants
-back rub
- TEDS (Antiembolism) Stockings and Intermittent Pneumatic Compression Stockings
(Sequential Compression Devices = SCDs)
Answer
- Used for patients at risk for DVT, PE, phlebitis
- Promote venous return
- Perform skin and neurovascular checks regularly
- types of bedmaking 2 / 4
Answer occupied unoccupied closed open
- Why is oral hygiene important?
Answer improves oral health and limits growth of pathogens which decreases risk of respiratory diseases
- how often should the nurse perform oral care?
Answer often enough to keep mouth moist in dependent patients
- unconscious patient oral care
Answer -prevent aspiration
-turn on side (turn head to side) -emesis basin under mouth -allow saliva to flow from mouth -gentle care
- conscious patient oral care
Answer assess need for assistance
- where should dentures be when not in use?
Answer labeled denture container
- cleaning dentures
Answer 3 / 4
-place washcloth in sink
-use cool or warm water -brush dentures with toothpaste
- eye care
- Wear gloves
Answer
- Use water only
- Cleanse from inner canthus to outer canthus
- Use different part of washcloth for each stroke
- foot care
Answer do not clip toenails! (refer to podiatrist)
- hygiene evaluation
Answer -patient's ability to assist in hygiene
-skin and mucous membrane condition
- before leaving the room, ensure...
Answer -patient positioning
-bed in lowest position -call bell within reach
- When caring for the skin of patients of different age groups, which of the following should
the nurse consider?
- An infant's skin and mucous membranes are protected from infection by a natural immunity.
- Secretions from skin glands are at their maximum from age 3 on.
- The skin becomes thicker and more leathery with aging and is prone to wrinkles and
dryness.
- An adolescent's skin ordinarily has enlarged sebaceous glands and in- creased glandular
- / 4