hygiene and basic care

Question 1

skin

Answer 1

largest organ
physical barrier than protects internal organs
contains langerhans cells that sense and kill pathogens found on the skin

Question 2

skin layers

Answer 2

epidermis
dermis
hypodermis

Question 3

skin assessment

Answer 3

color
hydration (turgor)
lesions
impaired skin intergrity
inflammation

Question 4

skin integrity

Answer 4

compromised when a client’s skin is irritated, inflamed, or open
increased risk of infection, loss of limb, or death
washing regularly helps in removing dead skin cells, oil, bacteria, feces or urine from the skin surface

Question 5

skin breakdown

Answer 5

urine and bowel incontinence
hips, genitals, buttocks, perineum area are the most affected sites

Question 6

mucous membranes

Answer 6

physical barrier to block pathogens from invading the body through tissues or blood
locations-> respiratory tract, digestive tract, urinary tract, eyes, nose
mucus is secreted by the mucosal membranes and traps pathogens and small particles

Question 7

tooth anatomy and defense

Answer 7

enamel is the hardest material in the body and protects the teeth from pathogens and plaque
dentin lies beneath enamel and shields the pulp

Question 8

primary roles of teeth

Answer 8

chew food->easy swallowing
provides support and structure to the face
shape facial appearance
assist in providing sound during speech

Question 9

tooth decay

Answer 9

mouth bacteria produces acid
acid gradually dissolves enamel, which can lead to:
dental caries, infection, tooth lose

Question 10

teeth and oral assessment

Answer 10

check conditions of teeth and gums for dryness
gums and mucosa inflammation
pain of oral mucosa

Question 11

nail anatomy

Answer 11

nails protect the distal ends of the fingers and toes from injury
nails are made of layers of keratin
the cuticle surrounds the proximal and lateral edges of the nail

Question 12

nail assessment

Answer 12

observe the nail size, shape, conditions of nails and nail bed
nail abnormalities:
cracking
clubbing
fungus

Question 13

disabilties

Answer 13

clients may suffer from motor loss, weakness, or hemiplegia
clients may struggles to grab onto objects, reduced accuracy of movement, muscle fatigue, and coordination issues
increased risk for aspiration pneumonia associated with oral care->always assess ability to swallow firtst
assessments->balance, mobility, swallowing

Question 14

stroke and affected extremity

Answer 14

it is not the weak or damaged arm!
be mindful of your words and how you address it
undress the unaffected side first, then the affected side
dress affected side first, then unaffected side

Question 15

spinal cord injuries

Answer 15

may causes loss of ability to feel temps
have clients test water temps
remember to feel water with wrist or back of ungloved hand
utilize accessibility equipment to promote independence
increased risk for pressure injuries related to moisture, hard surfaces, and immobility

Question 16

bariatric challenges

Answer 16

increased body weight and BMI
increased need for assistance with personal care due to increased comorbidities and functional abilities
assist clients in providing care while also promoting independence
deep skin folds may be found ion the groin, gluteus maximus under breast, behind the knees, elbows, ankles, and neck
at risk for excessive sweating and overheating

Question 17

bariatric assessment

Answer 17

skin breakdown
rashes
friction
odors
excessive moistures with incontinence
fungal infection
dermatitis

Question 18

dementia

Answer 18

patients conditions worsen over time and ultimately lead to inability to independently perform ADLs
decreases quality of life
non-traditional methods may be required to get the client to bathe: towel bathing or chair bath

Question 19

ADLs

Answer 19

activity daily living

Question 20

dementia assessments

Answer 20

the client”s ADL abilities, likes, dislikes, demanor
incontinence, current hygiene practices
oral health-> these patients are also a higher risk for aspiration pneomonia

Question 21

amputation

Answer 21

accidents may happen at an increased risk related to injury while attempting ADLs
assistive devices are imperative for patients to decrease injury and promote independence

Question 22

amputation interventions

Answer 22

provide/advocate for assistive devices
keep supplies near patient
implement safety precautions (non-slip mats)

Question 23

amputation assessments

Answer 23

balance
strength
coordination

Question 24

cultural and social considerations

Answer 24

preferences-clients may have a variety of routines and priorities related to their hygiene care
culture-some cultures have unique practices of hygiene, remain respectful and do not make assumptions
dignity-a clients only sense of control may be their hygiene practices, provide reassurance and allow for as much control as possible
socioeconomic status-hygiene may not be the top priority without basic resources, do not be judgemental and ensure adequate resources prior to discharge

Question 25

older adult considerations

Answer 25

older adults have dryer and thinner skin-they may not tolerate frequent bathing hair increases in the ears, nose, and face with aging increased risk of infection and periodontol disease dentures must fit correctly and be taken care of dry mouth is common in older adults due to decreased saliva production and certain medications

Question 26

safety and privacy

Answer 26

performing ADL tasks allow for a good assessment of clients and their health status the nurse can further advocate or help as needed the nurse makes the decision on what tasks can or cannot be delegated ADL care is often a delegated task allow clients to complete as much of their ADLs as they can never leave clients in a position where they may be injured or harmed practice proper body mechanics when completing tasls raise bed-always lower bed all the way when completed

Question 27

bathing types

Answer 27

complete bed bath (head to toe) partial bed path (hot spots/PTA) shower bathtub

Question 28

bathing purpose

Answer 28

may be utilized to increase blood circulation, remove pathogens, dirt, sweat, dead skin perform and document a skin assessment during the procedure look for redness/open area psychological well-being

Question 29

bathing methods

Answer 29

disposable wipes or washcloths soap, water, basin basins may increase risk of infection chorhexidine gluconate (CHG) bathing is used to decrease risk of hospital acquired infections

Question 30

bathing implications and safety

Answer 30

always provide privacy warm bath water 43-46 degrees C use discretion when discussing bowel and bladder incontinence as they can be uncomfortable

Question 31

bed making and linen changes

Answer 31

occupied and unoccupied always determine if the patient needs PRN pain meds prior soiled bed linens increase the risk for infection always wear gloves and carry dirty linens away from the body place soiled linens into the proper receptable utilize bed rails for patient safety, always raise rails when rolling the patient away from you

Question 32

foot care

Answer 32

diabetes, poor circulation and immunocompromised: podiatry should be the ONLY speciality to clip/cut toenails an emery board/file may be utilized to file down long toe nails assess the feet for cuts, blisters, cracked skin, discoloration, or open areas, check between toes cautiously check temp of water as patients may be exhibiting neuropathy or decreased sensation of the feet

Question 33

perineal care

Answer 33

purpose-> maintain skin integrity, relieve discomfort, prevent infection safety and principles: males: retract foreskin to expose the meatus and ALWAYS return the foreskin female: wash front to back to decrease risk of UTI

Question 34

oral hygiene

Answer 34

twice daily with soft bristle brush clean the tongue with toothbrush or tongue scraper utilize facility provided mouth wash or rinse goal is to minimize pathogens, promote dentition, and prevent thrush

Question 35

oral hygiene (unconscious client)

Answer 35

have suction ready at bedside never place fingers in mouth position patients on their side when able utilize foam swabs and oral suction kits assessment and safety-> check gums, teeth, and oral mucosa assess swallowing and risk for aspiration pneumonia

Question 36

dentures and denture care

Answer 36

denture care removes food and other particles remove dentures if the patient is unable to do so independently dentures should be placed in a denture cup, emesis basin, or on a washcloth all surfaces should be brushed and cleansed with a toothbrush or denture brush

Question 37

nail care

Answer 37

nails are a primary transmission of germs encourage patients to practice good hand hygiene longer nails increase number of germs soak the nails prior to cleaning and clpiping always cut straight across the nail avoid nicking the skin and use a file to minimize going too short and sharp edges special caution for vascular disease, diabetes, immunocompromised. and patients on anticoagulants

Question 38

hair and scalp care

Answer 38

hair should be brushed daily to prevent matting and to spread oils through the hair hair may be placed in a protective style asl the client about preferred hair products when able-hair type, allergies, scalp conditions types- no-rinse shampoo cap, shampoo basin, or tray in bed

Question 39

hair and scalp assessment

Answer 39

pressure injuries head lice dandruff flaky skin

Question 40

eyes

Answer 40

clean eyes from the inner to outer canthus poor eyesight is lined with an increased risk for falls assessments-> vision, pain, dryness, damage if the patient has a visual aid-ensure the patient has them and they are clean

Question 41

shaving

Answer 41

patients who are prone to bleeding or on anticoagulants or have a low platelet count should use an electric razor move the razor over the skin in the direction of hair growth