Chapter 15 Personal Care

closed bed

a bed made following the discharge of a patient fresh linens top linens at the head of the bed to keep bed clean converted to open bed when staff gets new admission

Occupied bed

a bed made while a person is in the bed usually when patient cannot get out of bed can be delegated to UAP/CNA made by changing soiled and cleaned and patient rolls over this "hump" of linens make sure to keep guard rails up

Captive ring

a circular shaft with two ends meeting inside a single ball. To remove, use very small needle nose type pliers. Insert them in the ring and gently separate the handles to widen the ring. As the ring ends spread open, the single ball is released. Then slide the shaft out of the piercing.

circular barbell

a circular shaft with two round knobs. Both may unscrew or only one. Unscrew the removable knob and carefully slide in a circular motion to remove from the piercing

Prince Albert Piercing

a curved barbell place in a piercing of the penis enters low portion of the head and exit through urethra

Curved barbell

a curved shaft with round knobs on each end. Only one knob will unscrew; the other is fixed. To remove, unscrew the movable knob and slide the curved shaft out of the piercing

Mottling

a purple blotching of the skin when circulation slows down significantly

Which technique should the nurse use to remove a curved barbell piercing? a. Unscrew the knob and slide the shaft out b. Use small needle-nose type pliers c. Gently separate the handles to widen the ring d. Apply Vaseline to remove the piercing

a. A curved barbell piercing has a curved shaft with round knobs on each end. Only one knob will unscrew. The other is fixed. To remove, unscrew the movable knob and slide the curved shaft out of the piercing.

Nail care

assess nails for: -discoloration -ridges -redness clean under the nails to remove material with *orangewood stick* always cut nails STRAIGHT ACROSS

The nurse is observing an unlicensed assistive personnel (UAP) provide denture care. Which action by the UAP would the nurse praise? a. Washes dentures in hot water b. Places metal, partial dentures in water only c. Gently removes dental implants d. Cleans denture over a metal sink

b. Avoid treating partial dentures containing metal parts with a cleaning tablet; instead, place them in water overnight.

Which of the following can occur if a client wears scented products in the hospital setting? a. heart attack b. asthma attack c. infections

b. asthma attacks -can trigger any respiratory diseases with perfumes, scented lotions, cologne, after shave

What does thick, yellow toenails indicate? a. viral infection b. fungal infection c. poor circulation d. pooling of the blood in extremities

b. fungal infection (page 256) prescription medications treat this advise client to see podiatrist

How do you clean a patient's glasses? a. with an alcohol swab pad and let air dry b. warm water and soft cloth c. warm water with paper towel/tissues

b. warm water and cloth paper towel and tissues will scratch the lenses do not use alcohol or soap on lenses

Semi-fowler's bed position

back is up, not knees for continuous tube feedings prevents aspirations when client does not wish to be flat

How to clean hearing aids:

behind the ear style: clean molds with warm soapy water and make sure to turn it off in the canal style: clean cloth and tap on hard surface to remove hard wax from screen/filter others: damp cloth and small tip to remove wax build up

How would the nurse explain the difference between a blanket bath and bag bath to a coworker? a. "One is heated and one is not." b. "One has a no-rinse skin cleanser and the other uses soap and water." c. "One has blanket, washcloths, and towels and the other has just washcloths." d. "One is in a bag and one is in a wooden container."

c. The blanket bath has a bath blanket, washcloth(s), and towels(s). The bag bath contains 12 to 15 washcloths.

Client ability considerations with bathing

can the client: -understand and follow directions -move and turn to assist bathing -tolerate the physical demands of a bath

Clean the prosthesis

clean with sterile water or saline irrigate the eye socket with eye irrigating solution small amount of mucous may gather in the socket

Why would a client be unable to complete ADLs

client might be weak, in pain, emotionally distraught, confused or lacking mobility. you would need to assist in their ADLs *partially or completely*

Why do you cut a client's nails straight across?

clipping the toenails deeply at the corners can lead to ingrown nails

Body piercings

common sites: nose, eyebrow, lip, tongue, nipples, navel and genitalia. -must be kept clean & prevent infections -sopa water and alcohol typically used to clean -asses for redness, swelling , pain, drainage from the site for potential infection -remove when interference with *surgery intubation for tongue piercing, MRI using magnets for metal, catheterization for genitalia* -kits available for removal

Which of the following baths are the most demanding physically for the client? *Select all that apply* a.Complete bed bath b.Assisted/help bath c.Partial bath d.Tub bath e. Shower f.Therapeutic baths g.Towel/blanket bath h.Bag bath

d. tub baths e. showers f. therapeutic baths explanation: these require the most effort due to client must be able to sit or stand (usually 5-5 minutes) as well as get in and out of tub or bath. *page 254*

Hearing Aids

electronic devices that are worn to correct a hearing loss

Reverse trendelenburg

elevated the client's head without bending at waist eg. when legs need to be kept starlight at the groin during cardiac catheterization

The nurse is giving a bath to a patient. In which order would the nurse proceed? 1 legs and feet 2 arms and upper body 3 back 4 face 5 eyes 6 perineal area 7 buttocks

eyes, face, arms and upper body, legs and feet, back, buttocks, and perineal area

Purpose of a draw sheet

keep bottom linen clean and dry increase risk of skin breakdown decrease comfort move helpless residents reduce friction and shearing

Fowler's bed position

knees elevated back is up eg. when client wants to sit up, watch TV, converse with visitors

The nurse is helping a patient turn over the "lump" when making the bed. Which action should the nurse take to help the patient turn? 1.Turn the patient toward the nurse. 2.Remove the pillow. 3.Lower the side rail. 4.Go to the other side of the bed.

option 1 Assist the patient to turn to the other side of the bed on which the nurse is standing.

Define self care

patient able to perform ADLs without assistance most hospital clients need some form of assistance

Define total care

patients are able to do very little or nothing for themselves

Why tuck top linen and blanket together?

prevents loosing of the top sheet when tucking blanket

How to assess early stage of skin breakdown in bony prominences

reddened area that does not return to normal color after pressure is removed

Perineal care for men

retract foreskin for uncircumcised clients circle motion cleaning from tip to glans repeat rinse and pat dry replace foreskin to prevent *constriction of circulation and possible edema/necrosis of glans penis* wash shaft and scrotum. rinse and pat dry

Barbells

round knobs screwed off and some are not removeable

Excoriation

scapes of the skin may be from scratching or from performing care

Maceration of the skin

softened skin due to continuous exposure to moisture -eg. under client's crevices like under breast and scrotum, in axilla, groin, between the toes, between the buttocks

Vertical barbell

straight shaft with knobs at ends when one is removed, you can pull out the shaft

Definition of hygiene

terms used to describe keeping oneself clean and well groomed

Define assisted care

the need of some assistance with ADls eg. needing another person to wash their legs, help with getting out of the tub/shower, needing someone to reach personal care items like bath basin with water

What is the purpose of the mitered corner in linens?

the purpose of this corner is to anchor the linens more firmly than if they were only tucked at the foot of the mattress

Define seborrhea

thick, oil scales on the scalp from overproduction of sebum -occurs in infants: called cradle cap

Hair functions

to keep the head from losing body heat by providing insulation

Perineal care for women

use bath blanket in diamond shape bend knees and feet flat wear gloves wash front to back to prevent e.coli infection in urethra/vagina damp cloth and apply soap/periwash use mitt spread labia clean far side, nearside, and middle last

Trendelenburg

very low blood pressure (shock) this returns blood back to brain and vital organs this is the preference for clients with breathing difficulty or head injury

Precautions with dentures

wear gloves put paper down to prevent breaks if it slips remove with gauze for better grip rock dentures to remove with ease adhesive can be applied if client desires cold water only do not dry denture when applying back to mouth

Importance of venous return

when the blood pools at the extremities, there is a higher risk for a blood clot formation -medical term for blood clot is *thrombus*

Unoccupied bed

when the client is out of the bed may be sitting in chair, doing therapy in a different unit, or getting diagnostic testing

What is plantar flexion and how do you prevent it?

when you tuck the linen, client's foot is pointed down causing plantar flexion. this results in pressure injuries and contributes to foot drop this means the foot remains in that position permanently this impairs their ability to walk again can be remedied by grasping top linens for 1-2 inches to make room for natural foot positions

Vasodilation in shower/bath causes what?

widening of the blood vessels this can lower a client's blood pressure result: client becomes light-headed or dizzy and can faint *stay with a client during their first shower or bath after a surgery or illness because of this fall risk* and you can delegate this to the UAP but have to tell them it is important to stay near

Types of care

- self care - assisted care - total care

Oral care for unconscious patient

-*MUST be careful to minimize any chance of aspiration of fluids. Position patient on either side with the bed FLAT so fluids can run out of the mouth instead of down the throat. keep a device for suction nearby* -it IS still necessary to give them oral care -assess mouth lesions and sordes -usually use 5 mL or less fluid -small paste with brush and use sponge to wipe mouth and teeth

Afternoon (p.m.) care

-After lunch -Patients may need assistance to be comfortable to rest to receive visitors -Assist the patient with toileting -Straighten the bed -Assist the patient to a position of comfort -Provide the patient's preference of oral fluids unless contraindicated

bedtime h.s. care

-Assist client to prepare for sleep -Assist with toileting -Offer client preferred oral fluids unless c/i -Brush teeth/remove dentures -Remove glasses and hearing aids -Give back massage -Place items within reach -Straighten room -Make sure there is a clear path to the restroom if the client is ambulatory -Straighten the linens and *extra blanket* if needed -*Dim lights/turn off and add nightlight*

morning care

-This is after breakfast -Assist for a bath -Toileting, oral care, back massage, shaving, hair care, change gowns -Sit client on the couch (if able to ambulate to change/straighten linens

Can routine care be delegated?

-Yes, but it your job to make sure it was completed. -You can delegate to UAP or CNA.

surgical bed

-a bed is made with top linens fanfolded to the side of th bed that is away from the door. -top and blanket are spread over the patientand tucked at the foot -from stretcher to bed

What is ADLs and some examples

-activities of daily living -eg. bathing, washing, styling hair, brushing, flossing, dressing and shaving

Shaving clients on blood thinner medications

-anticoagulants delay blood clotting -if client has a cut related to shaving, they can have excessive bleeding -*use electric razors* -move razor in circular motion -clean blade to prevent injury for the next time razor is used (remove head and brush blades then replace head)

Sweat gland function

-apocrine sweat glands -located in axilla and genital areas -sweat produced during stress and emotional situations *A for Axilla* -eccrine sweat glands -located everywhere especially in the palms of the hands, upper lip, and forehead -in response to heat and exercise -sweat remains on the skin and bacteria breaks it down to cause "body odor" *E for Everywhere*

Define hair care

-assess the client's scalp and hair root area -assess for lesions, tinea capitus, dandruff, seborrhea, lice, nits.

Nursing Responsibilities During Bathing

-assessing the skin for rashes, breaks in integrity, bruising, and lesions. -complete bath in timely manner -know signs of fatigue to assist or finish bath for them -intervene to save their energy by: a. use *terry cloth robe* after bath/shower to dry off b. use bench in shower c. use spray to wash client's body

Shaving a female client

-axilla and legs -may need help with plucking hairs on chin and upper lip -some cultures do not shave the legs

Hospital furniture

-both head and foot of bed can be elevated -areas under knees can be lifted to prevent sliding -mattress covered with water-repellant furniture and is firmer -usually rails of the bed are raised -over-bed table can contain mirror -bedside stand -empty everything when pt is discharged

Nurse-Patient Relationship

-build trust and rapport -demonstrate respect, preserve their modesty, show caring and compassionate feelings towards client -imagine how you want a nurse to treat your loved one

Define complete bed bath

-cannot get out of bed -use basin of water at bedside -all body parts washed -too sick to help-nurse does everything

Bathing related to sleep/comfort/relaxation

-cleanliness brings comfort, relaxation, easy to sleep/rest -sleep is important for healing and restoration of health -assess client for muscle tension in back/shoulders and give massage -talk/ease them about their care and concerns -if client does not feel welcome in their bed, they will not sleep with ease. clean their bed, remove wrinkles

Nail care for diabetics

-clients easily develop infections around the nails -look at toenails and fingernails -do *not* cut their nails ONLY file

Rules with bed bathing

-cover client with *bath blanket-large lightweight flannel blanket* to prevent exposure -fold washcloth to prevent *cold trailing edges* -wash from the cleanest to the dirtiest (bc you don't bring dirty material to the clean areas) -wash from distal to proximal -*wash the arm/leg that is away from you first* -change the water when it is dirty, soapy or cool. -*always* change water after cleaning feet, buttocks, rectal -some clients might not be able to bathe with tap water like postsurgical clients -perineal care during bed bath or after incontinent -some client would do their own perineal care

Denture care

-dentures are expensive -breakable if dropped -use cool water to clean bc hot water causes damage -place towel on sink to prevent dentures falling on hard surface -*store dentures overnight in a cup and water & add cleaning tablet if pt desires* -no cleaning tablet if dentures contain metal

Back massage

-during bath or evening care -stimulates circulation -*need to use lotion or oil* to prevent friction rubbing -need to massage muscles with sides of the thumbs -massage longer in tight areas like trapezius with stress/anxiety -lumbar and sacral area massage to prevent pressure injuries

Situations you would use artificial eye

-enucleated (completely removed) -blind globe (eye is intact but blind due to birth or disease)

Name the types of bed positions

-flat -fowler's -semi-fowler's -trendelenburg -reverse trendelenburg

Define special mouth care (pg 255)

-for clients with conditions needing more frequent care and assistance eg. NPO clients, have O2 mask or cannula, nasogastric/feeding tube, unconscious client -done *every 2 hours*

Flossing conscious client

-glide 6-10 inch piece -do not go into the gum line due to damage of the gums leading to bleeding

Hair, Nails, and Glands

-hair and nails are dead cells (appendages of the skin) -hair comes from root -matrix of hair root is where new cells are formed and produce *keratin* -when dead, they add length to hair

Client assistance need consideration in bathing

-important to encourage the client to do as much as possible within their limits -do not assume how much the client is able to tolerate the physical demand of self-care

Define towel/blanket bath

-in bed -commercially prepared or made by nurse -includes the following in a large bag: bath blanket washcloth(s) towel(s) -heated in *microwave* -replace bath blanket with heated one -massage client through the heated towel -heat cloths on: *face* -heat towels on: *back, buttocks and perineum*

Define assisted/help bath

-in bed or in chair -helps with what they can -if becomes tired, nurse finishes the rest of bath

Steps with rinse free hair cair

-involves shampoo and conditioner -warm the shampoo cap -high fowler's position -comb hair -apply shampoo and work through -remove cap and dry hair -comb and remove tangles -hair drier

Enucleated eye (completely removed)

-leaves only the socket -globe is implanted in the socket to restore eye shape: either attached to muscles or not

Define lice vs. nits

-lice: tiny parasites -nits: bumps on shaft of the hair/lice eggs -causes intense itching of the scalp due to lice burrow in to obtain nourishment -easily transmitted to others with close contact and cross contamination of objects -common in day care facilities -hair treatment 1-2 wks after initial treatment due to toxic shampoo

open bed

-made with top linens fan folded to the foot of the bed -client can easily get into the bed and pull them up

Patient room environment

-majority of time in pt unit.hospital room -private or semiprivate rooms -provide privacy when roommate is there -move client to another room if needed for talking about sensitive topics

Benefits of assisting clients' with ADLs

-making a deeper and more profound assessment of your client -forming a client-nurse bond and patient can confide in you about changes and concerns

home-health bathing

-may have to add adaptive equipment to prevent injury and facilitate bathing process -eg. rustproof chair in shower/tub, add hand held water spray

Hair care for African American clients

-natural hair can mat or tangle easily -combed and brushed daily -apply oil to hair and scalp -shampoo with cornrows or braids -cover hair with stocking cap and then shampoo through cap

Oral care for unconscious patient pt. 2

-natural reflex is to bite down -made padded tongue blade and tape in place -turn vertically to hold mouth open when you perform oral care

New environment for the client

-noise: keep hallway door closed, avoid shouting, keep any desirable background noises on like TV or white noise, stop alarms promptly, answer call lights -odors: remove bedpans, urinals, bedside commodes, emesis bins promptly, use spray to neutralize scents, and no perfumes bc it can trigger the client, remove food trays that are no desired/save for later, empty trash

Timing of bath

-not all patients want their bath in the morning -do not wait for the client to ask for a bath -do not make client take a bath at a specific time because it is easier for you -"would this be a good time to assist you with bathing or would you prefer i come back in an hour?"

Bathing provides opportunity for skin assessment

-observe redness, cracking, maceration -look for excoriation -assess temp of the skin -assess for skin break down at bony prominences

Comatose clients during bathing

-one of the last sensations to go is hearing and sensory -the sensory input of bathing is stimulating for the mind of a client who has no/some sensory deficits -assess pain and discomfort through grimaces, pulling, pushing hand, moaning or "ouch/stop"

Define partial bath

-only selected areas -limited movement so it is safe for pt with pain/nausea -usually is face,hands,axilla,buttocks, perineal or odor producing areas

Types of unoccupied beds

-open bed -surgical bed -closed bed

Define grooming

-oral care -hair care -applying deodorant -applying lotion -dressing gown on client -shaving -nail care -female client: makeup

When you would avoid bathing client with tap water

-post surgical -post sternotomies (open heart/open lung surgery) -impaired immune system order sterile water for client or use commercially prepared towel bath kit

Nail functions

-protects the ends of the fingers and toes to increase ability to pick up small objects with fingers -when you trim nails, you are cutting off solidified keratin cells

Environment for the client pt 2

-reduce clutter, do not move pt belongings without their permission, keep certain things in reach -equipment: keep pathways from the bed to the bathroom clear for the client to prevent falls, watch client with IV lines, remove cords out of the way

personal care in long-term care facility

-resident may bathe 2-3x per week -elderly skin is more fragile -if client is incontinent, provide frequent and thorough perineal care (reduce maceration) -requires application of lotion due to low sebum levels in skin causing dryness -keep environment warm because elderly chill easily

Bedmaking

-routine changes -change linens if soiled -options: unoccupied bed and occupied

Types of artificial eyes

-scleral cover shell (thick contact lens from opaque acrylic- painted to look like other eye) and is compatible with blind globe and implanted globe. it will move along with the other eye when globe is attached to the muscles. -ocular prosthesis (entire eye custom made to fit and hand painted to match the other eye and this type *does not move*)

Sebaceous glands function

-secretes sebum (oil) -provides skin and hair lubrication -skin is first line of defense and sebum contributes by keeping skin moist and does not let skin get cry and cracking -if skin lacks sebum, pathogens have an easier way of entering through first line -add lotion to your client with dry skin

Shaving a male client

-shave 2-3 days max -shave in direction of hair growth to reduce razor burn and "ingrown whiskers" -assess for eczema, lesions, ingrown whiskers -use moist washcloth on face 1-3 minutes to soften beard and lift whiskers -don gloves -shave down in face/upper lip and shave up in neck -rinse blade to avoid clogging -electric razor is circular motion

Define bag bath

-similar to "towel bath" = *12-15 washcloths* -washcloths are saturated with no-rinse skin cleanser -heated in microwave as well -one washcloth per area then discard -disposable version is expensive (per textbook) -can be duplicated with zip lock bag

Define shower

-sit on bench or shower chair -turn off spray when applying soap/shampoo -do not chill client -not hard to wash hair this way

Oral care for conscious patient

-small amount of toothpaste on brush -brush at 45 degree angle to gums -move in small circles inside and outside of teeth -back and forth motion on chewing surfaces -remain close due to choking hazard

Nail care steps from 15.8 Skills

-soak hand and feet 5-20 minutes to soften nails -you do push back cuticles -apply skin lotion after soaking, cutting and cleaning under nail -with toes, look for maceration between the toes -no lotion between the toes

Preferences when it comes to bathing a client

-timing -type of bath -culture -abilities and assistance needed additionally: -is client able to tolerate the inhalation of steam?

Shampooing hair

-try to do in bath or shower -protect the eyes with head tilted back -use special shampoo without rinse needed & cleans oils from hair after brushing through product -warm rinse-free cap in microwave -touch cap to wrist to test temp before applying to client's head

Define tub bath

-tub -may/may not have whirlpool -hard to sit and get out -fall/slip risk -some have handle bars at the sides to prevent injury

Culture consideration with bathing

-usually female-female and male-male -ask patient if it is okay, bc some don't mind -if your coworker does your bathing on the same sex patient, offer to bathe one of their clients -family members can be present in time of bathing -sometimes bathing is a weekly thing for some cultures

Define therapeutic baths

-usually for super specific reason -whirlpool action -to remove infected/necrotic tissue from wound -medication soak to smooth itching/skin disorders

Increasing client circulation during bathing

-venous return -assess blood pooling at extremities -assess mottling -give opportunity to flex joint and extremities to stimulate circulation and aid joint stiffness

Cleaning skin during bathing

-washing removes dirt, bacterial, dead skin cells, sweat and odors from the client -smell fresh -helps prevent infections

When should bathing not be delegated to a UAP/CNA?

-when the client is unstable -when you need more information on the skin condition of the client -when you need to assess the client's capability to assist with personal care -when you need to develop/strengthen patient-nurse relationship

Self-esteem related to bathing

-you smell good, you feel good -style their hair at their preference NOT YOURS -assist males with facial hair (2-3 days post shave is uncomfy) -assist female with leg hair/axilla and makeup -assess how treatment, illness, injury has affected their view about themselves -eg. woman with mastectomy (removal of breast tissue r/t cancer diagnosis) does not feel like a real woman anymore -eg. man states his facial scar will scare children away

Venous return

-you wash from distal to proximal during bathing -aiding blood to return back to the heart from the extremities -from tip to trunk of the body

The nurse is contributing to a staff education program about hygiene care. Which information should the nurse recommend including about the benefits of bathing a patient? Select all that apply. 1. Removes debris and dead cells 2.Allows for skin inspection 3.Impedes blood flow 4.Increases sensory input 5.Improves communication

1, 2, 4, 5 3 is incorrect because- Bathing increases circulation (blood flow).

The nurse is caring for an older adult patient who is weak and incontinent of urine. The patient wears a hearing aid, dentures, and glasses. Which actions would the nurse take when caring for this patient? Select all that apply. 1.Assist patient with a bed bath 2.Clean patient's glasses with a paper towel 3.Brush the top and bottom of the lower and upper dentures 4.Observe for macerated areas in the groin 5.Check the scalp for nits

1, 3, 4 Cleaning glasses with a paper towel can scratch the glasses. Water and a soft cloth should be used. The patient does not have lice, so nits, or eggs, will not be present. page 263

Skill 15. 1 Complete bed bath

1. activity orders and position restrictions 2. ability to turn, follow instructions, remain in one position 3. determine need of assistance 4. status on pain, fatigue, SOB, cultural issues 5. gather: basin, towels, washcloths, soap, bath blanket, clean gown/pj, laundry bag, clean linens for occupied bed change

Skill 15. 1 Complete bed bath pt 2

1. asses pt and room temp, privacy, offer bedpan/urinal 2. fill basin 2/3 with 105F water and test with inner wrist 3. place basin on over bed table and place parallel to bed 4. lower side rail, assist moving pt toward you 5. remove blanket and spread bath blanket over top sheet and lower top sheet when pt holds bath blanket 6. untie gown and remove careful if with IV (do not remove IV bc infection) 7. towel under head to protect pillow 8. dampen cloth and make into mitt

Inserting hearing aid steps:

1. check battery by turning on and hearing it whistle when full volume 2. if you do not hear whistle, you need to check/replace battery 3. turn off hearing aid and lower the volume 4. insert the hearing aid into the ear and adjust the volume as needed

Listed order of sheets starting from mattress

1. mattress cover 2. fitted sheet 3. draw sheet/turn sheet aligned with the shoulders and bottom is aligned with the client's knees 4. under the mattress and springs and tightly pull down to the bottom of the bed 5. incontinence pad 6. top linen with seams away from client 7. apply blanket and both get tucked *together* 8. form a mitered corner (slanted) 45 degrees 9. cuff the top sheet over the blanket 10. untuck if needed to prevent drop foot

Skill 15. 1 Complete bed bath pt 3

1. one corner of mit from inner to outer eyes 2. other corner of mit from opposite inner eye to outer 3. no soap on the face, wash neck and ears then pat dry 4. towel under head under arm farthest to you 5. finger to axilla in long strokes with arm support to prevent injury then pat dry with towel underneath 6. repeat with other arm and apply deodorant

Skill 15. 1 Complete bed bath pt 4

1. place towel on chest and clean under breasts and dry after 2. expose abdomen and wash and dry 3. expose far leg from ankle to hip long strokes 4. bend knee and place foot in basin and allow to soak to soften dead skin buildup and easy cleaning btwn toes then pat dry 5. repeat with leg and foot near you 6. clean the back with towel along back 7. perform back massage 8. wash rectal area with gloves 9. if there is poop, clean with toilet paper then wash cloth 10. change water for perineal care & perform care 11. change gloves and wash hands 12. new gown or pj 13. change linens 14. document, eval condition, how it was tolerated

How to remove eye prosthesis

1. small suction cup on a hollow handle is used to move the prosthesis to and from the orbit 2. while squeezing the suction handle of the cup, place it on the eye and release the handle 3. it will remain attached to the prosthesis

The nurse grasps the top linen and spread at a patient's foot and pulls up about 2 inches. What is the purpose of the nurse's action? 1.To prevent footdrop 2.To enhance plantar flexion 3.To promote dorsiflexion 4.To reduce sordes

1. to prevent footdrop Tucking the top linens under the foot of the mattress can result in pressure injuries on the toes or contribute to footdrop, where the foot remains in a permanent state of plantar flexion. This is also uncomfortable for the patient and can be easily remedied by grasping the top linens above the patient's toes and pulling upward an inch or 2, making room for the natural foot position.

Remove a hearing aid steps:

1. turn off hearing aid 2. turn the ear mold slightly to nose and lift out 3. store aid in case or moisture-controlled container

Replace the artificial eye:

1. wash hands 2. dip the suction cup in saline 3. squeeze and attach to iris of the prosthesis 4. stop squeezing handle of the suction cup 5. ensure that prosthesis is wet and lubricated 6. lift the upper eyelid making a gap between it and the globe 7. slide the top of the prosthesis under upper eyelid and release the lid 8. pull lower lid and slide prosthesis behind lower lid 9. release the lower lid 10. squeeze the handle of the suction cup and it will release the prosthesis 11. return suction cup into storage

Remove prosthesis from implanted globe (attached to eye muscles):

1. wash hands and don gloves 2. dip the end of the suction cup in saline 3. squeeze the suction cup and place on the iris of the prosthesis 4. stop squeezing 5. raise the upper eyelid 6. tilt the prosthesis out from under the upper eyelid 7. lift it out *with natural blind globe, do not touch or press on the cornea (super sensitive)*

Contact lenses

1. wash hands and don gloves 2. pull lower lid and place finger on upper lip and apply gentle but firm pressure 3. ask the patient to blink 4. hand lenses pop between fingers soft lenses wrinkle off the eye 5. if it does not come off, you pull the contact down from the iris (colored portion), grasp, and remove 6. place correctly left lense on the left of the lense case, etc. 7. fill wells with normal saline or special solution. -do not pull from iris due to lense is able to scratch the cornea

Remove prosthesis without implanted globe:

1. wash hands and wear gloves 2. dip the end of the suction cup in saline 3. lift upper eyelid 4. squeeze suction cup and place on iris 5. stop squeezing 6. use the handle of the suction cup to lift it out of the socket

The nurse is checking the bed an unlicensed assistive personnel (UAP) made. Which finding indicates the UAP made the bed comfortable for a patient? 1.Cuffed the spread over the top sheet 2.Left a few wrinkles in the bottom fitted sheet 3.Positioned the draw sheet horizontally at the patient's shoulders and the patient's knees 4.Formed a mitered corner for the top sheet and then for the blanket

1.Cuffed the spread over the top sheet Whether making an occupied or unoccupied bed, it is important to cuff the top sheet over the blanket or spread to prevent rough fabric edges from irritating the skin of the patient's face and neck.

The nurse made an unoccupied, open bed. Which type of bed did the nurse make? 1.Patient in bed with covers pulled up over chest 2.Empty bed has top linens fanfolded to the foot of the bed 3.Patient in bed with covers pulled to the side 4.Empty bed has top linens fanfolded to the side of the bed

2. empty bed has top linens to the foot of the bed 4 is incorrect because- a surgical bed is made with the top linens fan folded to the side of the bed (the side away from the door).

Which technique should the nurse use when providing a back massage to a patient? 1.Use fingertips to massage the neck 2.Use the side of the thumbs to massage muscles 3.Use alcohol gel to massage the skin 4.Use light pressure on patients with broken ribs

2. use the side of the thumbs to massage muscles

The nurse is planning patient care task assignments for a.m. care. Which task would be most appropriate to assign to an unlicensed assistive personnel (UAP)? 1.Offer a warm, wet cloth before breakfast 2.Provide denture care 3.Remove hearing aid 4.Dim the lights in the room

2.Provide denture care Oral care is a component of a.m. care and can be assigned to a UAP.

The nurse is caring for a patient who has a catheter. How should the nurse clean the catheter during the bath? 1.Use betadine to clean the catheter and perineum. 2.Hold the catheter taut while washing. 3.Start at the insertion site and clean down the tube. 4.Gently pull the catheter about ½ inch while cleaning.

3. Gently wipe the catheter from the insertion site away from the body. You would not clean toward the insertion area because that is dirty to clean wipe

The nurse is giving a patient a back massage. In which area should the nurse use thumbs? 1.Lower back 2.Neck to shoulders 3.Around the scapula 4.Over the vertebrae

3. around the scapula Use the sides of the thumbs, alternating between the left and right thumb, to massage around each scapula. for the neck to shoulders: Massage from the neck to the shoulder, keeping fingers flat and sliding them down the side of the neck and along the trapezius muscle. Repeat on the other side. for the lower back-Massage over the low back in small circles using the flat part of the fingers. -do not massage directly over the vertebrae to prevent possible injury

A patient is sitting in the chair while the nurse makes the bed. The nurse has just finished tucking in the clean fitted sheet and draw sheet. What should the nurse do next? 1.Pull the side rail up. 2.Walk around to the other side of the bed. 3.Unfold the top sheet to cover half of the bed. 4.Prepare the pillow.

3. unfold the top sheet to cover half the bed Unfold the top sheet to cover the half of the mattress closest to the nurse. This keeps the nurse from walking around the bed several times during the procedure, conserving energy.

The nurse is providing eye care to several different patients. Which technique should the nurse use? 1.Clean patient's glasses with tissue 2.Slide soft contact lenses with firm pressure off the iris 3.Tilt the ocular prosthesis out from under the upper lid 4.Wet eye prosthesis with saline when reinserting

4 Ensure that the prosthesis is wet with saline or lubricating solution when replacing the artificial eye.

The nurse is making a patient's bed. Which sequence would the nurse follow? 1. Fanfold clean fitted sheet and draw sheet toward patient 2. Change pillowcase 3. Roll soiled linens, place in hamper, pull clean linens tightly 4. Fold dirty linens toward the patient and tuck next to patient 5. Turn patient over lump 6. Put on top sheet and blanket/spread

4. Fold dirty linens toward the patient and tuck next to patient 1. Fanfold clean fitted sheet and draw sheet toward patient 5. Turn patient over lump 3. Roll soiled linens, place in hamper, pull clean linens tightly 6. Put on top sheet and blanket/spread 2. Change pillowcase

The nurse is checking a mitered corner an unlicensed assistive personnel (UAP) made. At which degree angle should the mitered corner be hanging? Record answer as a whole number.

45 The nurse should have a tight, slanted corner at 45 degrees from the end of the mattress for a correctly mitered corner.

Which of the following statements are true? Select all that apply. a. The nurse provides oral care for a client to assess mouth problems b. The nurse provides oral care for a client to look for decay, broken or missing teeth c. The nurse provides oral care for a client to observe bleeding gums, or ulcerations of the mucosa d. The nurse provides oral care for a client to assess coating of the tongue

All of the above. Real questions won't be that easy though

Antibacterial vs. Non-antibacterial Soap

Antibacterial soap contains *triclosan* which is prohibited. Only in hospital for MRSA with 2% concentration

early AM care

Assist with toileting Give client warm, wet washcloth to hands and face Assist with oral care if desired Provide fresh water if there is no NPO status

Full or partial dentures are known as ____.

Bridge

List the type of baths (8)

Complete bed bath Assisted/help bath Partial bath Tub bath Shower Therapeutic baths Towel/blanket bath Bag bath

Wrinkles in the bed can cause what?

Discomfort Pressure injuries

Flat bed position

Entire bed frame horizontally parallel with floor Used for resting, sleeping, after certain procedures like lumbar puncture and back surgery

Why do you file nails for a client with diabetes? Why do you not cut?

Filing prevents accidentally clipping tissue. Diabetics have poor circulation, so a cut can lead to severe infection and *amputation*.

What does it mean to find large amounts of thick yellow or green mucus in the eye?

Infection!

Why do you cuff the top sheet of the bed?

It is *important* so that rough edges do not irritate the skin of the client's face or neck

Would you use lemon glycerin swabs for oral care for a client who is unconscious? Yes or no.

NO! Lemon glycerin swabs cause a client's oral mucosa to DRY. Long term use: can cause damage to tooth enamel

True or false: Tinea capitus is a fungal infection, presenting with open lesions with surrounding hair loss to indicate ringworms.

TRUE plus, this type of fungal infection can spread to another part of the body and from one person to another. (page 256)

True or false: Sordes is a term for dried mouth secretions.

True!

True or false: Leukoplakia are white patches on the tongue/oral mucosa and are related to cancer.

True- they can be precancerous lesions.