Unit 8, Chapter 40 - Hygiene
Outline a basic hygiene care schedule.
- make instruction relevant on the basis of your assessment of the patient's knowledge, motivation, preferences and health beliefs - adapt instruction to the patient's personal bathing facilities and resources - teach patients ways to avoid injury - reinforce infection control practices Early morning care - AM care includes toileting, washing the patient's hands and face and helping with oral care. Routine morning care - after breakfast, offer toileting, provide full or partial bath or shower, including perineal care and oral, foot, nail and hair care; give a back rub; change a patient's clothing; change bed linens; straighten a patient's bedside unit and room Afternoon care - washing hands and face, helping with oral care, toileting and straightening bed linens Evening, or hour-before sleep, care - offer personal hygiene care that helps patients relax and promotes sleep; change soiled bed linens, gowns or pajamas; help patient wash face and hands; provide oral hygiene; give back massage; toileting Pg. 836 Box 40-4
The nurse is caring for a patient who is immobile. The nurse is aware that the patient is at risk for Impaired skin integrity because a. Pressure reduces circulation to affected tissue. b. Patients with limited caloric intake develop thicker skin. c. Inadequate blood flow leads to decreased tissue ischemia. d. Local nerve damage leads to pain sensation.
ANS: A Body parts exposed to pressure have reduced circulation to affected tissue. Patients with limited caloric and protein intake develop thinner, less elastic skin with loss of subcutaneous tissue. Inadequate blood flow causes ischemia and breakdown. Patients with paralysis, circulatory insufficiency, or local nerve damage are unable to sense an injury to the skin.
Scaling of the scalp accompanied by itching is known as a. Dandruff. b. Pediculosis. c. Alopecia. d. Ticks.
ANS: A Dandruff is scaling of the scalp that is accompanied by itching. Pediculosis (lice) consists of tiny, grayish-white parasite insects that infest mammals. Alopecia is hair loss or balding. Ticks are small, gray-brown parasites that burrow into the skin and suck blood.
The nurse is caring for a patient who refuses "AM care." When asked why, the patient tells the nurse that she always bathes in the evening. The nurse should a. Defer the bath until evening and pass on the information to the next shift. b. Tell the patient that she must bathe because that is the "normal" routine. c. Explain to the patient the importance of maintaining morning hygiene practices. d. Cancel hygiene for the day and attempt again in the morning.
ANS: A Each patient has individual desires and preferences about when to bathe, shave, and perform hair care. Knowing the patient's personal preferences assists the nurse in providing individualized care for the patient. Hygiene care is never routine. Maintaining individual personal preferences is important unless new hygiene practices are indicated by an illness or condition. Cancelling hygiene is not an option. Adapting practices to meet individual needs is required. No evidence demonstrates greater benefit with AM or PM hygiene.
The nurse is caring for an unresponsive patient who has a nasogastric tube in place for continuous tube feedings. The nurse assesses the patient's oral hygiene because good oral hygiene a. Helps prevent gingivitis. b. May cause glossitis. c. May lead to halitosis. d. Causes tongue coating.
ANS: A Early identification of poor oral hygiene practices and common oral problems reduces the risk for gum disease and dental caries. Patients frequently develop common oral problems as a result of inadequate oral care or as a consequence of disease (e.g., oral malignancy) or as a side effect of treatments such as radiation and chemotherapy. These problems include receding gum tissue, inflamed gums (gingivitis), a coated tongue, glossitis (inflamed tongue), discolored teeth (particularly along gum margins), dental caries, missing teeth, and halitosis (foul-smelling breath).
When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. The nurse is aware that this condition is caused by a. Fungi. b. Nail polish. c. Friction. d. Nail polish remover.
ANS: A Inflammatory lesions and fungus of the nail bed cause thickened, horny nails that separate from the nail bed. Ask women whether they frequently polish their nails and use polish remover because chemicals in these products cause excessive nail dryness. Friction and pressure from ill-fitting or loose shoes causes keratosis (corns). It is seen mainly on or between toes, over bony prominences.
A number of factors influence a patient's personal preferences for hygiene. Because of this, it is important for the nurse to realize that.. a. No two individuals perform hygiene in the same manner. b. It is important to standardize a patient's hygienic practices. c. Hygiene care is always routine and expected. d. Hygiene is not the time to learn about patient needs.
ANS: A No two individuals perform hygiene in the same manner; it is important to individualize the patient's care based on knowing about the patient's unique hygiene practices and preferences. Hygiene care is never routine; this care requires intimate contact with the patient and communication skills to promote the therapeutic relationship. In addition, during hygiene, the nurse should take time to learn about the patient's health promotion practices and needs, emotional needs, and health care education needs.
The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. The nurse realizes that patients with these conditions a. Have decreased pain sensation and increased risk of skin impairment. b. Are at decreased risk of developing infection due to urinary pH level. c. Also have decreased caloric intake, which results in accelerated wound healing. d. Have impaired venous return, allowing for greater circulation and less breakdown.
ANS: A Patients with paralysis, circulatory insufficiency, or local nerve damage are unable to sense an injury to the skin. The presence of perspiration, urine, watery fecal material, and wound drainage on the skin results in breakdown and infection. Patients with limited caloric and protein intake develop thinner, less elastic skin, with loss of subcutaneous tissue. This results in impaired or delayed wound healing. Impaired venous return decreases circulation to the extremities. Inadequate blood flow causes ischemia and breakdown.
The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. She does this for which of the following reasons? a. Washbasins can harbor gram-negative organisms. b. Bag baths use soaps that enhance cleansing. c. Bag baths do not contain emollients. d. Bag baths increase skin flaking and scaling.
ANS: A When washbasins are not cleaned and dried completely after use, the risk of contamination by gram-negative organisms is introduced. Successive uses of the washbasin cause the patient's skin to harbor more gram-negative organisms. Bag baths do not contain soap. Instead, they contain a no-rinse surfactant, a humectant to trap moisture, and an emollient that significantly reduces overall skin dryness, especially skin flaking and scaling.
The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. His driver's license states that he needs glasses to operate a motor vehicle, but no glasses were brought in with the patient. The nurse should a. Assume that the glasses were lost during the accident. b. Stand to the side of the patient's eye and observe the cornea. c. Assume that the patient was not wearing glasses while driving. d. Assume that the ambulance personnel have them.
ANS: B An important aspect of an eye examination is to determine if the patient wears contact lenses, especially in patients who are unresponsive. To determine whether a contact lens is present, stand to the side of the patient's eye and observe the cornea for the presence of a soft or rigid lens. It is also important to observe the sclera to detect the presence of a lens that has shifted off the cornea. An undetected lens causes severe corneal injury when left in place too long. Never assume that glasses were lost or were not worn. Contacting ambulance personnel takes time. Examine the eyes.
The patient is diagnosed with athlete's foot (tinea pedis). The patient says that she is relieved because it is only athlete's foot, and it can be treated easily. The nurse explains that athlete's foot is a. Generally isolated to the feet and never recurs. b. Contagious and frequently recurs. c. Caused by the papillomavirus. d. Treated with salicylic acid or electrodesiccation.
ANS: B Athlete's foot spreads to other body parts, especially the hands. It is contagious and frequently recurs. It is caused by a fungus, not the papillomavirus, and is treated with applications of griseofulvin, miconazole, or tolnaftate. It is not treated with salicylic acid or electrodesiccation. Those are treatments for plantar warts.
The nurse is caring for an elderly patient with Alzheimer's disease who is ambulatory but requires total assistance with his activities of daily living (ADLs). The nurse notices that his skin is dry and wrinkled. The nurse should a. Make sure that the patient is receiving daily baths. b. Reduce the number of baths per week if possible. c. Be aware that sweat glands become more active with aging. d. Be sure that the patient is using soap with his bath.
ANS: B Decreasing the number of baths per week may help prevent further drying of the skin. As people age, the skin loses its resiliency and moisture, and sebaceous and sweat glands become less active. Daily bathing as well as bathing with water that is too hot or soap that is harsh causes the skin to become excessively dry.
Social groups influence hygiene preferences and practices, including the type of hygienic products used and the nature and frequency of personal care. Which of the following developmental stages is most likely to be influenced by family customs? a. Adolescent b. Toddler c. Adult d. Older adult
ANS: B During childhood, family customs influence hygiene. As children enter their adolescent years, peer group behavior often influences personal hygiene. During the adult years, involvement with friends and work groups shapes the expectations people have about their personal appearance. Some older adults' hygiene practices change because of living conditions and available resources.
The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. The term for "bad breath" is a. Alopecia. b. Halitosis. c. Dental caries. d. Neuropathy.
ANS: B Halitosis is the term for "bad breath." Alopecia indicates hair loss. Dental caries are cavities in the teeth. Neuropathy is a degeneration of peripheral nerves leading to loss of sensation in the extremities.
The nurse is caring for a patient who has head lice (pediculosis capitis). The nurse knows that in treating this condition, one must understand that a. Products containing lindane are most effective. b. Head lice may spread to furniture and other people. c. Treatment must be repeated in 7 to 10 days. d. Manual removal is not a realistic option as treatment.
ANS: B Head lice are difficult to remove and spread to furniture and other people if not treated. Caution against use of products containing lindane because the ingredient is toxic and is known to cause adverse reactions. Treatments need to be repeated 12 to 24 hours after the initial treatment. Manual removal is the best option when treatment has failed.
The nurse is bathing a patient and notices movement in the patient's hair. The nurse should a. Ignore the movement and continue. b. Use gloves or a tongue blade to inspect the hair. c. Examine the hair without gloves to make picking lice easier. d. Shave the hair off of the patient's head.
ANS: B In community health and home care settings, it is particularly important to inspect the hair for lice so appropriate hygienic treatment can be provided. Suspicions cannot be ignored. If pediculosis capitis (head lice) is suspected, the nurse must protect himself/herself against self-infestations by handwashing and by using gloves or tongue blades to inspect the patient's hair. Shaving hair off affected areas is the treatment for pediculosis pubis (crab lice) and is rarely used for head lice.
When providing the patient with a complete bed bath using soap and water (not a bag bath), it is important to a. Use alkaline soaps to help prevent infection. b. Towel dry completely to prevent maceration. c. Use soap liberally when cleansing the eyes. d. Cleanse the eye from outer canthus to inner canthus.
ANS: B Moisture and sediment that collect in skinfolds predispose skin to maceration. Towel dry to prevent maceration. Soap irritates the eyes. Use of separate sections of the mitt reduces infection transmission. Bathing the eye from inner to outer canthus prevents secretions from entering the nasolacrimal duct. Alkaline soap residue is irritating to skin and can decrease the normal protectiveness of acid pH.
14. Of the following disorders, which is caused by a virus? a. Corns b. Plantar warts c. Athlete's foot d. Callus
ANS: B Plantar warts appear on the sole of the foot and are due to the papillomavirus. Corns are caused by friction and pressure from ill-fitting or loose shoes. Athlete's foot (tinea pedis) is a fungal infection. A callus is caused by local friction or pressure.
The nurse is caring for a patient who has multiple ticks on her legs and body. To rid the patient of ticks, the nurse should a. Burn the ticks in an ashtray once removed. b. Use blunt tweezers and pull upward with steady pressure. c. Allow the ticks to drop off by themselves. d. Use products containing lindane to kill the ticks.
ANS: B Using blunt tweezers, grasp the tick as close to the head as possible and pull upward with even, steady pressure. Hold until the tick pulls out, usually for about 3 to 4 minutes. Save the tick in a plastic bag, and put it in the freezer if necessary to identify the type of tick. Because ticks transmit several diseases to people, they must be removed. Allowing them to drop off by themselves is not an option. Lindane is an ingredient that was used in treatment for pediculosis capitis (head lice); it should no longer be used because the ingredient is toxic and is known to cause adverse reactions.
In examining a patient for pediculosis capitis (head lice), the nurse would expect to find a. Grayish-white parasites with red legs. b. Pustules or bites behind ears and at the hairline. c. Balding patches in periphery of the hairline. d. Brittle and broken hair.
ANS: B With head lice, the parasite is on the scalp attached to hair stands. Bites or pustules may be observed behind the ears and at the hairline. Grayish-white parasites with red legs are pediculosis pubis (crab lice), not head lice, and are found in pubic hair. Alopecia (hair loss) is found in all races, with brittle and broken hair and balding patchiness in the periphery of the hairline.
Successful critical thinking requires synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards. Once the assessment has been done, it is important for the nurse to understand that a. The nursing diagnoses never change. b. The patient's condition never changes. c. Critical thinking is ongoing. d. Hygiene needs to become a simple routine.
ANS: C A patient's condition is always changing, requiring ongoing critical thinking and changing of nursing diagnoses. Because hygienic care is so important for a patient to feel comfortable, refreshed, and renewed, the nurse should avoid making hygiene care a simple routine.
The nurse is caring for a patient who has undergone external fixation of a broken leg and has a cast in place. To prevent skin impairment, the nurse should a. Not allow the patient to turn in bed because that may lead to redislocation of the leg. b. Restrict the patient's dietary intake to reduce the number of times on the bedpan. c. Assess all surfaces exposed to the cast for pressure areas. d. Keep the patient's blood pressure low to prevent overperfusion of tissue.
ANS: C Assess all surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopedic braces. An external device applied to or around the skin exerts pressure or friction on the skin, leading to skin impairment. When restricted from moving, dependent body parts are exposed to pressure that reduces circulation to affected tissues. Know which patients require assistance to turn and change positions. Patients with limited caloric and protein intake develop impaired or delayed wound healing. Keeping the blood pressure artificially low may decrease arterial blood supply, leading to ischemia and breakdown.
In providing perineal care to a female patient, the nurse should wash a. Upward from rectum to pubic area. b. From back to front. c. From pubic area to rectum. d. In a circular motion.
ANS: C Cleansing from pubic area to rectum (front to back) reduces the transfer of microorganisms to the urinary meatus and decreases the risk of urinary tract infection. Cleansing from rectum to pubic area or back to front increases the risk of urinary tract infection. Circular motions are used in male perineal care.
The nurse is teaching the patient about flossing and oral hygiene. The nurse teaches the patient that a. Flossing needs to be done at least three times a day. b. To prevent bleeding, the patient should use waxed floss. c. Flossing removes plaque and tartar from the teeth. d. Applying toothpaste to the teeth before flossing is harmful.
ANS: C Dental flossing removes plaque and tartar between teeth. To prevent bleeding, the patient should use unwaxed floss. Flossing once a day is sufficient. If toothpaste is applied to the teeth before flossing, fluoride will come in direct contact with tooth surfaces, aiding in cavity prevention.
3. The patient has been diagnosed with diabetes for the past 12 years. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about his hygiene habits, the patient tells the nurse that baths are taken once a week where he comes from, although he takes a sponge bath every other day. To provide ultimate care for this patient, the nurse understands that a. Personal preferences determine hygiene practices and are unchangeable. b. Patients who appear unkempt place little importance on hygiene practices. c. The patient's illness may require teaching of new hygiene practices. d. All cultures value cleanliness with the same degree of importance.
ANS: C Each patient has individual desires and preferences about when to bathe, shave, and perform hair care. However, they are not unchangeable. In addition, the nurse must assist the patient in developing new hygiene practices when indicated by an illness or condition. For example, the nurse will need to teach a patient with diabetes proper foot hygiene. Patients who appear unkempt often need further assessment regarding their ability to participate in daily hygiene. Patients with certain types of physical limitations or disabilities often lack the physical energy and dexterity to perform hygienic care. Culturally, maintaining cleanliness does not hold the
The patient is diagnosed with pediculosis capitis (head lice) and was treated upon admission and was re-treated 24 hours later, yet the patient is still infested. The nurse should next a. Re-treat the patient with a medicated shampoo for eliminating lice. b. Use a product containing lindane to get rid of the lice. c. Manually remove the lice using a fine-toothed comb. d. Have the patient bathe or shower thoroughly.
ANS: C Manual removal is the best option when treatment has failed. Re-treating with a medicated shampoo may lead to adverse reactions and should not be done without consulting the care provider. Products containing lindane should not be used because the ingredient is toxic and is known to cause adverse reactions. Although bathing or showering is a good idea, this is usually considered a treatment for pediculosis corporis (body lice), not pediculosis capitis (head lice).
The female nurse is caring for a male patient who is uncircumcised but not ambulatory, although he has full function of arms and hands. The nurse is providing the patient with a partial bed bath. Perineal care for this patient a. Is not necessary because he is not circumcised. b. Should be postponed because it may cause him embarrassment. c. Should be done by the patient. d. Should be done by the nurse.
ANS: C Patients most in need of perineal care are those at greatest risk for acquiring an infection such as uncircumcised males. If a patient is able to perform perineal self-care, encourage this independence. Embarrassment should not cause the nurse to overlook the patient's hygiene needs. The nurse should provide this care only if the patient is unable to do so.
The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). In doing so, the nurse should a. Use one towel for the entire bath. b. Dry the skin with a towel. c. Allow the skin to air dry. d. Not use a bath blanket or towel.
ANS: C The nurse should allow the skin to air dry for 30 seconds. Drying the skin with a towel removes the emollient that is left behind after the water/cleanser solution evaporates. It is permissible to lightly cover the patient with a bath blanket or towel to prevent chilling. The cleansing pack contains eight to ten pre-moistened towels for cleansing. Use a single towel for each general body part cleansed.
In providing oral care to an unconscious patient, it is important for the nurse to a. Moisten the mouth using lemon-glycerin sponges. b. Hold the patient's mouth open with his or her fingers. c. Rinse the mouth and immediately suction the oral cavity. d. Use foam swabs to help remove plaque.
ANS: C When providing oral hygiene to an unconscious patient, the nurse needs to protect him or her from choking and aspiration. Have two nurses provide care. One nurse does the actual cleaning, and the other caregiver removes secretions with suction equipment. The nurse can delegate nursing assistive personnel to participate. Some agencies use equipment that combines a mouth swab with the suction device. This device can be used safely by one nurse to provide oral care. Commercially made foam swabs are ineffective in removing plaque. Do not use lemon-glycerin sponges because they dry mucous membranes and erode tooth enamel. While cleansing the oral cavity, use a small oral airway or a padded tongue blade to hold the mouth open. Never use your fingers to hold the patient's mouth open. A human bite contains multiple pathogenic microorganisms.
A self-sufficient bedridden patient unable to reach all body parts needs which type of bath? a. Complete bed bath b. Bag bath c. Sponge bath d. Partial bed bath
ANS: D A partial bath consists of washing body parts that the patient cannot reach, including the back, and providing a back rub. Dependent patients in need of partial hygiene or self-sufficient bedridden patients who are unable to reach all body parts receive a partial bed bath. Complete bed baths are administered to totally dependent patients in bed. The bag bath contains several soft, nonwoven cotton cloths that are pre-moistened in a solution of no-rinse surfactant cleanser and emollient. It can be used for any patient. The sponge bath involves bathing from a bath basin or a sink with the patient sitting in a chair.
After the patient's bath, the nurse should a. Not offer a backrub because it is not therapeutic. b. Routinely give backrubs of 2 minutes or less. c. Assume that all patients need backrubs after their bath. d. Not offer a backrub for 48 hours after coronary artery bypass surgery.
ANS: D Consult the medical record for any contraindications to a massage (e.g., fractured ribs, burns, heart surgery). A backrub of 3 minutes' duration actually enhances patient comfort and relaxation and thus is very therapeutic. It is important to ask whether a patient would like a backrub because some individuals dislike physical contact.
When providing hygiene for an elderly patient, it is important for the nurse to closely assess the skin. This is because as the patient ages a. Skin becomes more resilient. b. Sweat glands become more active. c. Skin becomes less subject to bruising. d. Less frequent bathing may be required.
ANS: D Daily bathing as well as bathing with water that is too hot or soap that is harsh causes the skin to become excessively dry. As the patient ages, the skin loses its resiliency and moisture, and sebaceous and sweat glands become less active. The epithelium thins, and elastic collagen fibers shrink, making the skin fragile and prone to bruising and breaking.
Of the following interventions, which would be the most important for preventing skin impairment in a mobile patient with local nerve damage? a. Turn the patient every 2 hours. b. Limit caloric and protein intake. c. Insert an indwelling urinary catheter. d. During a bath, assess for pain.
ANS: D During a bath, assess the status of sensory nerve function by checking for pain, tactile sensation, and temperature sensation. When restricted from moving freely, dependent body parts are exposed to pressure that reduces circulation. However, this patient is mobile and therefore is able to change positions. Limiting caloric and protein intake may result in impaired or delayed wound healing. The presence of perspiration, urine, watery fecal material, and wound drainage on the skin results in impaired or delayed wound healing. However, a mobile patient can use bathroom facilities or a urinal.
The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. The nurses understands that this is important for the patient because a. Plantar warts can develop from foot fungi. b. Poor foot care leads to neuropathy. c. A strong dorsalis pedis pulse indicates poor blood flow. d. Foot ulcers are the most common precursor to amputation.
ANS: D Foot ulceration is the most common single precursor to lower extremity amputations among persons with diabetes. Plantar warts are due to the papillomavirus, not to a fungus. Palpation of the dorsalis pedis and posterior tibial pulses indicates that adequate blood flow is reaching peripheral tissues. Neuropathy is a degeneration of the peripheral nerves usually due to poor control of blood glucose levels; it is not a direct result of poor foot care.
When assessing a patient's skin, the nurse needs to know that a. Restricted movement can increase blood circulation. b. Paralyzed patients have normal sensory function. c. Loss of subcutaneous tissue may increase the rate of wound healing. d. Moisture on the skin can lead to skin maceration.
ANS: D Moisture on the surface of the skin serves as a medium for bacterial growth and causes irritation, softens epidermal cells, and leads to skin maceration. When restricted from moving freely, dependent body parts are exposed to pressure that reduces circulation to affected tissues. Know which patients require help to turn and change positions. Patients with paralysis, circulatory insufficiency, or local nerve damage are unable to sense an injury to the skin. Patients with limited caloric and protein intake develop thinner, less elastic skin with loss of subcutaneous tissue, which results in impaired or delayed wound healing.
The patient is being treated for cancer with weekly radiation and chemotherapy treatments. The nurse is aware that the patient's oral mucosa needs to be assessed because chemotherapy and radiation can a. Increase saliva production. b. Decrease the risk of oral inflammation. c. Decrease drying of oral mucosa. d. Lead to oral problems.
ANS: D Patients frequently develop common oral problems as a result of inadequate oral care or as a consequence of disease (e.g., oral malignancy) or as a side effect of treatments such as radiation and chemotherapy.
The nurse is providing perineal care to an uncircumcised male patient. When providing such care, the nurse should a. Leave the foreskin alone because there is little chance of infection. b. Retract the foreskin for cleansing and allow it to return on its own. c. Retract the foreskin and keep retracted. d. Retract the foreskin and return it to its natural position when done.
ANS: D Return the foreskin to its natural position. Keeping the foreskin retracted leads to tightening of the foreskin around the shaft of the penis, causing local edema and discomfort. The foreskin may not return to its natural position on its own. Patients at greatest risk for infection are uncircumcised males.
The nurse is caring for a patient who is complaining of severe foot pain due to corns. The patient states that she has been using oval corn pads to self-treat the corns, but they seem to be getting worse. The nurse explains that a. Corn pads are an adequate treatment and should be continued. b. The patient should avoid soaking her feet before using a pumice stone. c. Tighter shoes would help to compress the corns and make them smaller. d. Depending on severity, surgery may be needed to remove the corns.
ANS: D Surgical removal is necessary, depending on severity of pain and the size of the corn. Oval corn pads should be avoided because they increase pressure on the toes and reduce circulation. Warm water soaks soften corns before gentle rubbing with a callus file or pumice stone. Wider and softer shoes, especially shoes with a wider toe box, are helpful.
A nurse is listening to a student provide instruction to a patient who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse? 1. Use tap water to clean soft lenses. 2. Follow recommendations of lens manufacturer when inserting the lenses. 3. Keep lenses moist or wet when not worn. 4. Use fresh solution daily when storing and disinfection lenses.
Answer: 1
A nurse uses long firm, strokes distal to proximal while bathing a patient's legs because: 1. It promotes venous circulation. 2. It covers a larger area of the leg. 3. It completes care in a timely fashion. 4. It prevents blood clots in legs.
Answer: 1
All of the following will help maintain skin integrity in older adults except: 1. Environmental air that is cold and dry. 2. Use of warm water and mild cleansing agents for bathing. 3. Bathing every other day. 4. Drinking 8 to 10 glasses of water a day.
Answer: 1
An 88-year-old patient comes to the medical clinic regularly. During a recent visit the nurse noticed that the patient had lost 10 lbs in 6 weeks without being on a special diet. The patient tells the nurse that he has had trouble chewing his food. Which of the following factors are normal aging changes that can affect an older adult's oral health? (Select all that apply.) 1. Dentures do not always fit properly. 2. Most older adults have an increase in saliva secretions. 3. With aging the periodontal membrane becomes tighter and painful. 4. Many older adults are edentulous, and remaining teeth are often decayed. 5. The teeth of elderly patients are more sensitive to hot and cold.
Answer: 1, 4
Mr. Gray is a 19-year-old patient in the rehab unit. He is completely paralyzed below the neck. The most appropriate bath for Mr. Gray is a: 1. Partial bed bath 2. Complete bed bath 3. Sitz bath 4. Tepid bath
Answer: 2
Mrs. Veech has diabetes. Which intervention should be included in her teaching plan regarding foot care? 1. Use a pumice stone to smooth corns and calluses. 2. File toenails straight across and square. 3. Apply powder to dry areas along the feet and between the toes. 4. Wear elastic stockings to improve circulation.
Answer: 2
The nurse delegates needed hygiene care for an elderly stroke patient. Which intervention would be appropriate for the nursing assistive personnel to accomplish during the bath? 1. Checking distal pulses. 2. Providing ROM exercises to extremities. 3. Determining type of treatment for stage 1 pressure ulcer. 4. Changing the dressing over an intravenous site.
Answer: 2
What is the proper position to sue for an unresponsive patient during oral care to prevent aspiration? (Select all that apply) 1. prone position 2. Sims' position 3. Semi-Fowler's position with head to side 4. Trendelenburg position 5. Supine position
Answer: 2, 3
The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply) 1. Cut nails frequently. 2. Assess skin for redness, abrasions, and open areas daily. 3. Soak feet in water at least 10 minutes before nail care. 4. Apply lotion to feet daily. 5. Clean between toes after bathing.
Answer: 2, 4, 5
A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands. Place the following steps in order for administration of oral care. 1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. 2. Raise bed, lower side rail and position patient close to side of bed with head of bed raised up to 30 degrees. 3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. 4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity. 5. Remove partial plate or dentures if present. 6. Gently brush tongue but avoid stimulating gag reflex.
Answer: 2, 5, 1, 3, 6, 4
A patient receiving chemotherapy experiences stomatitis. The nurse advises the patient to use: 1. Community mouthwash. 2. Alcohol-based mouth rinse. 3. Normal saline rinse. 4. Firm toothbrush.
Answer: 3
Assessment of the hair and scalp reveals that John has head lice. An appropriate intervention would be: 1. Shave hair off the affected area. 2. Place oil on the hair and scalp until all of the lice are dead. 3. Shampoo with medicated shampoo and repeat 12 to 24 hours later. 4. Shampoo with regular shampoo and dry with hair-dryer set at the hottest setting.
Answer: 3
The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply.) 1. Use antimicrobial toothpaste. 2. Brush teeth 4 times a day. 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses. 4. Use a soft toothbrush for oral care. 5. Avoid cleaning the gums and tongue.
Answer: 3
The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to: 1. Obsessive compulsive behavior. 2. Personal preferences. 3. The patient's cultural norm. 4. Controlling behaviors.
Answer: 3
When preparing to give complete morning care to a patient, what would the nurse do first? 1. Gather the necessary equipment and supplies. 2. Remove the patient's gown or pajamas while maintaining privacy. 3. Assess the patient's preferences for bathing practices. 4. Lower the side rails and assist the patient with assuming a comfortable position.
Answer: 3
Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (Select all that apply.) 1. Use of cough drops. 2. Immunosuppression 3. Radiation therapy 4. Dehydration 5. Presence of oral airway
Answer: 3, 4
When you are assigned to a patient who has reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? (Select all that apply.) 1. Oxygen saturation 2. Heart rate 3. Respirations 4. Gag reflex 5. Response to painful stimulus
Answer: 3, 4
A nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and thus requiring thorough bathing and skin care? 1. A 44-year-old female who has had removal of a breast lesion and is having her menstrual period. 2. 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line. 3. A 60-year-old female who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg. 4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool.
Answer: 4
When a nurse delegates hygiene care for a male patient to a nursing assistive personnel, the NAP must use an electric razor to shave the patient with the following diagnosis: 1. Congestive heart failure. 2. Pneumonia. 3. Arthritis. 4. Thrombocytopenia.
Answer: 4
Describe agents commonly used on the skin and scalp.
Brushing, combing and shampooing. Alcohol-free detangle products make it easier to comb. Special lanolin conditioners for African-American hair. Pediculicidal shampoo for lice. Shaving cream Pg. 841 - 843
Identify appropriate hygienic care of patients with various ethnic origins.
Cultural beliefs, values and religious preferences influence hygiene practices. Avoid forcing changes in hygiene practices unless the practices affect a patient's health. Pg. 824
Define the terms used to describe pathological color changes.
Cyanosis - bluish tinge Pallor - paleness Erythema - redness Jaundice - a yellowish tinge Ecchymosis - bruising Petechiae - non-blanching pinpoint-size, red or purple spots on skin caused by small hemorrhages in the skin layers
Identify nursing diagnosis, goals and outcomes for patients receiving skin care.
Diagnoses - Activity intolerance - Bathing self-care deficit - Dressing self-care deficit - Impaired physical mobility - Impaired oral mucous membrane - Ineffective health maintenance - Risk for infection - Risk for impaired skin integrity Goals - each patient will have different self-care abilities and needs - partner with patient and family to identify goals and expected outcomes to develop a mutually agreed upon POC based on nursing diagnosis. - SMART goals - establish realistic, individualized expected outcomes to measure patient's progress toward meeting goals. Pgs. 831 - 834
Explain common skin problems, characteristics and interventions.
Dry skin - bathe less frequently, rinse body of all soap, add moisture to air with humidifier, increase fluid intake, use moisturizing cream to aid healing, use creams to clean skin that is dry or allergic to soaps and detergents Acne - wash hair and skin thoroughly each day with warm water and soap to remove oil; use cosmetics sparingly; implement dietary restrictions if necessary; use prescribed topical antibiotics for severe forms of acne Skin rashes - wash area thoroughly and apply antiseptic spray or lotion to prevent further itching and aid in healing process; apply warm or cold soaks to relieve inflammation if indicated Contact dermatitis - avoid causative agents (cleansers, soaps) Abrasion - be careful not to scratch patient with jewelry or fingernails; wash abrasions with mild soap and water; dry thoroughly and gently; observe dressing or bandage for retained moisture because it increases risk of infection Pg. 828
Explain the purpose of hygiene.
Hygiene affects patients' comfort, safety and well-being; promote comfort and relaxation, foster a positive self-image, promote healthy skin and help prevent infection and disease Pg. 821
Identify and discuss the role of critical thinking in performance of hygienic care.
Integrate nursing knowledge with knowledge from other disciplines. During assessment, consider all factors to include to make appropriate nursing diagnoses. Integrate knowledge about developmental and cultural influences as you identify and meet hygiene needs. Be aware of the impact of critical thinking attitudes as you plan and implement care. Draw on your own experiences as you help with your patients' hygiene care. Rely on professional standards such as those for skin and foot care form the ADA and specialty nursing groups when planning care to meet a patient's hygiene needs. Pgs. 825, 826
Identify patients that are at risk for impaired skin integrity.
Oral problems -NPO -inability to use upper extremities because of paralysis, weakness or restriction -patients with nasogastric or oxygen tubes; mouth breathers -cancer patients on chemotherapy or radiation -diabetics -patients who recently underwent oral surgery, trauma to mouth, trach -immunosuppressed patients; altered blood clotting -endotracheal intubation with mechanical ventilation -patients on dialysis Skin problems -patients with immobilization -bariatric patients -patients with reduced sensation caused by stroke, spinal cord injury, diabetes, local nerve damage -patients with vascular insufficiency -patients with dementia, psychological disorders or temporary delirium -limited protein or caloric intake and reduced hydration (fever, burns, GI alterations, poorly fitting dentures) -patients with external medical devices (cast, restraint, bandage, dressing) Foot problems -patient unable to bend over or has reduced visual acuity Eye care problems -patient with reduced dexterity and hand coordination Pgs. 828, 829 Table 40-2
Explain physical assessment of the skin, developmental changes, self-care and risk for skin impairment during hygienic care.
Perform assessment of the skin noting color, texture, thickness, turgor, temperature and hydration. Pay attention to the presence and condition of any lesions. Note dryness indicated by flaking, redness, scaling and cracking. Look for edema. Determine the degree of cleanliness by observing the appearance of the skin and detecting body odors than can indicate inadequate cleansing or excessive perspiration caused by fever or pain. Inspect under breasts or scrotum, around female patient's perineum or in the groin for redness, excessive moisture and soiling or debris. Separate skinfolds for observation and palpation. Be attentive to characteristics of skin problems most influenced by hygiene measures. Assess skin under orthopedic devices (braces, casts, splints) and beneath items such as compression stockings and tape. Assess condition and cleanliness of the perineal and anal areas during hygiene care and when the patient requires toileting assistance. When caring for a patient with dark skin pigmentation, be aware of assessment techniques and skin characteristics unique to highly pigmented skin. Pg. 827, 829 Tale 40-3
Explain the four functions of the skin and implications for skin care.
Protection -weakening of the epidermis occurs by scraping or stripping its surface (dry razors, tape removal, improper turning or positioning techniques) -excessive dryness causes cracks and breaks in skin and mucosa that allow bacteria to enter. Emollients soften skin and prevent moisture loss, soaking skin improves moisture retention and hydrating mucosa prevents dryness. -constant exposure of skin to moisture causes maceration or softening, interrupting dermal integrity and promoting ulcer formation and bacterial growth. -keep bed linens and clothing dry. -misuse of soap, detergents, cosmetics, deodorant and depilatories cause chemical irritation. Alkaline soaps neutralize the protective acid condition of skin. Cleaning skin removes excess oil, sweat, dead skin cells and dirt, which promote bacterial growth. Sensation -minimize friction to avoid loss of stratum corneum, which results in development of pressure ulcers. -smooth linen out to remove sources of mechanical irritation -remove rings from fingers to prevent accidentally injuring a patient's skin. -make sure that bath water is not excessively hot or cold Temperature regulation -factors that interfere with heat loss alter temperature control. Wet bed linen or gowns interfere with convection and conduction. Excess blankets or bed coverings interfere with heath loss through radiation and conduction. Coverings promote heat conservation. Excretion and secretion -perspiration and oil harbor microorganisms -bathing removes excess body secretions; although, if excessive, it causes dry skin Pg. 822 Table 40-1
Describe the factors that influence personal hygiene.
Social practices Personal preferences Body image Socioeconomic status Health beliefs and motivation Cultural variables Developmental stage Physical condition Pgs. 823 - 825
Terms used in integument inspection/palpation:
Symmetry Hydration Oral mucosa Nail beds Lips Palms of hands Saliva Conjunctiva Moisture Turgor Temperature Texture Lesions Mobility Shape Contour Consistency Pgs. 822, 824, 825, 827 Skills Book pgs. 60 - 65
dandruff
a flaking of the outer layer of dead skin cells on the scalp
tartar
a hard calcified deposit that forms on the teeth and contributes to their decay.
emollient
a preparation that softens the skin (moisturizer, lotion)
podiatrist
a specialist in care for the feet
plaque
a sticky deposit on teeth in which bacteria multiply.
periodontal disease
an inflammatory disease that affects the soft and hard structures that support the teeth; early stage called gingivitis
sebum
an oily secretion of the sebaceous glands.
pyorrhea
another term for periodontitis; inflammation of the tissue around the teeth, often causing shrinkage of the gums and loosening of the teeth
caries
cavities; tooth decay
vesicle
circumscribed elevation of skin filled with serous fluid; smaller than 1 cm (herpes simplex, chickenpox)
pustule
circumscribed elevation of skin similar to vesicle but filled with pus; varies in size (acne, staphylococcal infection)
ulcer
deep loss of skin surface that extends to dermis and frequently bleeds and scars; varies in size (venous stasis ulcer)
cerumen
ear wax
nodule
elevated, solid mass, deeper and firmer than papule, 1 - 2 cm (wart)
Macule
flat, non-palpable change in skin color; smaller than 1 cm (freckle, petechiae)
halitosis
foul-smelling breath
gingiva
gums
alopecia
hair loss
ischemia
inadequate blood supply to an organ or part of the body
pediculosis
infestation with lice
gingivitis
inflammation of the gums
wheal
irregularly shaped, elevated area or superficial localized edema; varies in size (hive, mosquito bite)
papule
palpable, circumscribed, solid elevation in skin, smaller than 1 cm (elevated nevus)
epidermis
several thin layers of epithelial cells comprising the outer layer of skin
integument
skin
tumor
solid mass that extends deep through subcutaneous tissue; larger than 1 - 2 cm (epithelioma)
erythema
superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.
necrosis
the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply.
nits
the egg of a louse or other parasitic insect
dermis
thick layer of skin below the epidermis; contains blood capillaries, nerve endings, sweat glands, hair follicles and other structures
atrophy
thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent; varies in size (arterial insufficiency)
