Hygiene and skin
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What would be an observation during your assessment that would tell you the patient is having problems? What kinds of things cause problems with hands and feet?
Pg. 741 Performing foot and hand care. Helathy feet are crucial in helping people stand and walk. Unnatural gait can be caused by painful feet or bone and muscle disorders. Poor fitting foot wear, nail problems.
What is the purpose of performing foot and hand care?
Maintain skin integrity, provide for client's comfort and sense of well being, maintain foot function and ability to ambulate, and encourage self care.
How do you allow the client to be as independent as possible? How do you motivate patients?
Pg 707 Performing a task independently to the fullest extent possible enables a person to gain independence and self confidence and bolsters self- concept.
What is proper oral hygiene? What does it include?
Pg 704 & 708 Be sure dentures are removed and cleaned regularly. Proper oral hygiene includes daily brushing, flossing, and rinsing of teeth and care of dentures or other appliances. Keep dentures in a labeled denture cup to prevent breakage or loss.
The ability ot feed oneself may be the most important self care skill in terms of independence, what assessments are essential for patient safety? How do you promote self care?
Pg 724 & 725 Adequate swallowing is essential for safe eating. To avoid food aspiration for the client, carefully assess his or her ability to swallow. Elicit the gag refelx by stroking the inside of the throat with a tongue depressor. Often clients are spoon fed in institutional settings even though they are capable of self feeding if given adequate time. Verbal prompts and physical guiding can assist the cognitively impared client.
How do you determine what the client considers to be normal self care activities? How do you determine problems and possible solutions?
Pg 708 By asking questions the nurse can learn what the client considers normal self care activity and determine which areas may be problematic. These questions are designed to elicit the clients feelings about the problem, what he or she sees as the solution and his or her level of motivation.
How do you determine the type of bath that is best for the client?
Pg 717 When assessing the type of bath to use take into account the clients abilities and adopt the method that allows the most independence in self care.
What is pannus? How do you care for a patient with pannus?
Pg 729 The pannus is the large protuberant abdominal skin fold that provides a dark moist environment where fungal infection can occur. All skin folds need to be inspected cleansed and dried thoroughly at least daily.
How do you assess skin for adequate blood flow? What does impaired venous function look like?
Pg 992 Alteration in any skin perfusion can lead to skin that has abnormal color, texture, thickness, moisture, or temperature or that becomes ulcerated. Impaired venous function in the lower extremities causes pooling of the blood causing edema, vasodilation, and plasma extravasation.
What are factors that effect integumentary function? What are some examples?
Pg 992 & 993 Circulation, nutrition, condition of the epidermis, allergies, infections, abnormal growth rate, systemic diseases, trauma, mechanical forces. EX: Allergic reactions caused by internal or external irritants, cutaneous warts caused by the papillomavirus are one of the most common diseases of the skin, with hand and feet most typically affected.
What is psoriasis? What causes it?
Pg 993 Psoriasis is a nonmalignant, chronic disorder that greatly increases the rate of skin production. The elbows, knees, scalp, and soles of the feet are common sites for psoriasis. It has periods of remission and exacerbations that can be triggered by stress, infection or environmental factors.
What are accidental wounds? What are surgical wounds?
Pg. 993 Common wounds include abrasions, lacerations, and puncture wounds. An abrasion results when the skin rubs against a hard surface scraping away the epithelial layer. A laceration is an open wound or cut. Surgical wounds vary. An example is ostomie, a surgical opening in the abdominal wall that allows part of an organ to open onto the skin.
How do you prevent pressure ulcers?
- pg 1007 Box 39-3
- Identify clients at risk and the specific factors placing them at risk
- Maintain and improve tissue tolerance to pressure to prevent injury. Inspect pressure points at least once a day. Document all findings.
- Cleanse skin regularly and whenever soiled using a mild cleansing agent and wam not hot water.
- Minimize factors that dry the skin. Treat dry skin with moisturizers.
- Do not massage bony prominences.
- Minimize exposure of skin to incontinence, perspiration, or wound drainage.
- Protect skin from friction and shear.
- Provide adequate calories and nutrients.
- Maintain or improve mobility, activity level, and range of motion.
- Reposition every 2 hours. Use a 30 degree side lying position when the patient is lateral to avoid excessive pressure on the trochanter.
- Use pillows to keep bony prominences from rubbing against each other.
- Keep heels from pressing on the bed if the client is completely immobile.
- When the client is on his or her side avoid positioning directly on the trochanter.
- Limit the time the head of the bed is elevated.
- Lift, do not drag, clients to move them up in bed. Use overbed trapeze.
- Place clients on a pressure- reducing device when in bed.
- Avoid prolonged sitting. Reposition or shift the client's weight every hour.
- For chair bound clients, place a pressure reducing device on the chair that maintains good postural alignment, balance and stability.
- Use a written plan regarding the use of postioning devices and repositioning schedules.
- Provide structured education about pressure ulcer prevention to healthcare providers, clients, and family or caregivers.
How does altered integumentary function manifest?
Pg 995 & 997 Disruption in normal skin integrity can manifest as pain, pruritus, rashes, lesions or open wounds; usually more than one symptom is present Any break in the skins epidermal layer signifies that the skin integrity is altered. Microscopic breaks in the skin may manifest as redness.
What are the types of wound healing?
- pg 997
- Primary Intention- The edges of the primary wound are approximated or lightly pulled together. Granulation tissue is not visible, and scarring is usually minimal.
- Secondary Intention- the wound has edges that are not approximated and gradually fills with granulation tissue.
- Tertiary Intention- also referred to as delayed primary closure, wound is purposely left open until there is no sign of infection, then closed with sutures.
What is dehiscence? Who is at risk? What actions can you take to prevent it?
Pg 1002 Dehiscence is total or partial disruption in wound edges. Obesity, poor nutritional status and increased stress on the incisional area increase the risk. Prevent undue stress to the wound by supporting the wound during coughing or vomiting.
What are the parameters of a thorough wound assessment?
- Pg 1003
- Wound type: surgical vs nonsurgical, acute vs chronic.
- Wound location: use proper anatomical terms such as trochanter instead of hip.
- Wound size: leangth width and depth in Cm
- Wound classification: partial vs full thickness, stage if a pressure ulcer.
- Wound base (percentage of viable vs nonviable) viable is healthy pink and red. nonviable or necrotic is white or yellow (slough) or brown to black (eschar).
- Wound drainage: color, amount, consistency, and odor.
serous drainage is
pale yellow, watery, and like the fluid from a blister
sanguinous drainage is
bloody as from an acute laceration.
serosanguineous drainage is
pink-yellow, thin, and contains plasma and red cells.
purulent drainage is
white cells and microorganisms. It is thick, opaque and range from pale yellow to green to tan.
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