HYGIENE ADN 150 Exam 1
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HYGIENE ADN 150 Exam 1
lccc adn nursing fundamentals hygiene
for LCCC ADN Exam 1
What are the 4 LCCC ADN nursing concepts?
Human, Health, Nursing, Environment
What are the 6 course threads?
2. Nursing Process
5. Therapeutic communication
6. socialization to the role of a nurse
Who is the LCCC nursing theorist and what theory is our program based on?
Sister Callista Roy's adaptation/systems theory
When doing a skin assessment, what are some important things to remember?
-Always palpate the skin and not just look at it
-Difficult to see or touch areas need special care
-Always check the feet and nails
-->foot ulcerations in diabetics are serious problems!
Check hair for critters
check oral cavity
What are the risk factors for Oral Problems?
Broad Spectrum Antibiotics
What are the risk factors for skin issues?
decreased sensation (stroke, DM, SCI)
decreased protein intake
decreased blood flow (PVD)
equipment added to body
What are the risk factors for the peri area?
female gyn parts
What are some hygiene nursing diagnoses?
bathing self care deficit
risk for infection
risk for impaired skin integrity
impaired oral mucus membrane
What are some ways to care (hygiene) for a confused patient?
Get familiar with the patient
gentle, focused and unhurried manner
focus on person, not task
do not start with face
bed in bad
What are some nursing alerts for foot and nail care?
DO NOT SOAK FEET OF PATIENT WITH DM
DO NOT TRIM TOE NAILS ON PATIENT WITH DM
Who are some people groups that are at risk for amputation?
decreased joint mobility (CVA, arthritis, fibromyalgia)
What are the ANA guidelines for foot care?
Foot exam (at least yearly)
Inspect feet daily
Wash feet daily; dry completely
shoes always; no bare feet
clean, dry socks
emollient notion (not inbetween toes!)
trim nails flat with square edges
do not cross legs
keep feet in moderate temps
What are some negative effects of poor oral hygiene?
blood sugar swings
pneumonia (esp in LTC institutions)
What are some oral care interventions?
Brush 2x daily (OD)
Chlorhexidine for rinses if high risk
floss once a day
includes gently brushing tongue
new tooth brush every 3 months
new tooth brush after URI
*no lemon glycerine or alcohol based mouth wash if high risk!
How do you perform oral care for someone who is unconcious?
*Check for gag reflex (CN IX)
-turn patient to side lying position or HOB elevated if suction equipement
-may be a two person job
How do you perform oral care for someone who is vented?
Main priority is maintaining the airway!
ETT (endotracheal tube goes through the glottis)
may be sedated
increased risk for infection
-VAP (ventilator associated pneumonia)
How do you care for a patient with stomatitis?
Frequent oral assessments
check calorie count and fluid intake
How do you care for dentures?
Make sure you know how to remove and replace
Take special care when brushing
keep in moist water when not in use
place in labeled container not on the over the bed table
if musculoskeletal challenges, can get a large handled toothbrush
encourage patients to wear their dentures to prevent warping and changing of mouth
Who has special hair care needs for delousing medication?
*These shampoos can contain a neurotoxic component
-Organochloride lindane is contraindicated in the following:
-pregnancy and breast feeding
-over irritated skin
-those under 110lbs
What are things to be sure of when shaving a patient?
Assess if the patient is on anticoagulants!
-its a safety issue!
-coumadin, heparin, lovenox, aspirin (ASA)
Do not shave off a mole, wart, etc.
Shave with the grain of the skin
How do you perform eye care?
First check for the blink reflex
(check for and remove contacts, check for infection)
clean from the inner canthus to the
use different section of wash cloth for each eye
What are the two main concepts of Ear Care?
1. Never put anything into the ear that can penetrate the ear drum
(you can only irrigate ears with MD order)
: Pull pinna up and back
: down and back
What are the different positions for a bed?
Fowlers, High Fowlers, Flat, Trendelenburg, reverse Trendelenburg
What is the process for making a bed?
Bed to do when patient is OOB
Asses patient's needs prior (br?)
Bed locks on (Safety!!!)
Check armband and call name
BED UP TO WORK AND DOWN WHEN YOU FINISH!
Complete the task, siderails up on the side you are turning the patient towards
ask patient if they need anything else?
make sure call bell is at the bedside (safety)
What is one main concept for bathing?
Always promote venous return when possible
-move from distal to proximal