HYGIENE ADN 150 Exam 1

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julianne.elizabeth
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234876
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HYGIENE ADN 150 Exam 1
Updated:
2013-09-14 23:31:08
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lccc adn nursing fundamentals hygiene
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for LCCC ADN Exam 1
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  1. What are the 4 LCCC ADN nursing concepts?
    Human, Health, Nursing, Environment
  2. What are the 6 course threads?
    • 1. Cultural/spiritual
    • 2. Nursing Process
    • 3. Teaching/Learning
    • 4. Ethical/legal
    • 5. Therapeutic communication
    • 6. socialization to the role of a nurse
  3. Who is the LCCC nursing theorist and what theory is our program based on?
    Sister Callista Roy's adaptation/systems theory

    • -biopsychosocial
    • -holistic
    • -stressors
    • -adaptation
    • -stimulus
  4. 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
  5. What are the risk factors for Oral Problems?
    • DM
    • Chemotherapy
    • Broad Spectrum Antibiotics
    • Radiation
    • Devices
  6. What are the risk factors for skin issues?
    • Immobility
    • decreased sensation (stroke, DM, SCI)
    • decreased protein intake
    • excessive wetness
    • decreased blood flow (PVD)
    • equipment added to body
  7. What are the risk factors for the peri area?
    • scrotum
    • female gyn parts
    • rectal area
    • certain patients
    • -ob/gyn patients
    • -childbirth
    • -indwelling caths
    • -uncircumcised
  8. What are some hygiene nursing diagnoses?
    • bathing self care deficit
    • risk for infection
    • risk for impaired skin integrity
    • impaired oral mucus membrane
  9. What are some ways to care (hygiene) for a confused patient?
    • Get familiar with the patient
    • eliminate triggers
    • gentle, focused and unhurried manner
    • focus on person, not task
    • do not start with face
    • bed in bad
    • warm water
    • privacy
  10. 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
  11. Who are some people groups that are at risk for amputation?
    • DM
    • previous amputation
    • PVD
    • peripheral neuropathy
    • decreased joint mobility (CVA, arthritis, fibromyalgia)
    • pressure sores
  12. 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
    • Buerger-Allen exercises
  13. What are some negative effects of poor oral hygiene?
    • poor nutrition
    • stroke
    • blood sugar swings
    • pneumonia (esp in LTC institutions)
  14. 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!
  15. How do you perform oral care for someone who is unconcious?
    • *Check for gag reflex (CN IX)
    • Aspiration precautions
    • -turn patient to side lying position or HOB elevated if suction equipement
    • -may be a two person job
  16. 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)
    • -chlorhexidone
  17. How do you care for a patient with stomatitis?
    • Frequent oral assessments
    • check calorie count and fluid intake
    • NSS rinses
    • -when rising
    • -after meals
    • -at bedtime
  18. 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
  19. Who has special hair care needs for delousing medication?
    • *These shampoos can contain a neurotoxic component
    • -Organochloride lindane is contraindicated in the following:
    • -seizure patients
    • -pregnancy and breast feeding
    • -over irritated skin
    • -those under 110lbs
    • -older adults
  20. 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
  21. 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
  22. 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)
    • 2. Adults: Pull pinna up and back
    • Child: down and back
  23. What are the different positions for a bed?
    • Fowlers, High Fowlers, Flat, Trendelenburg, reverse Trendelenburg
  24. What is the process for making a bed?
    • Bed to do when patient is OOB
    • Asses patient's needs prior (br?)
    • Get supplies
    • 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)
  25. What is one main concept for bathing?
    • Always promote venous return when possible
    • -move from distal to proximal

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