Kozier Ch 33

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Author:
cswett
ID:
97991
Filename:
Kozier Ch 33
Updated:
2011-09-01 20:25:15
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Fundi Nursing Hygiene
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Description:
Notes from reading of Ch 33 on Hygiene
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  1. Functions of the skin
    • •Largest organ of the body
    • •Protects underlying tissues from injury
    • •Regulates body temperature
    • •Secretes sebum- oily lubricant of skin & hair, it is also
    • bactericidal
    • •Transmits sensations- pain, temp, touch, pressure
    • •Produces and absorbs Vit D
  2. Skin Problems
    • Abrasion- layers of skin scraped away or rubbed away
    • - prome to infection - keep clean
    • - no jewelry to avoid abrasion to patients
    • - Lift, dont pull, client acress a bed
    • - get help when needed

    • •Excessive dryness- flaky & rough
    • -prone to infection if skin cracks - lotion for moisture
    • -bathe less - no soap
    • -Encourage fluid intake - prevent dehydration

    • Ammonia dermatitis (Diaper rash)
    • - keep skin dry & clean - zinc oxide
    • -boil diapers or antibacerial to avoid infection

    • Acne- inflammation with papules & pustules
    • -keep skin clean
    • -treatment varies

    • Erythema- redness
    • -wash skin to remove microorganisms
    • - antiseptic spray - prevent itch, promote healing, prevent skin breakdown

    • •Hirsutism- excessive hair
    • -remove unwanted hair
    • -enhnace clients slef-concept
  3. Foot problems
    •Corns- thick epidermis

    •Calluses- keratosis from friction of shoe

    •Plantar warts- viral

    • •Fissures- deep grooves,
    • between toes

    • •Tinea pedis (athlete’s foot)- ringworm of the foot (fungus)
    • scaling & cracking of skin (usually between toes)
    • may be small blisters

    • •Ingrown nail- grows
    • inward from imporper trimming
  4. Nail Problems
    Healthy nails are slightly concave with an angle of about 160

    •Spoon nails- concave outer surface from iron deficiency anemia

    •Clubbing- angle is 180 or greater from long-term lack of O2

    •Excessive thickness- poor circ. or fungal infection

    •Grooves or furrows- anemia

    •Beau’s lines- horizontal depression in nails from injury or illness
  5. Abnormal findings of nails
    • •Discolored or detached- fungus
    • •Bluish or purplish tint or pallor
    • •Hangnails
    • •Paronychia- infection of nail margins
    • •Delayed capillary refilling time
  6. Abnormal findings of the mouth
    •Halitosis- bad breath

    Stomatitis- inflammation of oral mucosa

    Glossitis- inflammation of the tongue

    •Gingivitis- inflammation of the gums

    Parotitis- inflammation of parotid gland (salivary glands)

    Periodontal disease- gum disease - gums apprear spongy and bleeding

    •Reddened or excoriated mucosa

    •Excessive dryness of the buccal mucosa

    • •Cheilosis- condition of lips with red appearance &
    • fissures at angles, see with deficiency of Vit B (riboflavin)

    •Dental caries (cavities)

    •Sordes- crusts on mouth, teeth,lips from accumulation of foul matter
  7. Abnormal findings of the Hair
    Dandruff- scaling of scalp

    •Hair loss

    Ticks- parasites, bit into scalp

    • Pediculosis (Lice), parasitic insects, different type
    • based on where they are

    Scabies- itch mite, burrows into upper layers of skin

    •Hirsutism- excessive body hair
  8. Abnormal findings of Eyes
    •Loss of hair, scaling, flaky eyebrows

    •Redness, swelling, flaking, crusting, discharge, asymmetrical closing, ptosis of eyelids

    •Jaundiced sclera

    •Unequal pupils

    •Pupils fail to dilate or constrict

    •Inability to see
  9. Hygiene Assessment
    • •Nursing history to determine:
    • –Self care practices
    • –Self-care abilities
    • –Past or current problems
    • –Identification of clients at risk for developing
    • impairment

    •Physical assessment
  10. Nursing Process - Hygiene Diagnosis
    • •Deficient knowledge
    • •Situational low self-esteem
    • •Risk for impaired skin integrity
    • •Impaired skin integrity
    • •Self-care deficit
    • •Risk for infection
    • •Impaired oral mucous membrane
    • •Disturbed body image
    • •Risk for injury
  11. Nursing Process - Hygiene Interventions
    •Assisting dependent clients with hygiene activities

    •Educating clients and/or family about appropriate hygienic practices

    •Demonstrating use of assistive equipment and adaptive activities

    •Assessing and monitoring physical and psychological responses
  12. Purposes of Bathing
    •Remove transient microorganisms, body secretions and excretions, and dead skin cells

    •Stimulate circulation

    •Produce a sense of well-being

    •Promote relaxation and comfort

    •Prevent or eliminate unpleasant body odors
  13. Types of Baths
    •Complete bed

    •Self-help

    • •Partial - face, hands, axillae, perineal area, back
    • (omit arms, chest, abdomin, legs, and feet)

    •Bag- pre-packages, warm clothes

    •Tub

    •Sponge- newborns

    •Shower
  14. Hospitalized patient hygiene
    • •Early morning care
    • –Urinal or bedpan
    • –Washing face and hands
    • –Oral care

    • •Morning care
    • –Usually after breakfast
    • –Elimination
    • –Bath or shower
    • –Perineal care (p.756)
    • –Back massage
    • –Oral, nail, and hair care

    • •Hour of sleep (HS) or P.M.
    • –Elimination
    • –Washing face and hands
    • –Oral care
    • –Back massage

    • •As needed (prn)
    • –As required by client need
    • •More frequent bathing
    • Changes of clothes
  15. Abnormal Findings of Ears
    • •Asymmetrical, excessively red or tender auricles
    • •Lesions, flaky, scaly skin over auricles
    • •Normal voice tones not heard
  16. Abnormal findings of the Nose
    • •Asymmetrical
    • •Discharge
    • •Localized redness, tenderness or lesions
  17. Pericare
    • •Embarrassing
    • •Clients needing a bedbath can sometimes do this on own
    • •Terminology- “Private parts”
    • •Privacy is important
    • •Comfort
    • •Removing debris & preventing infection are important
    • •May need to do often if area becomes soiled
  18. Bed Postion
    Flat
    • Matress completely horizontal
    • Uses:

    • 1. Maintain spinal allignment for clients with spinal injuries
    • 2. To assist clients to move and turn in bed
    • 3. Bed-Making by nurse
  19. Fowler's Position
    Head of bed is at angle of at least 45o - knees may be flexed or horizontal

    • 1. Promote lung expansion for client with respiratory problems
    • 2. Assist client to a sitting position on the edge of the bed
  20. Semi-Flowler's
    Head of bed raised to 30o angle

    • 1. Relief from lying position
    • 2. To promote lung expansion
  21. Trendelenburg's position
    Head of bed is lowered and the food raised in a straight incline

    • 1. Promote vonous circulation in certain clients
    • 2. Provide postural drainage of basal lung lobes
  22. Reverse Trendelenburg's position
    Head of bed raised and foot lowered in a straight incline

    • 1. Promote stomach emptying
    • 2. Prevent esophageal reflux in client with hiatal hernia

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