WK 4 Exam 2 Key Concepts
WK 4 Exam 2 Key Concepts
WK 4 Exam 2 Key Concepts
Chapter 40 Hygiene
What is the function of the skin and the implications for skin care? The skin serves several
functions, including protection, secretion, excretion, body temperature regulation, and
cutaneous sensation
Weakening of the epidermis occurs by scraping or stripping its surface (e.g., use of 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 linen and clothing dry.
Misuse of soap, detergents, cosmetics, deodorant, and depilatories causes 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.
Factors that interfere with heat loss alter temperature control.
Wet bed linen or gowns increase heat loss.
Excess blankets or bed coverings conserve heat and interfere with heat loss through
radiation and conduction. Coverings promote heat conservation.
Perspiration and oil sometimes harbor microorganisms.
Bathing removes excess body secretions, but excessive bathing causes dry skin.
Minimize friction to avoid loss of stratum corneum, which increases risk for pressure
injuries.
What does personal hygiene affect? Personal hygiene influences patients’ comfort, safety, and
well-being.
What does personal hygiene include? Hygiene includes cleaning and grooming activities that
maintain personal body cleanliness and appearance.
Discuss nursing considerations when providing: assess each patient’s ability to perform self–
hygiene care according to individual needs and preferences. Always ensure privacy, convey
respect, and foster a patient’s independence, safety, and comfort.
Maintain privacy, especially for women from cultures that value female modesty, and
provide gender-congruent caregivers as requested.
Collaborate with community leaders when providing health education for a diverse
community.
Allow family members to participate in care if desired by adapting the schedule of
hygiene activities.
Recognize that some cultures prohibit or restrict touching. Incorporate awareness
that people from different cultural backgrounds have differing preferences regarding
personal space. In some cases touch is considered magical and healing; others view
it as evil or anxiety producing.
Recognize cultural hair practices, and do not cut or shave hair without prior
discussion with patient or family.
Be aware that toileting practices vary by culture.
Recognize that different cultures have preferences about hot and cold water and
their effects on healing or disease.
frequently or is exposed to an environment with low humidity, it becomes dry and flaky. With
aging the rate of epidermal cell replacement slows, and the skin thins and loses resiliency.
Moisture leaves the skin, increasing the risk for bruising and other types of injury. As the
production of lubricating substances from skin glands decreases, the skin becomes dry and
itching.These changes warrant caution when bathing, turning, and repositioning older adults.
Too-frequent bathing and bathing with hot water or harsh soap cause the skin to become
excessively dry.
Older adults do not always have the strength, flexibility, visual acuity, or manual dexterity to
care for their feet and nails. Foot problems may be overlooked and impact a patient’s comfort,
mobility, and quality of life.
Common problems of the feet affecting older adults include corns, calluses, bunions,
hammertoes, maceration between toes, and fungal infections.
As a person ages, numerous factors result in poor oral health, including age-related changes
of the mouth, changes resulting from chronic disease such as diabetes, physical disabilities
Dr. Aniekwe pg. 2
involving hand grasp or strength affecting the ability to perform oral care, lack of attention to
oral care, and prescribed medications that have oral side effects. Gums lose vascularity and
tissue elasticity, which may cause dentures to fit poorly.
With aging, as scalp hair becomes thinner and drier, shampooing is usually performed less.
Hygiene of sensory structures must be provided in a way to prevent injury to sensitive tissues
such as the cornea of the eye and the internal ear canal.
Safety is a priority for a patient with a sensory deficit. Be careful because they can not feel hot
or cold
Patients who become tired or short of breath frequently need to have complete hygiene care
provided.
Include periods of rest during care to allow patients who are tired the opportunity to participate
in their care.
Cultural and/or Religious Practices • Do you have preferences for how you bathe, shampoo
your hair, brush your teeth, or care for your feet? • How comfortable are you with someone
helping you with your bathing? • In what way can I best help you with your bath, hair care?
Tolerance of Hygiene Activities • Tell me about any symptoms, such as shortness of breath,
pain, or fatigue, that you have during bathing. • What can I do to minimize these symptoms? •
Which aspects of bathing, toothbrushing, or foot care cause discomfort or fatigue? Assistance
with Hygiene • Do you use any aids to help you with your bath such as grab bars in your tub or
shower? • Do you prefer someone of the same gender to help in your hygiene care? • Which
parts of the bath, toothbrushing, and foot care can you do for yourself? With which parts of
hygiene care do you need help?
Skin Care • Which type of bath do you prefer? • How often and when do you usually bathe? •
What kind of soap and lotion do you use? • Have you noticed any skin changes or irritation? •
Do you have any known allergies or reactions to soaps, cosmetics, or skin care products?
Mouth Care • Do you have any mouth pain or toothaches? Have you noticed any sores in your
mouth? Do your gums bleed during brushing or flossing? • Do you wear dentures or a partial
plate?
Hair and Scalp Care • Have you recently experienced itching of the scalp or noticed flaking or
dandruff? • Have you noticed any changes in the texture or thickness of your hair?
What are nursing considerations for common skin problems such as dry skin etc.?
Bathe less frequently. Rinse body of all soap because residue left on skin can cause
irritation and breakdown.
Add moisture to air with use of humidifier.
Increase fluid intake when skin is dry.
Use moisturizing cream to aid healing. (Cream forms protective barrier and helps
maintain fluid within skin.)
Use creams to clean skin that is dry or allergic to soaps and detergents.
Complete bed bath: Bath administered to totally dependent patient in bed (see Skill 40.1).
Partial bed bath: Bed bath that consists of bathing only body parts that would cause
discomfort if left unbathed such as the hands, face, axillae, and perineal area. Partial
bath may also include washing back and providing back rub. Provide a partial bath to
dependent patients in need of partial hygiene or self-sufficient bedridden patients who are
unable to reach all body parts.
Sponge bath at the sink: Involves bathing from a bath basin or sink with patient sitting in a
chair. Patient is able to perform part of the bath independently. Assistance is needed for
hard-to-reach areas.
Tub bath: Involves immersion in a tub of water that allows more thorough washing and
rinsing than a bed bath. Commonly used in long-term care. A patient may require the
nurse’s help. Some institutions have tubs equipped with lifting devices that facilitate
positioning dependent patients in the tub.
Shower: Patient sits or stands under a continuous stream of water. The shower provides
more thorough cleaning than a bed bath but can cause fatigue.
Bag bath/travel bath: Contains several soft, nonwoven cotton cloths that are
premoistened in a solution of no-rinse surfactant cleanser and emollient. The bag
Describe nursing care for the following devices: eyeglasses, contact lenses, artificial eyes,
dentures, and hearing aids. assess their knowledge and methods used for care, and have
them describe the typical approach used in routine care.
o Dentures- They must be removed at night to rest the gums and prevent bacterial
buildup. To prevent warping, keep dentures covered in water when they are not worn
and always store them in an enclosed, labeled cup with the cup placed on the patient’s
bedside stand.
o Be careful when cleaning glasses and protect them from breakage or other damage
when they are not worn. Put them in a case in a drawer of the bedside table when not in
use. Cool water sufficiently cleans glass lenses
o all contact lenses must be removed periodically to prevent ocular infection and corneal
ulcers or abrasions from infectious agents Keep lenses moist or wet when not worn.
Thoroughly wash and rinse lens storage case on a daily basis. Clean periodically
with soap or liquid detergent, rinse thoroughly with warm water, and air dry
Hearing Aids-
Ear Whistling sound indicates incorrect earmold insertion, improper fit of aid, or buildup of
earwax or fluid.
• Adjust volume to comfortable level for talking at distance of 1 yard.
• Do not wear aid under heat lamps or hair dryer or in very wet, cold weather.
• Batteries last 1 week with daily wearing of 10 to 12 hours.
• Remove or disconnect battery when not in use.
• Replace earmolds every 2 or 3 years.
• Routinely check battery compartment: Is it clean? Are batteries inserted properly? Is
compartment shut all the way?
How do you maintain hygiene in the patient’s room environment (Ex. room equipment, beds,
bed making, linens)? It needs to be safe and large enough to allow the patient and visitors to
move about freely. Removal of barriers around the bed and along walkways reduces risk of
falls. Control room temperature, ventilation, noise, and odors. Keeping the room neat and
orderly also contributes to the patient’s sense of well-being.
Bed Linen- frequent inspection to be sure that linen is clean, dry, and free of wrinkles. When
patients are diaphoretic, have draining wounds, or are incontinent, check more frequently for
wet or soiled linen.
Usually you make a bed in the morning after patients bathe or while they bathe
Place soiled linen in special linen bags before placing in a hamper. To avoid air currents that
spread microorganisms, never shake the linen. To avoid transmitting infection, do not place
soiled linen on the floor. If clean linen touches the floor or any unclean surface, immediately
place it in the dirty-linen container.
Pressure injury, pressure ulcer, decubitus ulcer, and bedsore are terms used to describe
impaired skin integrity related to unrelieved, prolonged pressure. pressure injury is localized
damage to the skin and underlying soft tissue, usually over a bony prominence or related to a
medical device or other device.
Any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary
incontinence, and/or poor nutrition is at risk for pressure injury development.
• Older adults, those who have experienced trauma
• Those with spinal-cord injuries (SCI)
• Those who have sustained a fractured hip
• Those in long-term homes or community care, the acutely ill, or those in a hospice setting
• Individuals with diabetes
• Patients in critical care settings
Review locations where pressure injuries are likely to occur.
Stage 1 Pressure Injury: Nonblanchable erythema of intact skin. Intact skin with a localized area of
nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of
blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.
Color changes do not include purple or maroon discoloration; these may indicate deep tissue
pressure injury.
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Partial-thickness loss of
skin with exposed dermis. The wound bed is viable, pink or red, and moist and may also present as
an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible.
Granulation tissue, slough, and eschar are not present.
Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose
(fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often
Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss
with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the
ulcer, Slough and/or eschar may be visible.
Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin
and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed
because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4
pressure injury will be revealed.
Define Braden Scale. The Braden Scale is the most widely used risk-assessment tool for
pressure injuries and is in the WOCN guidelines (2016) as being a valid tool to use for
pressure injury risk assessment. Sensory perception, moisture, activity, mobility, nutrition,
and friction/shear. The total score ranges from 6 to 23; a lower total score indicates a higher
risk for pressure injury development .
o What are the six categories?
1. sensory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. friction/shear.
o What score would a client have who is at highest risk for pressure ulcer formation?
o What score would a client have who is at lowest risk for pressure ulcer formation?
Describe normal wound closure. Discuss the different types of healing process.
Primary intention- The skin edges are approximated, or closed, and the risk of infection is
low. Healing occurs quickly, with minimal scar formation, as long as infection and
secondary breakdown are prevented
secondary intention- The wound is left open until it becomes filled by scar tissue. It takes
longer for a wound to heal by secondary intention; thus the chance of infection is greater. If
scarring from secondary intention is severe, loss of tissue function is often permanent
tertiary intention - Spontaneous opening of a previously closed wound, Closure of wounds
occurs when they are free of infection and edema, Extensive drainage and tissue debris,longer
healing time
Inflammatory stage- tissue and mast cells secrete histamine, resulting in vasodilation of
surrounding capillaries and movement/migration of serum and white blood cells into the
damaged tissues. This results in localized redness, edema, warmth, and throbbing. The
inflammatory response is beneficial, and there is no value in attempting to cool the area or
reduce the swelling unless the swelling occurs within a closed compartment
proliferative stage- With the appearance of new blood vessels as reconstruction progresses,
the proliferative phase begins and lasts from 3 to 24 days. The main activities during this
phase are the filling of a wound with granulation tissue, wound contraction, and
Dehiscence: A partial or total rupture (separation) of a sutured wound, usually with separation
of underlying skin layers. When an incision fails to heal properly, the layers of skin and tissue
separate.
Evisceration: A dehiscence that involves the protrusion of visceral organs through a wound
opening.
Hemorrhage: bleeding from a wound site, is normal during and immediately after initial
trauma. However, hemostasis occurs within several minutes unless large blood vessels are
involved, or a patient has poor clotting function. Hemorrhage occurring after hemostasis
indicates a dislodged surgical suture, a clot, infection, or erosion of a blood vessel by a foreign
object.
Infection: Wound infection is present when the microorganisms invade the wound tissues.
o Define any associated risk factors.
Dehiscence: patient who is at risk for poor wound healing (e.g., poor nutritional status, infection, or
underlying diseases such as diabetes mellitus or peripheral vascular disease) is at risk for
dehiscence. Obese patients have a higher risk of wound dehiscence because of the constant strain
placed on their wounds and the poor healing qualities of fat tissue. After a sudden strain such as
coughing, vomiting, or sitting up in bed.
Infection: contaminated or traumatic wounds
Hemorrhage: patient has poor clotting function
o What are indications of wound infection? The local clinical signs of wound infection can
include erythema; increased amount of wound drainage; change in appearance of the
wound drainage (thick, color change, presence of odor); and peri wound warmth, pain,
or edema.
Consider potential nursing diagnosis.
with a 22-gauge needle, pulling 0.5 mL of air into the syringe. Insert the needle through intact
skin next to the wound; withdraw plunger and apply suction to the 10-mL mark. the syringe is
capped and sent to the lab.
Quantitative Swab Procedure (Aerobic Organisms) Use a sterile swab from a culturette tube.
Identify a 1-cm area of the wound that is free from necrotic tissue. Rotate the swab while applying
pressure sufficient to express fluid from the wound tissue label, and transport to the laboratory.
Why may a client have a drain? Drains provide a means for fluid or blood that accumulates
within a wound bed to drain out of the body. placed by the interventional radiologist to drain an
area found after or before surgery.
What should the nurse asses if the client has a drain? Assess the number and type of drains,
drain placement, character of drainage, and condition of collecting equipment. Observe the
security of the drain and its location with respect to the wound. Next note the character of
drainage. If there is a collecting device, measure the drainage volume.
When may a client need an abdominal binder? A simple gauze dressing is often not enough to
immobilize or provide support to a wound and a larger dressing or bandage is required.
Binders are bandages that are made of large pieces of material, usually elastic or cotton, to fit
Cold therapy is designed to treat the localized inflammatory response of an injured body part that
presents as edema, hemorrhage, muscle spasm, or pain. Improvement to joint mobility
following cold therapy is related to reducing pain and swelling, inhibiting muscle spasm, and
reducing muscle tension. Before applying heat or cold therapies, assess a patient’s physical
condition for signs of potential intolerance to heat and cold. Cold is contraindicated if the
site of injury is already edematous. It further retards circulation to the area and prevents
absorption of the interstitial fluid. If a patient has impaired circulation. contraindicated in
the presence of neuropathy.
Warm applications are contraindicated when a patient has an acute, localized inflammation
such as appendicitis because the heat could cause the appendix to rupture. If a patient has
cardiovascular problems, it is unwise to apply heat to large parts of the body because the
resulting massive vasodilation disrupts blood supply to vital organs. Excessive heat causes a
burning sensation.
Inspection perform a head-to-toe observation of the patient for skin and mucous membrane color,
general appearance, level of consciousness, adequacy of systemic circulation, breathing patterns,
and chest wall movement. Clubbed nails often occur in patients with chronic oxygen
deficiency, such as cystic fibrosis and congenital heart defects. Also note the shape of the chest
wall. Conditions such as advancing age and chronic obstructive pulmonary disease (COPD)
cause the chest to assume a rounded “barrel” shape. Observe chest wall movement for
retraction and use of accessory muscles. Elevation of a patient’s clavicles at rest reveals
increased work of breathing. Also observe the patient’s breathing pattern.
point of maximal impulse. Palpate the pulses in the neck and extremities to assess arterial blood
flow.
Percussion detects the presence of abnormal fluid or air in the lungs. It also determines
diaphragmatic excursion, Adventitious breath sounds” is another term for abnormal breath
sounds. They include wheezing, crackles, and rhonchi. Wheezing is a continuous, high-pitched
musical sound caused by high-velocity movement of air through a narrowed airway. It is
associated with asthma, acute bronchitis, or pneumonia. It occurs during inspiration, expiration, or
both.
Auscultation helps identify normal and abnormal heart and lung sounds.
o What is the normal respiratory rate for an adult? At rest the normal adult respiratory rate
is 12 to 20 breaths/min
o Define the following terms:
Bradypnea- Rate of breathing is regular but abnormally slow (less than 12
breaths/min).
Tachypnea- Rate of breathing is regular but abnormally rapid (greater than 20
breaths/min).
Eupnea- is normal, good, unlabored breathing, sometimes known as quiet
breathing or resting respiratory rate
Apnea- Respirations cease for several seconds. Persistent cessation results in
respiratory arrest.
Define hypoxia. Hypoxia is inadequate tissue oxygenation at the cellular level. It results from a
deficiency in oxygen delivery or oxygen use at the cellular level. It is a life-threatening
condition. Causes of hypoxia include
(1) a decreased hemoglobin level and lowered oxygen-carrying capacity of the blood
(2) a diminished concentration of inspired oxygen, which occurs at high altitudes
(3) the inability of the tissues to extract oxygen from the blood, as with cyanide poisoning
(4) decreased diffusion of oxygen from the alveoli to the blood, as in pneumonia
(5) poor tissue perfusion with oxygenated blood, as with shock
(6) impaired ventilation, as with multiple rib fractures or chest trauma
o What are the early signs and symptoms of hypoxia?
Cyanosis, blue discoloration of the skin and mucous membranes caused by the
presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Central
cyanosis, observed in the tongue, soft palate, and conjunctiva of the eye where blood
flow is high, indicates hypoxemia. Peripheral cyanosis, seen in the extremities, nail
beds, and earlobes, is often a result of vasoconstriction and stagnant blood flow
Interventions- Oxygen is used to relieve or prevent hypoxia, which can lead to hypoxemia
o Describe the patient that may need a nasal cannula. to deliver supplemental oxygen or
increased airflow for flow rate 1-6 L/min: 24%-44% Effective for low concentrations
o Discuss techniques used during tracheostomy care.
Use surgical asepsis for all other types of suctioning.
Obtain baseline breath sounds and vital signs, including SaO2 by pulse oximeter. Can monitor
SaO2 continually during the procedure.
use no larger than a 16 French suction catheter when suctioning an 8 mm endotracheal tube
or tracheostomy tube. Hyper-oxygenate the client.
Use suction pressure no higher than 120 to 150 mm Hg.
Limit each suction attempt to no longer than 10 to 15 seconds to avoid hypoxemia and the
vagal response.
Repeat suctioning if needed. Limit total suctioning time to 5 min
o What are the indications for chest tube placement? - to remove air, fluids, or blood;
to prevent air or fluid from reentering the pleural space; or to reestablish normal
intrapleural and intrapulmonic pressures after trauma or surgery. chest tubes are
common after chest surgery and chest trauma and are used for treatment of
pneumothorax or hemothorax to promote lung re-expansion.
Describe the nursing role during the procedure:
Keep a chest tube drainage system closed and below the chest
Normal: 1200-1500 ml
Color: pale yellow, straw, amber, or transparent
Odor: Faint aromatic
Consistency: Clear liquid
pH: 4.6 to 8
Specific gravity: 1.010 to 1.025
Constituants: urea, uric acid, creatinine, hippuric acid, indican, urine pigments, undetermined nitrogen
Abnormal: Under 1200 ml
Color: Dark amber, Cloudy, dark orange, Red or dark brown
Odor: Offensive
Consistency: Mucous plugs, viscid, thick
pH: Under 4.5
Specific gravity: Over 1.025
Constituants: blood, pus, albumin, glucose, ketone bodies, casts, gross bacteria, and bile
Urinary retention is the inability to partially or completely empty the bladder. Acute or rapid-onset
urinary retention stretches the bladder, causing feelings of pressure, discomfort/pain,
tenderness over the symphysis pubis, restlessness, and sometimes diaphoresis. Patients may
have no urine output over several hours and in some cases experience frequency, urgency, small-
volume voiding, or incontinence of small volumes of urine. Postvoid residual (PVR) is the amount of
urine left in the bladder after voiding and is measured either by ultrasound or straight catheterization.
Discuss teaching needed for patient with a urinary tract infection (UTI).
patient with stress incontinence often has a long-term goal that depends on weeks of pelvic floor
muscle exercise to improve urinary control Kegel exercises.
be sitting or lying with head of bed at 30° to 45° while on enteral feeds at all times.
Discuss why a patient may need parenteral nutrition. What is the expected timeframe of the
Age- Older adults may have decreased chewing ability. Partially chewed food is not digested as
easily. Peristalsis declines, and esophageal emptying slow
Fluid intake- An inadequate fluid intake or disturbances resulting in fluid loss (such as vomiting)
affect the character of feces.
Physical activity- Physical activity promotes peristalsis, whereas immobilization depresses it.
Phycological Factors- Prolonged emotional stress impairs the function of almost all body systems,
digestive process is accelerated, and peristalsis is increased.
Personal Habbits- A busy work schedule sometimes prevents the individual from responding
appropriately to the urge to defecate, disrupting regular habits and causing possible alterations
such as constipation. Individuals need to recognize the best time for elimination.
Pregnancy- A temporary obstruction created by the fetus impairs passage of feces. Slowing of
peristalsis during the third trimester often leads to constipation.
Surgery- anesthetic agents used during surgery cause temporary cessation of peristalsi
Medications- For example, opioid analgesics slow peristalsis and contractions, often resulting in
constipation; and antibiotics decrease intestinal bacterial flora, often resulting in diarrhea
If a patient’s condition permits, raise the head of the bed to help him or her to a more normal
sitting position on a bedpan, enhancing the ability to defecate.
Define Constipation- infrequent bowel movements (less than three per week) and hard, dry
stools that are difficult to pass
o What is the type of diet that is best for constipation and provide some examples?
Define Diarrhea.
o What is the type of diet that is best for a patient with diarrhea and provide some
examples?
Discuss the role of the nurse in caring for a patient with the following an ostomy
(colostomy/ileostomy).
Remove used pouch and skin barrier gently, and observe amount of effluent
Note consistency of effluent, and record intake and output. Normal colostomy effluent is soft or
formed stool, whereas normal ileostomy effluent is liquid.
Observe existing skin barrier and pouch for leakage and length of time in place. Pouch should
be changed every 3 to 7 days, not daily
• The changes in a patient’s stoma and surrounding skin integrity that should be reported