26 Questions
When is a Tepid Sponge Bath recommended?
To promote dispersal of body heat when the body temperature is 39.5°C and over
What is an indication that a patient may benefit from a sponge bath?
Bedsores forming due to inability to move
What is the main principle behind tepid sponging?
Evaporation and conduction
Why might hospitals use a sponge bath for some patients?
For clients who have mobility issues and can't safely bathe in a tub
What is the purpose of evaporation in tepid sponging?
To lose heat from the body
Who might particularly benefit from a sponge bath according to the text?
Patients with mobility issues
What can happen if excess dirt or oil on the body is not addressed?
Increased risk of infections
What is an alternative reason for using a sponge bath for young babies according to the text?
Concern about slipping in large tubs
What might be an effect of using tepid sponging on a patient with a fever?
Reducing their body temperature
Why is tepid sponging recommended for patients with mobility issues in hospitals?
To aid in cleaning when traditional bathing is not possible
What should be documented to establish irreversible cardiorespiratory arrest has occurred?
Total of heart and respiratory sounds for at least five minutes
Who is responsible for pronouncing the death and providing the time for documentation?
The health care provider who completes the assessment
What action is recommended if a patient is found unresponsive with no respirations, pulse, or heart sounds?
Immediately begin CPR
What should be done based on an advance directive and a signed DNR order in the patient's chart?
Perform postmortem care
Why is it important to document any discussions with staff members or relatives of the deceased in relation to the death?
To show transparency in communication
What information should be documented regarding the disposition of the patient's body?
Name, telephone number, and address of the funeral home
What is the recommended nursing care for an unconscious client?
Lateral position
In what position should a conscious client be placed according to the text?
Fowler’s position
Which action should be taken if a client is diaphoretic according to the text?
Change linens
What is a measure included in the skin care recommendations for clients with incontinence?
Moisturizing cream and lotions
When should catheterization be considered according to the text?
Client feels pressure touch
What is a key nursing implication for a client in the denial stage of grieving?
Dealing with practical problems like prosthesis
What is a common response of a client in the denial stage of grieving according to Kübler-Ross's model?
Refusing to believe that loss is happening
What could be a potential nursing intervention for a client experiencing pain during the grieving process?
Following a pain management protocol
What type of nursing care might be needed for an end-stage dementia patient?
Application of moisturizing cream and lotions
When should an unconscious client receive oxygen inhalation according to the text?
When placing in lateral position
Study Notes
Medical Asepsis and Hand Hygiene
- Sterile means free of all microorganisms.
- Good hand hygiene is the first line of defense in medical asepsis.
- Hand washing is the easiest and most effective way to prevent and control the transmission of infectious agents.
Hand Washing Procedure
- Assemble equipment and assess hands for breaks in the skin.
- Approach the sink without touching uniform to the sink.
- Turn on the water with foot or knee control and regulate the temperature.
- Wet hands and lower forearm thoroughly under running water.
- Apply generous amounts of soap or gel and rub each part of the hands.
- Rinse hands and forearms thoroughly and dry with a paper towel.
Personal Hygiene
- Hygiene is the practice of cleanliness that is conducive to the preservation of health.
- Assisting patients with hygienic and personal care activities is an essential nursing function.
- Personal hygiene measures include cleaning, bathing, and oral care.
Bathing
- Provide privacy and keep the patient warm during bathing.
- Use a bed bath for patients who are unable to use a tub or shower.
- Keep the bed in a flat position and remove top linens to keep them from getting wet.
- Use a washcloth and soap to clean the patient's eyes, face, and body.
- Pay special attention to areas behind and around the ears and between the toes.
Oral Hygiene
- Provide privacy and use a washcloth to clean the mouth and teeth.
- Use a separate corner of the washcloth for each eye and wipe from the inner to the outer canthus.
- Rinse and dry the patient's mouth and teeth thoroughly.
Foot Care
- Assemble equipment and supplies and sit in a chair to facilitate immersing feet in a basin.
- Warm water softens nails and thickened epidermal cells, reduces inflammation of skin, and promotes local circulation.
- Concurrently assess skin and function, noting dryness, redness, cracks, blisters, discoloration, trauma, pain, numbness, tingling, swelling, muscle wasting, decreased sensation, hair growth, or pulse.
- Check pulses, turgor, and capillary refill.
Physiologic Changes After Death
- Death is recognized when respiration and cardiac action cease.
- Rigor mortis (post-mortem rigidity) occurs 2-4 hours after death and starts in the involuntary muscles.
- Algor mortis (post-mortem cooling) is a gradual decrease of the body's temperature after death.
- Livor mortis (post-mortem lividity) is bluish discoloration of the skin after death.
- Putrefaction is the destruction of a dead body by bacteria.
Five Stages of Grief
- Denial: avoid reinforcing denial and help clients understand that anger is a normal response to feelings of loss and powerlessness.
- Anger: help clients understand that anger is a normal response to feelings of loss and powerlessness.
- Bargaining: listen attentively and encourage clients to talk to relieve guilt and irrational fear.
- Depression: allow clients to express sadness and communicate nonverbally by sitting quietly without expecting conversation.
- Acceptance: help family and friends understand client's decreased need to socialize and encourage clients to participate as much as possible in the treatment program.
Learn about the essential techniques for making a patient's bed in a nursing setting, ensuring comfort, convenience, and hygiene. Proper bed-making can enhance patient care and save time and resources.
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