Podcast
Questions and Answers
What is a primary benefit for nurses when involved in patient hygiene?
What is a primary benefit for nurses when involved in patient hygiene?
Which of the following is NOT a purpose of hygiene practices?
Which of the following is NOT a purpose of hygiene practices?
What should nurses consider when providing hygiene care to patients?
What should nurses consider when providing hygiene care to patients?
Which type of bath involves washing the entire body of a patient who cannot bathe themselves?
Which type of bath involves washing the entire body of a patient who cannot bathe themselves?
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When caring for patients with dementia during bathing, what is an essential approach?
When caring for patients with dementia during bathing, what is an essential approach?
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Which bed position is best for promoting breathing assistance?
Which bed position is best for promoting breathing assistance?
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What is a safety consideration when assisting with patient bathing?
What is a safety consideration when assisting with patient bathing?
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Who can hygiene tasks be delegated to in a nursing setting?
Who can hygiene tasks be delegated to in a nursing setting?
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Which of the following methods is NOT a core temperature measurement site?
Which of the following methods is NOT a core temperature measurement site?
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What is a potential cause of pulse deficit?
What is a potential cause of pulse deficit?
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Which of the following is an appropriate nursing intervention for bradypnea?
Which of the following is an appropriate nursing intervention for bradypnea?
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What factors influence respiratory rate and depth?
What factors influence respiratory rate and depth?
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What defines orthostatic hypotension?
What defines orthostatic hypotension?
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Which of the following is a sign of fever?
Which of the following is a sign of fever?
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What are the primary determinants of blood pressure?
What are the primary determinants of blood pressure?
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Which of the following statements about the Glasgow Coma Scale is true?
Which of the following statements about the Glasgow Coma Scale is true?
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When should an automated blood pressure cuff NOT be used?
When should an automated blood pressure cuff NOT be used?
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Study Notes
Nursing Hygiene Practices
- Nurses build rapport with patients through hygiene care.
- Assessments during hygiene include skin condition, range of motion, and potential complications.
- Hygiene practices remove dirt and bacteria, preventing infection and promoting comfort.
- Hygiene allows assessment of the patient's skin, mouth, and overall well-being.
- Client care considerations include patient preferences, culture, health conditions, and environment.
Types of Baths
- Complete Bath: Entire body wash for patients needing assistance.
- Partial Bath: Specific areas cleaned for patients who can bathe independently.
- Therapeutic Bath: Specific health purposes, like sitz baths or oatmeal baths.
Bathing Patients with Dementia
- Patience and understanding are key.
- Allow patient participation in routine as much as possible.
- Calming techniques reduce anxiety.
Patient Positions
- Flat: Resting/sleeping position.
- Fowler's: 45-60° for breathing/eating assistance.
- Semi-Fowler's: 30° for comfort/post-surgery.
- Trendelenburg: Head lower than feet, for venous return.
- Reverse Trendelenburg: Head higher than feet, for certain procedures/reducing reflux.
Hygiene Care Goals
- Encourage patient independence in hygiene.
- Ensure patient cleanliness and comfort.
- Promote skin integrity and prevent infection.
Hygiene Safety
- Ensure appropriate water temperature.
- Never leave patient unattended during hygiene.
- Provide mobility aids as needed.
- Prevent injury to both patient and nurse.
Delegation and Documentation
- Basic hygiene tasks can be delegated to nursing assistants.
- Nurses are responsible for overall patient assessment.
- Document assistance, skin condition, patient tolerance, and observed changes during hygiene.
Level of Consciousness Assessment
- Glasgow Coma Scale (GCS) assesses eye opening, verbal response, and motor response.
Vital Signs
- Vital signs reflect body homeostasis.
- They detect deviations needing immediate intervention.
- Routine vital signs can be delegated, but nurses interpret results.
Temperature Measurement
- Core sites include rectum, tympanic membrane, and esophagus.
- Surface sites include skin, mouth, and axilla.
Temperature Management
- Hyperthermia: Treat cause, cool patient with fluids/removing clothes.
- Hypothermia: Warm slowly with blankets, warm fluids, and adjusted environment.
Fever Management
- Fever symptoms include chills, skin flushing, increased pulse/respiratory rate.
- Nursing interventions include fluids, antipyretics, and rest.
Pulse Assessment
- Factors influencing pulse include age, activity, medications, stress, health.
- Assess rate, rhythm, strength, and equality.
- Bradycardia/tachycardia may indicate underlying conditions.
- Pulse deficit occurs when apical pulse exceeds radial pulse, indicating possible heart contraction inefficiency.
Respiratory Assessment
- Respiratory rate/depth influenced by age, physical state, altitude, and emotion.
- Bradypnea: Stimulate patient, investigate causes (sedatives). Administer oxygen if needed.
- Tachypnea: Address causes (pain, anxiety, respiratory issues), provide treatment to slow rate.
Altered Breathing Patterns & Sounds
- Cheyne-Stokes: Cycles of deep breathing/apnea
- Kussmaul's: Deep, rapid respirations
- Wheezing: High-pitched whistling sounds (often with asthma)
- Crackles: Bubbling/popping sounds (fluid in lungs).
Pulse Oximetry Accuracy
- Factors affecting accuracy include poor circulation, low hemoglobin, movement, and nail polish.
Oxygenation Goal
- Ideal pulse oximetry reading: 95-100% for most.
- Patients with COPD may have lower acceptable levels.
Blood Pressure Assessment
- Factors influencing blood pressure include age, gender, medications, stress, and position.
- Other influences include fluid volume and artery elasticity.
- Blood pressure determined by cardiac output and systemic vascular resistance.
Hypertension and Hypotension
- Hypertension: Causes include stress, obesity, high sodium diet.
- Hypotension: Causes include dehydration, heart failure, excessive vasodilation.
Orthostatic Hypotension
- Drop in blood pressure upon standing (systolic decrease of 20 mmHg or diastolic decrease of 10 mmHg).
- May cause dizziness/fainting.
Blood Pressure Measurement
- Automated cuffs useful for routine checks but not for irregular heart rates, trauma, or rapidly changing conditions (manual measurement is usually more accurate).
- Errors such as cuff size (too small/large) can lead to false readings.
Pain as the 5th Vital Sign
- Nurses assess pain regularly, document level, and intervene to manage pain.
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Description
This quiz explores the essential hygiene practices in nursing, including types of baths and techniques for bathing patients with dementia. It emphasizes the importance of patient comfort, assessment, and individualized care based on patient needs and preferences.
