Fundamental of Nursing Exam Revision PDF

Hygiene learning outcomes: **1. Describe hygienic care that nurses provide to clients.** - Nurses provide hygienic care that includes **bathing**, **oral care**, **perineal care**, **nail and foot care**, **hair care**, and **back care**. These tasks help maintain cleanliness, prevent...

Hygiene learning outcomes: **1. Describe hygienic care that nurses provide to clients.** - Nurses provide hygienic care that includes **bathing**, **oral care**, **perineal care**, **nail and foot care**, **hair care**, and **back care**. These tasks help maintain cleanliness, prevent infections, promote comfort, and enhance well-being. In certain cases, therapeutic baths may be given to address specific health conditions such as skin irritation. **2. Identify factors influencing personal hygiene.** - Personal hygiene practices are influenced by several factors, including: - **Cultural and religious beliefs**: Different cultures have varying practices related to hygiene. - **Socioeconomic status**: Access to hygiene supplies and facilities can affect how personal hygiene is maintained. - **Physical and cognitive ability**: Individuals with limited mobility, illness, or cognitive impairments may require assistance with hygiene. - **Personal preferences**: Individual choices related to how and when hygiene is performed. - **Developmental stage**: Children, adults, and elderly people have different needs for hygiene. **3. Identify normal and abnormal assessment findings while providing hygiene care.** - **Normal findings** during hygiene care include: - Skin: Warm, dry, intact skin without lesions or pressure sores. - Nails: Smooth and clean nails without signs of infection. - Mouth: Pink gums, clean teeth, and no signs of plaque or infection. - Hair: Clean and free of lice or dandruff. - **Abnormal findings** include: - Skin: Pressure sores, redness that doesn't blanch, excessive dryness, or lesions. - Nails: Signs of fungal infections, ingrown nails, or thickened nails (common in diabetics). - Mouth: Plaque, gingivitis, cracked lips, or oral mucosa abnormalities. - Hair: Lice, dandruff, excessive hair loss. **4. Apply the nursing process to common problems related to hygienic care of the skin, feet, nails, mouth, hair, eyes, ears, and nose.** - **Assessment**: Collect data on hygiene practices, functional ability, and any skin or hygiene-related issues. - **Diagnosis**: Common diagnoses related to hygiene include **Bathing Self-Care Deficit**, **Impaired Skin Integrity**, **Risk for Infection**, **Risk for Impaired Oral Mucous Membrane**, and **Deficient Knowledge**. - **Planning**: Set specific hygiene goals with the patient, such as maintaining intact skin or preventing oral infections. - **Implementation**: Provide hygiene care based on the patient\'s needs, such as giving a bed bath, performing oral care, or assisting with foot care. - **Evaluation**: Assess whether the hygiene goals have been met, such as improved skin integrity or a reduction in infection risk. **5. Identify the purpose of bathing.** - Bathing serves several important purposes: - Cleansing the skin to remove sweat, oils, dead skin cells, and bacteria. - Stimulating circulation through the gentle action of washing and drying the body. - Providing comfort and a sense of well-being. - Offering an opportunity for the nurse to assess the patient\'s skin condition. **6. Describe various types of bathing.** - **Complete bed bath**: The nurse washes the entire body of the patient, often for those who are bedridden or unable to bathe themselves. - **Self-help bed bath**: The patient washes parts of their body, and the nurse assists with areas that are difficult to reach. - **Partial bath**: Only parts of the body that need to be cleaned are washed, such as the face, hands, axillae, and perineal area. - **Bag bath**: Pre-moistened disposable cloths are used to clean the patient without water. - **Towel bath**: Similar to a bag bath, but larger towels are used. - **Tub bath**: The patient sits in a tub of water, often used for those who can bathe themselves with minimal assistance. - **Shower**: The patient showers independently or with minimal assistance. **7. Identify specific ways in which nurses help hospitalized clients with hygiene.** - Nurses help hospitalized clients by providing: - **Bed baths or assistance with bathing** for patients with limited mobility. - **Oral care**, especially for unconscious patients or those unable to perform oral care themselves. - **Perineal care** to prevent infections and promote comfort. - **Foot care** for patients with diabetes or vascular issues. - **Nail care** to maintain hygiene and prevent infections. - **Hair care**, including brushing and washing. - **Back massages** to promote relaxation and enhance circulation. **8. Describe steps for identified hygienic-care procedures.** - The steps for common hygienic-care procedures generally include: - **Assessment**: Gather information about the patient\'s needs and skin condition before starting the procedure. - **Preparation**: Gather necessary supplies and explain the procedure to the patient. - **Procedure**: Perform the hygiene task (e.g., bathing, oral care) following best practices for cleanliness, safety, and patient comfort. - **Follow-up**: Ensure the patient is comfortable, assess the outcome of the care, and document the procedure. **9. Identify safety and comfort measures underlying bed-making procedures.** - When making a bed, it is important to: - **Maintain proper body mechanics** to prevent nurse injury. - **Use side rails or support devices** to prevent patient falls. - **Ensure the bed is wrinkle-free** to prevent skin irritation and pressure sores. - **Provide patient comfort** by adjusting the bed position and ensuring cleanliness. - **Use clean linen** to prevent infections and promote hygiene. Here are the **common problems** mentioned in the PowerPoint presentation related to hygiene care: **1. Skin Problems:** - **Pressure ulcers**: Often due to prolonged pressure on the skin. - **Dry skin**: Can lead to cracking and infection. - **Calluses**: Thickened skin due to friction or pressure, especially on feet. - **Corns**: Hardened areas of skin caused by friction or pressure from shoes. - **Fissures**: Cracks in the skin, commonly between the toes. - **Plantar warts**: Caused by a virus, often found on the soles of the feet. - **Athlete's foot (Tinea pedis)**: A fungal infection of the skin, usually between the toes. - **Ingrown toenails**: Nails growing into the skin, causing pain and possible infection. **2. Oral Problems:** - **Plaque**: A sticky film of bacteria on the teeth. - **Tartar**: Hardened plaque on the teeth. - **Gingivitis**: Inflammation of the gums. - **Advanced periodontal disease (Pyorrhea)**: Severe infection of the gums that can lead to tooth loss. - **Xerostomia (Dry mouth)**: Can be caused by medications or dehydration. **3. Nail and Foot Problems:** - **Risk for infection**: Particularly around the nail bed if the nails are not properly cared for. - **Diabetic foot issues**: Including the risk of infection, poor circulation, and neuropathy. - **Deficient knowledge regarding diabetic foot care**: Many patients are unaware of proper care techniques. **4. Hair and Scalp Problems:** - **Dandruff**: Flaking of the scalp due to dry skin. - **Alopecia**: Hair loss. - **Pediculosis (Lice)**: Parasitic insects that infest the hair. - **Hirsutism**: Excessive hair growth. **5. Self-Care Deficits:** - **Bathing Self-Care Deficit**: Inability to bathe oneself due to physical or cognitive limitations. - **Dressing Self-Care Deficit**: Difficulty or inability to dress oneself. - **Toileting Self-Care Deficit**: Difficulty managing toileting activities independently. **6. Risk for Impaired Skin Integrity:** - Patients with limited mobility or incontinence are at higher risk of skin breakdown. **7. Body Odor:** - Caused by bacteria acting on body secretions, often exacerbated by poor hygiene. learning outcomes from the **Vital Signs Part 1** PowerPoint: **1. Discuss the importance of human Vital Signs (V/S).** - Vital signs provide **important clues** about whether the body is functioning normally. They serve as measurable indicators of the body's physiological state and can reflect changes in health status. Vital signs are crucial for **monitoring** the body's response to treatment and help in early detection of potential health issues. They are essential for ensuring **safe, high-quality care**. **2. Determine when to assess the V/S.**\ Vital signs should be assessed: - On **admission** to a healthcare facility. - When there is a **change** in the client's health status. - If the client reports **symptoms** like chest pain, feeling faint, or feeling hot. - Before and after **surgery** or invasive procedures. - Before and after administering **medications** that affect the cardiovascular or respiratory systems. - Before and after a **nursing intervention** that may affect vital signs (e.g., ambulating a bedrest patient). **3. Describe factors that affect the vital signs and accurate measurement of them.**\ Factors influencing vital signs include: - **Age**: Vital signs vary significantly across different age groups. - **Exercise**: Increases pulse and respiratory rates and may affect body temperature. - **Hormones**: Changes in hormone levels can affect body temperature and other vital signs. - **Stress**: Can elevate heart rate, blood pressure, and respiration. - **Environment**: External temperature can impact body temperature and respiration. - **Medications**: Can alter heart rate, blood pressure, and other vital signs. - **Time of Day (Diurnal variations)**: Vital signs fluctuate throughout the day, with body temperature usually lower in the morning. **4. Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age.** - **Infants**: Tend to have higher body temperature, pulse, and respiratory rates compared to adults. - **Children**: Vital signs gradually stabilize but are still higher than adults. - **Adults**: Normal temperature ranges between 36°C and 37.5°C, with pulse and respiratory rates within the standard ranges. - **Older adults**: Typically have a lower core body temperature and reduced pulse and respiratory rates. **5. Compare methods of measuring body temperature.** - **Oral**: Common and accurate; affected by intake of food or fluids. - **Rectal**: Considered the most accurate but invasive. - **Axillary**: Less accurate than oral or rectal, often used for newborns. - **Tympanic (Ear)**: Measures core temperature via the ear canal. - **Temporal artery**: Non-invasive and quick; measures temperature across the forehead. **6. Describe appropriate nursing care for alterations in body temperature.** - **Hyperthermia (fever)**: Monitor temperature regularly, keep patient hydrated, and provide cool compresses if needed. Administer antipyretics if ordered. - **Hypothermia**: Gradually warm the patient using blankets, warm fluids, and monitor temperature closely to prevent shock. - Keep the environment comfortable and dry, and assess for signs of complications. **7. Identify sites used to assess the pulse and state the reasons for their use.** - **Radial pulse**: Common site, easily accessible for routine assessment. - **Carotid pulse**: Used in emergencies when peripheral pulses are difficult to assess. - **Apical pulse**: Used to assess pulse in infants or when a more accurate reading is needed (e.g., in patients with irregular heartbeats). - **Brachial pulse**: Often used for blood pressure measurement. - **Femoral pulse**: Assessed during critical situations to check circulation to the legs. **8. List the characteristics that should be included when assessing pulses.** - **Rate**: Number of beats per minute. - **Rhythm**: The regularity of beats (regular or irregular). - **Strength (Amplitude)**: The force of the pulse (bounding, strong, weak, thready). - **Equality**: Compare pulses on both sides of the body to ensure they are equal. **9. Describe the mechanics of breathing and the mechanisms that control respirations.** - **Breathing mechanics**: Inhalation occurs when the diaphragm and intercostal muscles contract, expanding the chest cavity and drawing air into the lungs. Exhalation is passive, as these muscles relax, forcing air out of the lungs. - **Respiratory control**: The medulla oblongata and pons regulate breathing. Chemoreceptors in the brainstem and arteries detect levels of carbon dioxide, oxygen, and pH, adjusting respiration accordingly. **10. Identify the components of a respiratory assessment.** - **Rate**: Count the number of breaths per minute. - **Rhythm**: Check for regular or irregular breathing patterns. - **Depth**: Assess whether breaths are shallow, deep, or normal. - **Effort**: Determine if breathing is labored or effortless. **11. Differentiate systolic from diastolic blood pressure.** - **Systolic pressure**: The pressure in the arteries during the contraction of the heart (highest pressure). - **Diastolic pressure**: The pressure in the arteries when the heart is at rest between beats (lowest pressure). **12. Describe five phases of Korotkoff's sounds.**\ Korotkoff sounds are used to measure blood pressure: 1. **Phase 1**: Sharp tapping (systolic pressure). 2. **Phase 2**: Swishing or whooshing sound. 3. **Phase 3**: A crisper, more intense tapping. 4. **Phase 4**: A softer, muffled sound. 5. **Phase 5**: Silence (diastolic pressure). **13. Describe methods and sites used to measure blood pressure.** - **Auscultation**: Using a stethoscope and sphygmomanometer to listen for Korotkoff sounds. - **Automated BP cuffs**: Provide a digital reading without auscultation. - **Sites**: Typically measured on the **brachial artery**, but can also be assessed at the thigh (popliteal artery) or wrist (radial artery) if necessary. **14. Discuss measurement of blood oxygenation using pulse oximetry.** - **Pulse oximetry** measures the oxygen saturation (SaO2) in the blood, usually via a clip on the fingertip, earlobe, or toe. Normal values range from 95% to 100%. It is a non-invasive method to quickly assess oxygen levels in patients, especially those with respiratory conditions. **(summary) Hygiene in Nursing Care:** **1. Importance of Hygiene Care:** - Promotes **cleanliness**, **comfort**, and **well-being**. - Helps in **preventing infections** and allows for **skin assessment**. - Supports a patient\'s **self-esteem** and **mental health**. **2. Types of Hygiene Care:** - **Bathing**: Complete, partial, self-help, therapeutic, or bed baths. - **Oral care**: For all patients, especially important for unconscious or dependent patients to prevent infections. - **Perineal care**: Prevents infections and promotes comfort, particularly for incontinent patients. - **Foot and nail care**: Important for diabetic patients to prevent infections and ulcers. - **Hair care**: Helps with cleanliness, preventing lice, and promoting comfort. **3. Factors Influencing Hygiene Practices:** - **Age**, **culture**, **socioeconomic status**, **physical and cognitive abilities**, and **personal preferences**. **4. Common Problems in Hygiene Care:** - **Pressure ulcers**, **dry skin**, **calluses**, **oral infections**, and **nail disorders**. - **Bathing self-care deficit**: Patients who need assistance with bathing. **5. Nursing Process for Hygiene Care:** - **Assessment**: Gather information about the patient's ability to perform hygiene independently. - **Planning**: Create hygiene care goals. - **Implementation**: Assist or perform hygiene care as needed. - **Evaluation**: Assess outcomes, such as skin integrity or infection prevention. **Vital Signs:** **1. Importance of Vital Signs (V/S):** - Vital signs reflect a patient's **health status** and physiological functioning. - Key for **monitoring response** to treatment and identifying health issues early. **2. Components of Vital Signs:** - **Temperature**, **Pulse**, **Respirations**, **Blood Pressure**, **Pulse Oximetry**, and **Pain**. **3. When to Assess Vital Signs:** - Upon **admission**, during **status changes**, before/after **surgery**, before/after administering **medications**, and after **interventions** that could affect V/S. **4. Factors Influencing Vital Signs:** - **Age**, **exercise**, **hormones**, **stress**, **environment**, **medications**, and **time of day**. **5. Normal Variations in Vital Signs Across the Lifespan:** - **Infants**: Higher heart rate, respiration, and temperature. - **Older adults**: Lower core temperature and slower pulse. **6. Body Temperature Measurement:** - Methods: **Oral**, **axillary**, **rectal**, **tympanic**, and **temporal artery**. - Factors affecting temperature: **Age**, **circadian rhythms**, **exercise**, **hormones**, **stress**, and **environment**. **7. Pulse Assessment:** - **Sites**: Radial, carotid, apical, brachial, and femoral. - **Characteristics**: Rate, rhythm, strength, and equality. **8. Blood Pressure:** - **Systolic** (pressure during heart contraction) and **Diastolic** (pressure during relaxation). - **Methods**: Auscultation using a stethoscope and sphygmomanometer or automated BP cuffs. **9. Respiratory Assessment:** - Observe **rate**, **rhythm**, **depth**, and **effort** of breathing. **10. Pulse Oximetry:** - Measures oxygen saturation in the blood (normal range: **95%-100%**). Vital signs 2 pptx learning outcomes: **1. Define blood pressure and identify normal values for systolic and diastolic blood pressure.** - **Blood pressure (BP)** is the force exerted by circulating blood on the walls of the arteries. It consists of two measurements: - **Systolic pressure**: The pressure when the ventricles of the heart contract (\