Nursing 308 exam 1 with !| !| !| !| !|
precise detailed solutions !| !|
AM care, hygiene, and activities of daily living
!| !| !| !| !| !| !|
Often delegated to assistive personnel
!| !| !| !|
Speech Pathology's Aspiration Precautions
!| !| !|
Thickened liquids, head of bed elevated, swallow twice, cough after
!| !| !| !| !| !| !| !| !| !|
swallowing, NO STRAWS, suction available. !| !| !| !|
Oral intake formula
!| !|
1 oz = 30 mL
!| !| !| !|
Impaired dentition/Impaired mucous membrane integrity outcomes/goals
!| !| !| !| !|
Oral cavity is intact, clean, and moist. Assesses teeth, gums, oral cavity, and
!| !| !| !| !| !| !| !| !| !| !| !| !|
need for dental referral.
!| !| !|
Bridges (fake attached teeth) !| !| !|
Permanant or removable !| !|
Edentulous patients !|
Have NO teeth. Remove and clean dentures. Rinse well after soaking in
!| !| !| !| !| !| !| !| !| !| !| !|
denture cleanser. Label denture cup. !| !| !| !|
Oral care frequency
!| !|
Twice daily (BID) to q 2 hours. Use a toothbrush and floss to remove plaque.
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
Oral swabs !|
NOT adequate for removing plaque but can be used to moisten the mouth.
!| !| !| !| !| !| !| !| !| !| !| !|
Mouthwash
,Use a non-alcohol-based mouth wash. Chlorohexidine antibacterial
!| !| !| !| !| !| !|
mouthwash ordered to prevent ventilator associated pneumonia. !| !| !| !| !| !|
What kind of oral care is given to a patient with decreased consciousness?
!| !| !| !| !| !| !| !| !| !| !| !|
Toothbrush with suction to prevent aspiration. !| !| !| !| !|
Bite block/padded tongue
!| !|
Used to prevent patient from biting the toothbrush, swab, or your finger.
!| !| !| !| !| !| !| !| !| !| !|
Outcomes/goals of bathing a patient !| !| !| !|
Skin is clean, intact, elastic, and well hydrated. Assess skin and report
!| !| !| !| !| !| !| !| !| !| !| !|
abnormalities. Use bathing as an opportunity communicate privately. !| !| !| !| !| !| !|
Bath timing
!|
Morning, evening, or night. Provide privacy (close the curtain/door).
!| !| !| !| !| !| !| !|
Types of baths !| !|
Complete a bath in bed or chair. Most products are rinse free. Foot soak is
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
optional.
Cleansing the eye !| !|
From inner to outer canthus without soap.
!| !| !| !| !| !|
Partial bath !|
Assist with the back, feet, or areas the patient can NOT reach. Velcro mitt if
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
patient can only use one arm. !| !| !| !| !|
Moist bathing wipes !| !|
Disposable bathing wipes in warming unit. Follow hospital protocol for
!| !| !| !| !| !| !| !| !| !|
heating. Microwaves CANNOT be used. !| !| !| !|
Bathing in bathroom sink !| !| !|
Assess the need for a chair. Cover the chair with a bath blanket/under pad.
!| !| !| !| !| !| !| !| !| !| !| !| !|
,Bath thermometer !|
A pediatric thermometer is cost effective and easy to read.
!| !| !| !| !| !| !| !| !|
Portable tub with handheld sprayer !| !| !| !|
Looks like cart/gurney. Secure the hose so water does NOT get on the floor
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
during transport. Disinfect bath equipment and tubs between patients.
!| !| !| !| !| !| !| !|
Chlorohexidine Bath !|
Bathe with 6 Chlorohexidine wipes kept in a warmer. Used on ICU patients
!| !| !| !| !| !| !| !| !| !| !| !| !|
with a central IV line. DO NOT wash off with soap or use incompatible
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
moisturizers or barrier creams. !| !| !|
Order of Chlorohexidine Bath wipes
!| !| !| !|
1) Neck 2) Arms 3) Perineal area 4) Right leg 5) Left leg 6) Back of
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
neck/midback/buttock. Not used above the neck. !| !| !| !| !|
Dry skin !|
Common in older adults and African Americans. Hydrating cleansers are
!| !| !| !| !| !| !| !| !| !|
appropriate (Cetaphil). Only bathe essential areas (hands, face, axillae, and
!| !| !| !| !| !| !| !| !| !|
perineum).
Humectants
Brings up moisture from within !| !| !| !|
Emollients
Seal in moisture but may be greasy
!| !| !| !| !| !|
Shaving
Wear gloves and dispose of razor in the sharps container. Electric razors
!| !| !| !| !| !| !| !| !| !| !| !|
must be checked by Biomedical engineering for electrical safety before use.
!| !| !| !| !| !| !| !| !| !| !|
Do not use if oxygen is present.
!| !| !| !| !| !|
Perineal care !|
, Assess whether the patient can perform self-care. Provide as often as needed
!| !| !| !| !| !| !| !| !| !| !| !|
with perineal cleanser or wipes. Most wipes CANNOT be thrown in the
!| !| !| !| !| !| !| !| !| !| !| !|
toilet. Apply barrier cream to protect skin if needed.
!| !| !| !| !| !| !| !|
Perineal washing !|
Pour water over perineum in bedpan. Portable sitz bath sits over the toilet to
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
cleanse the perineum. !| !|
How do you change a patient with an IV?
!| !| !| !| !| !| !| !|
Remove gown from the arm with the IV last. When redressing, put the IV
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
arm in the gown first.
!| !| !| !|
Hemiplegic
One sided paralysis of arm/face/leg.
!| !| !| !|
How to dress a hemiplegic patient
!| !| !| !| !|
Undress the unaffected side first. Redress the affected side first.
!| !| !| !| !| !| !| !| !|
Thromboembolic Deterrent (TED Hose) !| !| !|
Apply knee or thigh high elastic (TED hose) to increase venous return and
!| !| !| !| !| !| !| !| !| !| !| !| !|
prevent venous thromboembolism (a blot clot in the leg that travels to the
!| !| !| !| !| !| !| !| !| !| !| !| !|
lung). Contraindicated in peripheral arterial disease (PAD).
!| !| !| !| !| !|
How to measure a TED hose
!| !| !| !| !|
Measure the widest part of the calf and length to the knee or gluteal fold.
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
How to put on a TED hose
!| !| !| !| !| !|
Fold inside out to the heel and hold the heel. Apply to the heal, then slide
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
the stocking over the heel.
!| !| !| !|
What kind of person is it hard to find a correctly fitting TED hose for?
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
A short person.
!| !|
Putting on hearing aids !| !| !|
precise detailed solutions !| !|
AM care, hygiene, and activities of daily living
!| !| !| !| !| !| !|
Often delegated to assistive personnel
!| !| !| !|
Speech Pathology's Aspiration Precautions
!| !| !|
Thickened liquids, head of bed elevated, swallow twice, cough after
!| !| !| !| !| !| !| !| !| !|
swallowing, NO STRAWS, suction available. !| !| !| !|
Oral intake formula
!| !|
1 oz = 30 mL
!| !| !| !|
Impaired dentition/Impaired mucous membrane integrity outcomes/goals
!| !| !| !| !|
Oral cavity is intact, clean, and moist. Assesses teeth, gums, oral cavity, and
!| !| !| !| !| !| !| !| !| !| !| !| !|
need for dental referral.
!| !| !|
Bridges (fake attached teeth) !| !| !|
Permanant or removable !| !|
Edentulous patients !|
Have NO teeth. Remove and clean dentures. Rinse well after soaking in
!| !| !| !| !| !| !| !| !| !| !| !|
denture cleanser. Label denture cup. !| !| !| !|
Oral care frequency
!| !|
Twice daily (BID) to q 2 hours. Use a toothbrush and floss to remove plaque.
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
Oral swabs !|
NOT adequate for removing plaque but can be used to moisten the mouth.
!| !| !| !| !| !| !| !| !| !| !| !|
Mouthwash
,Use a non-alcohol-based mouth wash. Chlorohexidine antibacterial
!| !| !| !| !| !| !|
mouthwash ordered to prevent ventilator associated pneumonia. !| !| !| !| !| !|
What kind of oral care is given to a patient with decreased consciousness?
!| !| !| !| !| !| !| !| !| !| !| !|
Toothbrush with suction to prevent aspiration. !| !| !| !| !|
Bite block/padded tongue
!| !|
Used to prevent patient from biting the toothbrush, swab, or your finger.
!| !| !| !| !| !| !| !| !| !| !|
Outcomes/goals of bathing a patient !| !| !| !|
Skin is clean, intact, elastic, and well hydrated. Assess skin and report
!| !| !| !| !| !| !| !| !| !| !| !|
abnormalities. Use bathing as an opportunity communicate privately. !| !| !| !| !| !| !|
Bath timing
!|
Morning, evening, or night. Provide privacy (close the curtain/door).
!| !| !| !| !| !| !| !|
Types of baths !| !|
Complete a bath in bed or chair. Most products are rinse free. Foot soak is
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
optional.
Cleansing the eye !| !|
From inner to outer canthus without soap.
!| !| !| !| !| !|
Partial bath !|
Assist with the back, feet, or areas the patient can NOT reach. Velcro mitt if
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
patient can only use one arm. !| !| !| !| !|
Moist bathing wipes !| !|
Disposable bathing wipes in warming unit. Follow hospital protocol for
!| !| !| !| !| !| !| !| !| !|
heating. Microwaves CANNOT be used. !| !| !| !|
Bathing in bathroom sink !| !| !|
Assess the need for a chair. Cover the chair with a bath blanket/under pad.
!| !| !| !| !| !| !| !| !| !| !| !| !|
,Bath thermometer !|
A pediatric thermometer is cost effective and easy to read.
!| !| !| !| !| !| !| !| !|
Portable tub with handheld sprayer !| !| !| !|
Looks like cart/gurney. Secure the hose so water does NOT get on the floor
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
during transport. Disinfect bath equipment and tubs between patients.
!| !| !| !| !| !| !| !|
Chlorohexidine Bath !|
Bathe with 6 Chlorohexidine wipes kept in a warmer. Used on ICU patients
!| !| !| !| !| !| !| !| !| !| !| !| !|
with a central IV line. DO NOT wash off with soap or use incompatible
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
moisturizers or barrier creams. !| !| !|
Order of Chlorohexidine Bath wipes
!| !| !| !|
1) Neck 2) Arms 3) Perineal area 4) Right leg 5) Left leg 6) Back of
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
neck/midback/buttock. Not used above the neck. !| !| !| !| !|
Dry skin !|
Common in older adults and African Americans. Hydrating cleansers are
!| !| !| !| !| !| !| !| !| !|
appropriate (Cetaphil). Only bathe essential areas (hands, face, axillae, and
!| !| !| !| !| !| !| !| !| !|
perineum).
Humectants
Brings up moisture from within !| !| !| !|
Emollients
Seal in moisture but may be greasy
!| !| !| !| !| !|
Shaving
Wear gloves and dispose of razor in the sharps container. Electric razors
!| !| !| !| !| !| !| !| !| !| !| !|
must be checked by Biomedical engineering for electrical safety before use.
!| !| !| !| !| !| !| !| !| !| !|
Do not use if oxygen is present.
!| !| !| !| !| !|
Perineal care !|
, Assess whether the patient can perform self-care. Provide as often as needed
!| !| !| !| !| !| !| !| !| !| !| !|
with perineal cleanser or wipes. Most wipes CANNOT be thrown in the
!| !| !| !| !| !| !| !| !| !| !| !|
toilet. Apply barrier cream to protect skin if needed.
!| !| !| !| !| !| !| !|
Perineal washing !|
Pour water over perineum in bedpan. Portable sitz bath sits over the toilet to
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
cleanse the perineum. !| !|
How do you change a patient with an IV?
!| !| !| !| !| !| !| !|
Remove gown from the arm with the IV last. When redressing, put the IV
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
arm in the gown first.
!| !| !| !|
Hemiplegic
One sided paralysis of arm/face/leg.
!| !| !| !|
How to dress a hemiplegic patient
!| !| !| !| !|
Undress the unaffected side first. Redress the affected side first.
!| !| !| !| !| !| !| !| !|
Thromboembolic Deterrent (TED Hose) !| !| !|
Apply knee or thigh high elastic (TED hose) to increase venous return and
!| !| !| !| !| !| !| !| !| !| !| !| !|
prevent venous thromboembolism (a blot clot in the leg that travels to the
!| !| !| !| !| !| !| !| !| !| !| !| !|
lung). Contraindicated in peripheral arterial disease (PAD).
!| !| !| !| !| !|
How to measure a TED hose
!| !| !| !| !|
Measure the widest part of the calf and length to the knee or gluteal fold.
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
How to put on a TED hose
!| !| !| !| !| !|
Fold inside out to the heel and hold the heel. Apply to the heal, then slide
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
the stocking over the heel.
!| !| !| !|
What kind of person is it hard to find a correctly fitting TED hose for?
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
A short person.
!| !|
Putting on hearing aids !| !| !|
