Fall 2021 NU211: Hygiene by Stephanie https://padlet.com/chungst/qyfoqcrcp31n5oyy For your assigned topic please report on the Assessment of the body area, an appropriate Nursing diagnosis, Outcomes/Interventions, Goals, and any appropriate Client teaching en-us 2021-09-14 13:45:34 UTC 2024-03-10 20:44:34 UTC hello@padlet.com https://padlet.net/icons/png/1f485.png chungst https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/331277930 2019-02-14 13:51:57 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/331277930 Assessment https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1745997106 1) Subjective data - history, nail care practices, and their treatments. 
2) Objective - inspection, contour and cleanliness, appearance (manicured and trimmed), red or cracks]]> 2021-09-16 13:40:25 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1745997106 Nursing Analysis https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746011795 1) No real NANDA labels, but things related to nail care. 
- Impaired tissue related to ingrown nails
- Risk for infection

]]> 2021-09-16 13:44:46 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746011795 Assessment https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746012021 subjective data: 
pain or discomfort 
how often they clean their feet in the home setting. 

objective: 
dry/ cracked skin 
swelling 
pressure ulcers 
redness 
open wounds
 

]]> 2021-09-16 13:44:50 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746012021 Goals https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746019274 There are no NOC outcomes that relate specifically to nail care.
1) Demonstrate proper nail care
2) Seek a podiatrist for toenail care
3) Do not neglect self care]]> 2021-09-16 13:47:04 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746019274 Assessment (nonjudgmental, respectful manner ->many people are insecure about their skin) https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746022278 Subjective Data:
Ask patient about their usual bathing and skin care practices & preferences, as well as:
   * Past and current skin problems, & effects on the patient’s life
   * Prescription and over-the-counter (OTC) or herbal skin remedies being used
   * Allergic skin reactions to food, medications, plants, skin care products, and so on
   * History of diseases or other factors known to cause skin problems, including decreased mobility, decreased circulation, incontinence, inadequate nutrition, or deficient knowledge
Objective Data: 
Inspect each area of the skin in an orderly, head-to-toe manner, noting 
* overall cleanliness, condition, color, texture, turgor, hydration, and temperature. 
Observe for 
* rashes, lumps, lesions, and cracking. 
Look for 
* drainage from wounds or around tubes. 
Observe for the following changes in skin color:
   * Pallor in a light-skinned person may appear as pale skin without underlying pink tones. In a dark-skinned person, observe for an ashen gray or yellow color.
   * Erythema is redness of the skin related to vasodilation and inflammation. It is difficult to see in dark-skinned people, so you may discover it by palpating the skin for areas of increased warmth.
   * Jaundice:  yellow discoloration of the skin(impaired liver function). Best seen in the sclerae of the eyes.
   * Cyanosis: bluish coloring of the skin (caused by dec peripheral circulation or decreased oxygenation of the blood) may be related to cardiac, pulmonary, or peripheral vascular problems. 
In dark-skinned patients, you can best see cyanosis by examining the conjunctivae, tongue, buccal mucosa, and palms and soles for a dull dark color.

]]> 2021-09-16 13:48:01 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746022278 Outcome/Intervention https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746025647 We cant clip the patient's nails unless we have an order, so we need to file them:
- Soak before filing
- We do not cut or file callused areas
- remove hangnails, clean under the nail with hangwood stick
- We file straight across rounding the corner slightly to prevent scratching. Paying close attention to not file too deeply in the corners to cause ingrown nails ]]> 2021-09-16 13:49:01 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746025647 Nursing Diagnosis https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746026315 Impaired Dentition related to the inability to manage mouthcare as evidenced by Inflammation of the gums

Mouth Pain related to mouth lesions as evidenced by bleeding and inflammation of the gums ]]> 2021-09-16 13:49:13 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746026315 Nursing Diagnosis https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746035214 risk for infection r/t ingrown toenail AMB pain, redness, and swelling]]> 2021-09-16 13:51:56 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746035214 Assessment https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746036524 Subjective data- History of problems, diseases, or therapies that will affect the hair (chemotherapy). The hair products used, care they take for hair and scalp, patients physical ability to clean hair (impaired mobility)

Objective data- inspect condition and cleanliness or hair. Inspect for lesions, dandruff, pediculosis, and alopecia.]]> 2021-09-16 13:52:20 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746036524 Assessment of Body Area https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746037203 - Subjective: history of periodontal diseases, do they have dentures, eating habits / hydration levels, tobacco and alcohol use, cavities, oral hygiene patterns

-Objective: dry lips, oral mucosa, lesions or bleeding of the gums, missing or decaying teeth, stomatitis, unusual odors]]> 2021-09-16 13:52:30 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746037203 https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746040270 Eyes
Assessment 

  • Inspect eyes for redness, lesions, swelling, crusting, excessive tearing, and discharge 
  • Check to see if pt wears glasses or contacts, if so ask questions R/T it (ie when they use them, how bad their vision is without them, how often they wear them, and cleaning protocols)

Diagnosis
  • Risk for infection r/t improper hand washing and improper lens cleaning
  • Risk for injury r/t not cleaning contact lenses properly 

Planning outcomes
  • Pt demonstrates proper cleaning of contact lenses 
  • Eyes appear clean and healthy

Intervention 
  • For unconscious pt you would keep the eyes lubricated with saline or artificial tears, eye care should be done every 2-4 hours 
  • Caring for contact lenses and eyeglasses 
  • Eyeglasses need to be cleaned at least once a day
  • Keep free of infectious microorganisms 

Education
  • Teach cleaning and disinfecting measures to clients as needed
  • Teaching the importance as to why everything should be kept clean 
  • To always wash your hands before touching the eyes or the lenses 
]]> 2021-09-16 13:53:25 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746040270 Interventions https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746044754  For Impaired Skin (or Tissue) Integrity—Bathing, Cutaneous Stimulation, Perineal Care, Pressure Management, Skin Surveillance, and Wound Care
For Risk for Impaired Skin Integrity—Add to the above: Bed Rest Care, Circulatory Precautions, Pressure Ulcer Prevention, and Positioning
bathing
back massage


]]> 2021-09-16 13:54:44 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746044754 Goals https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746045159 The patient can clean and care for their dentures daily.

The patient can self perform oral hygiene as evidenced by proper oral care routine of brushing, flossing, and using mouthwash.






]]> 2021-09-16 13:54:52 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746045159 Goals/outcomes: https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746047426 Individualized goals/outcome statements you might write for a patient with skin problems include the following:
 Skin will remain intact and free of secretions.
 Skin will remain free of lesions.
 Patient will follow a regimen to improve skin dryness.


]]> 2021-09-16 13:55:36 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746047426 outcomes / interventions https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746052042 retrieve doctors order to remove ingrown toenail. 
gently file away rough or sharp edges using a nail file, best to do after a shower or bath. 
is clipping toenails, use clean nail clippers designated for patient to prevent contact transmitted infections. 
feet should be washed everyday 
cleaned and dried especially well in between toes. 
use moisturizer  daily, but avoid in between the toes. 
nonslip socks should be applied and changed daily after proper foot care. ]]> 2021-09-16 13:56:59 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746052042 Why should you not apply lotion between the toes? chungst https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746053829 moisture, warm, dark wet environment = risk for infection]]> 2021-09-16 13:57:29 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746053829 List at least three factors that cause dry mouth. chungst https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746054144 mouth breathing
medications, radiation
NPO, NGT
smoking, alcohol
Dehydration, oxygen
Seasonal
Oral airways]]> 2021-09-16 13:57:35 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746054144 Nursing Dx: https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746055104 Risk for Impaired Skin Integrity. 
Impaired Skin Integrity

Problem : Skin integrity
Etiology : r/t chemical injury, moisture, excretions , secretions , developmental age, alteration in metabolism , hormonal change, immunodeficiency , alteration in skin turgor, sensation 
Signs or symptoms: redness, bleeding, localized area hot to touch, vascular trauma, radiation agent, arterial puncture


]]> 2021-09-16 13:57:52 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746055104 Outcomes / Intervention https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746055310 Outcome:  
Oral mucous membranes will remain pink, moist, and intact. Patient demonstrates proper technique for brushing and flossing teeth.


Intervention: 
Provide necessary oral hygiene supplies, educate patient on proper oral hygiene, assist with keeping the mouth clean and moist, sideline patient when unconscious to brush teeth.
]]> 2021-09-16 13:57:56 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746055310 Appropriate Client Teaching https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746058151 - People with diabetes or circulatory issues we should file only.
- Teach client to inspect nails carefully 
- Encourage using moisturizer
- Avoid biting nails 
- Poor nail care can lead to infection


]]> 2021-09-16 13:58:52 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746058151 Nursing Diagnosis https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746058670 Risk for Infection r/t Alteration in skin integrity/broken skin AEB open wounds on patients scalp. ]]> 2021-09-16 13:59:02 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746058670 Nose: https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746059779 Assessment: Client function (conscious or unconscious, debilitated patients with NG tube)
Diagnosis: risk for infection. Risk for interfered respirations due to secretions. Risk for skin breakdown related to NG tube.
Outcomes/ Interventions: Remove secretions by gently inserting a moistened cotton-tipped applicator into the nostrils or use suction if needed. Provide special skin care and lubricant where the NG tube touches the nares. 

]]> 2021-09-16 13:59:24 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746059779 Teachings https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746060894 - Teach the client to avoid food high in sugar as sugar can cause tooth decay
- Instruct and tell the patient how important it is to have dental checkups and cleanings
-Teach the patient about the importance of oral hygiene and how it prevents gum disease and other dental issues ]]> 2021-09-16 13:59:46 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746060894 goals and appropriate teachings https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746061581 patient will be able to demonstrate proper hygiene after teachings daily within three days. 
teach client how to properly wash feet and clip toenails to avoid further risk of infections. ]]> 2021-09-16 13:59:59 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746061581 Outcomes/Interventions https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746061653 Keep hair and scalp clean. Keep hair and scalp free from infections, infestations, and dryness ]]> 2021-09-16 14:00:01 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746061653 https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746062072 Ears
Assessment
  • Assess for excess cerumen, any drainage, and hearing loss
  • Healthy ears require limited self care 

Diagnosis
  • Risk for hearing loss r/t excess wax build up
  • Risk for infection 
  • Risk for rupturing eardrum r/t pushing a cotton swab to far 
Intervention
  • Clean the auricle and remove wax from canal with the tip of a moistened washcloth or disposable wipe, if this doesn't remove the excess wax obtain a prescription for cerumenolytic drops and water irrigation
  • Make sure to handle and store hearing aid properly 
  • Cleaning and replacement of batteries 
  • Hearing aids should be replaced every 5-10 years 

Education
  • Teach proper care of cleaning the ears 
  • Teaching the importance of good ear care to prevent hearing loss and damage 
]]> 2021-09-16 14:00:08 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746062072 Study guide chungst https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746063308 Hygiene Chap 24
  • The skin, functions, factors affecting, age related skin changes, assessment terms
  • Risk factors for Hygiene Care
  • Assessment and care of the feet, eyes, ears, and nose and mouth – know procedures for skills related to these areas (Padlet content and lab)
  • Infection control and hygiene
  • Katz index of ADL’s (Ch 3- p.45)
]]> 2021-09-16 14:00:32 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746063308 Patient Education https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746064188  Patients should also be encouraged to comb or brush their hair a couple of times a day and wash as needed to prevent build up of oils and dry skin.]]> 2021-09-16 14:00:49 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746064188 Educating our Client : https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746066892 - importance of drying skin 
-good hydration,
-apply skin lotion after bath and after wash hands ( no lotion between the toes)
-instructed patient and caregiver on preventing skin tears. In terms of prevention, protective arm sleeves are helpful. 
-changing a patient's position 
-Avoid scratches, punctures, and other injuries.
- Nutrition 
- mobilization to improve circulation 



]]> 2021-09-16 14:01:42 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746066892 How to: https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746068329 Apply the shampoo and massage it into the hair. Using the jug, rinse the patient’s hair with water. Apply conditioner, if required by the patient, and rinse the hair again. Check, regularly, the patient is comfortable and can maintain their position. ]]> 2021-09-16 14:02:10 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746068329 How do you perform proper eye care? chungst https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746108088  Eyes should be cleansed from the inner to outer canthus to avoid dragging debris into the nasolacrimal duct. ]]> 2021-09-16 14:14:37 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746108088 What are important principles while making an occupied bed? chungst https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746109892 Rails up,  
Bed lowest position when leaving pt
Hip height when providing care, wide base of support
Don't soil clean linens
Have supplies
Assistance prn
Body mechanics
]]> 2021-09-16 14:15:11 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746109892 What precautions should you take while providing hygiene care? chungst https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746111801 Standard precautions @ minimum
Others prn]]> 2021-09-16 14:15:49 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746111801 What are ways to provide oral care that decrease infection ? chungst https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746114641 Unconscious
Critically ill
Dependent/Confused
side lying
Assessment
Brushing 2 minutes
Toothette swabs prn
Vaseline/chapstick]]> 2021-09-16 14:16:39 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746114641 What changes take place in the skin as a person ages? chungst https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746119583 Wrinkling, thinning, dry, reduced ability to heal - collagen, impaired sweating
 With age, both layers of the skin become thinner and more fragile. As collagen and elastin fibers in the dermis deteriorate, the skin becomes wrinkled. Sebaceous and sweat gland activity decreases, causing the skin to become dry, scaly, and itchy, and temperature regulation in hot weather becomes more difficult. As the number and activity of hair follicles and pigment cells (melanocytes) diminish, hair becomes thin, turns gray or white, and grows more slowly. Nails thicken and growth decreases. These changes increase the risk for skin problems. ]]> 2021-09-16 14:18:16 UTC https://padlet.com/chungst/qyfoqcrcp31n5oyy/wish/1746119583