Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
58 Cards in this Set
- Front
- Back
Aspiration
|
breathing fluid or an object in to the lung
|
|
Decubitus Ulcer
|
a pressure sore or bed sore
|
|
AM, PM, and HS Care
|
care performed before or after breakfast, and before or after the evening meal. Or at the time placing residents to bed (HS = Hour of Sleep) for the night
|
|
Perineal Care
|
(Peri-care) cleaning and anal areas of the body
|
|
Daily Care of the resident: before breakfast
|
AM care
brush teeth (give po care) comb hair, shave residents, male ans female bath/shower BRp |
|
DAILY CARE OF THE RES: After Breakfast
|
assist the res to the bathroom
clean incontinent residents, and assist with ADL's bath/shower finish with all ADL's which were not completed Clean unit/room |
|
DAILY CARE OF THE RES: Afternoon Care
|
BRP or assist to the bathroom
clean incontinent res. and assist w/ADL's Assist res to lie down and up after nap clean up the unit give report to oncoming NAC |
|
DAILY CARE OF THE RES: Evening Care
|
Assist res. to bathroom, BRP
Clean incontinent res. and provide ADL's help res to bed after pm care Dinner/supper |
|
Oral Care
|
Brushing teeth 3x/day (TID)
Oral care for unconscious res. is done every 2 hours Denture Care TID Partial Denture Care TID |
|
Bathing: General Rules
|
-Assure that the bath area is clean
-check water temperature (105-110F) -Find out type of bath and skin products needed for the res. -Collect necessary equipment (towels, wash cloths, soap) -protect privacy and cover for warmth protect from falling, never leave res. unattended -wash from clean to dirty -encourage the resident to help as much as is safe and possible -rinse skin thoroughly and pat the skin dry -use good body mechanics at all times |
|
Purpose for Bathing
|
hygiene
comfort/relaxation circulation observe the skin |
|
Types of baths
|
completes bed bath (water temp. 110-115)
Partial bed bath (water temp. 110-115) tub bath (water temp. 105) the shower Whirlpool Sitz Bath Bordet |
|
The Back Massage
|
1. the back massage relaxes muscles and stimulates circulation
2. use the firm hand motion from the sacrum up, and soft circular motion down 3. warm lotion by rubbing some between your hands 4. do not massage a res. w/a cardiac condition |
|
Perineal Care
|
1. Use Gloves
2. Wash front to back 3. Wipe, look ,turn and apply (A and D ointment, follow facility policy) 4. Clean all skin fold areas 5. Remove gloves before touching res. linen for covering |
|
Hair Care
|
1. Brushing and combing (place a towel around the back of the neck)
2. Shampooing x2 3. Shaving; place a towel around the front of the neck |
|
Care of Nails and Feet
|
Cut during shower time as the nails are soft, or soak the nails
cut with the contour of the finger or toes, and clean with orange stick never cut nails of diabetic res. place a towel under the hands/feet |
|
Dressing/Undressing Res
|
1. Undress unaffected side first
2. Dress affected side first |
|
Decubitus Ulcers: General Rules
|
The elderly, paralyzed, obese, or very thin and malnourished res. are at high risk.
The first sign is pale or white skin or a reddened area. Res may c/o pain, burning, or tingling in the area Some may not feel and abnormal sensation |
|
Sites of Decubitus Ulcers
|
-Back and Side of head
-Ear -Shoulders -Elbows -Hip and greater trochanter -Sacrum -Heels, Malleolus, Toes -Knees -Palms of hand -Nose |
|
Prevention of Decubitus Ulcers
|
-reposition res. in good health at least q2h
-Provide good skin care and apply lotion -do not massage pale or reddened pressure points -keep linen clean, dry, and free of wrinkles and crumbs -NO SKIN TO SKIN CONTACT - SAR - Use a drew sheet or incontinent pad in bed to reposition the res. |
|
Treatment of Decubitus Ulcers
|
Sheepskin
Bed Cradle Foot Board Heel and Elbow Protectors Alternating Pressure mattresses/Flotation mattresses/pads Egg crate mattresses and w/c pads special beds spanco mattress |
|
Who is at risk for Decubitus Ulcers
|
poor circulation
diabetes obese or thin poor nutrition or hydration incontinent paralysis diminished pain awareness weakened immune system corticosteroid therapy mental impairment decreased level of consciousness sedation confusion use of restraints previos ulcers chronic ulcers that require bed rest |
|
Stages of decubs.
|
Stage 1: Skin appears red and fails to turn to a normal color even after 30 min. w/o pressure; capillaries refill slower then normal; revers the reddened condition by removing pressure
Stage II: Blistering w/ reddened. Epidermis may not be intact. Skin erosion involves Epidermis and part of dermis; Ulcer area is pink and moist, res c/o pain and numbness; can become infected and it takes 2 pr more weeks to heal Stage III: Full thickness wound resembles a shallow crater and may have extending tunnels; becomes easily infected, healing may take up to 3 mo. Stage IV: Extend through all layers of the skin, fat, muscle and to the bone; Possible tunneling and infection occurs; healing is several months or even a year. this is due to a compromised elderly person |
|
Catheter
|
a tube used to drain or inject fluid through a body opening
|
|
Foley Catheter
|
A catheter that is left in the urinary bladder for drainage
|
|
Continent
|
Having control of bladder or bowel function
|
|
Voiding
|
urination
|
|
Incontinent
|
involuntary bladder or bowel release
|
|
The regular Bedpan and Fracture Bed Pan
|
to void in
|
|
Normal Urination
|
1000-1500 ml/cc per day (formula 1 oz. = 30 ml.cc)
People usually urinate before going to bed abd after getting up Some ppl. void every 2-3 hours, others 8-12 Certain substances increase urination - coffee, tea, alcohol, and some drugs are diuretics Usually "straw" color or light amber |
|
Maintaining Normal Urination: General Rules
|
Help the res. to the bathroom and assume position
Cover for warmth and privacy Give signal light and toilet paper with in reach run water if res has difficulty voiding remain neaerby wash res. hands post BRP |
|
Urination: What to Report to Nurse
|
1. Color, clarity, odor
2. amount and particles 3. c/o urgency 4. burning upon urination 5. Dysuria, or problem starting to urinate 6. frequent small amounts 7. spotting/bleeding 8. back pain |
|
s/s of full bladder
|
distended abdomen
c/o pain in low abd pr peri area fullness no urine in foley cath |
|
Catheters: types
|
indwelling foley cath
condom cath suprapubic |
|
Catheters: General Rules
|
1. make sure the urine flows freely
2. keep the drainage beg below the bladder and in a covering bag 3. coil tubing on the bed and fasten to bedding 4. use catheter straps (leg straps) to prevent pulling 5. provide cath care 6. empty drainage bag at the end of each shift 7. report any c/o and follow standard precautions |
|
Catheters: Bladder Training
|
to gain voluntary control
res. may be asked to void q 1 1/2 - 2 hours |
|
Collection and Testing Urine Specimens
|
The random Urine Specimen: is collected for PRN UA
The Midstream Specimen 24- hour specimen The Double-Voided Specimen: urine collected w/in 30 min apart |
|
Testing Urine
|
Testing for pH, glucose and ketones, testing for blood, reagent strips
|
|
The Res. w/a Ureterostomy
|
a surgical removal of the urinary bladder
|
|
Dialysis
|
Hemodialysis: Waste products and fluids are removed by filtering blood
Peritoneal Dialysis: The lining of abd cavity to remove waste and fluid from blood |
|
Colostomy
|
an artificial opening between the colon and abd
|
|
Constipation
|
the passage of hard dry stool (difficulty of passing in stool)
|
|
Enema
|
introduction of liquid into the rectum and lower colon
|
|
Impaction
|
inability to pass the hard stool
|
|
flatus
|
(GI gas) or air in the stomach or intestines
|
|
Ileostomy
|
an artificial opening between the ileu (small intestins) and the abdomen
|
|
Stoma
|
an opening
|
|
Peristalsis
|
alternating contraction and relaxation of the intestinal muscles
|
|
Suppository
|
a cone-shaped solid medication that is inserted into the rectum
|
|
Normal Bowel Movements
|
1. Frequency is highly individual qd or 2-3 days
2. Brown in color 3. odor present due to bacterial action in intestine 4. normally soft, formed and shaped like rectum, S shaped |
|
BM: What to report to the nurse
|
shape, size and frequency
color if not brown consistency (coffee grounds) odor: C-diff |
|
S/S of Impaction
|
seepage/oozing
no BM stops eating/feeling of fullness urgent use for BRP pain |
|
Factors Affecting Bowel Elimination
|
Privacy, Disability
aging diet and fluids activity medication |
|
Bowel Training (B & B)
|
Gaining control of BM
Develop regularity in pattern of elimination |
|
Enemas: General Rules
|
Soln. temp 105F
the sims position enema bag raised only 16" from rectum or 18" from bed and given slowly Tip lubricated/ask res. to breath Retain solution as long as possible bathroom should be empty or commode ready report the results to the nurse or ask the nurse to see it use standard precations and blood borne pathogens procedure instill 500-700 cc for adults |
|
Types of Enemas
|
Commercial Enemas: Fleets, SSE, TWE
Rectal Tubes Suppository TWE (tap water enema) and or SSE (soap, sude enema) |
|
The Resident with an ostomy
|
colostomy - stool is soft
Ileostomy - stool is liquidy consistency of stool |
|
Collecting Stool Specimens
|
Use standard precautions
Use Clean container Label name, date and time |