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level: Level 1 of Lesson 10

Questions and Answers List

level questions: Level 1 of Lesson 10

QuestionAnswer
The science of health and its meaintenanceHygiene
Is the self-care by which people attend to such functions as bathing, toileting, general body hygiene, and groomingPersonal hygiene
Factors affecting personal hygiene behavior:1 culture 2 Socio-economic status 3 Religion 4 Developmental level 5 Health status 6 Personal references
Hygenic care:Early morning care Morning care Hour of sleep (HS) or PM Care As-needed (prn) Care
Integrate nursing knowledge Consider developmental and cultural influences Think creatively Be nonjudgmental and confident Draw on your own experiences Rely on professional standardsCritical thinking
Common diagnoses associated with hygiene:Activity intolerance Bathing self-care deficit Dressing self-care deficit Impaired physical mobility Impaired oral mucous membrane Ineffective health maintenance Risk for infection
Use the patients' ??? for which they are at riskactual alteration or the alteration
You are caring for a non-English-speaking male patient. When preparing to assist him with personal hygiene, you should: A. use soap and water on all types of skin B. ensure that culture and ethnicity influence hygiene practices. C. shave facial hair to make the patient more comfortable. D. Know that all patients need to be bathed daily.B. ensure that culture and ethnicity influence hygiene practices
Parts of the body which problems related to hygienic care are common:1. skin 2. feet 3. nails 4. mouth 5. hair
Is the largest organ of the body 5 major functions: 1. it is the first line of defense against injury and microorganisms 2. It maintains body temperature. 3. It is a secretory organ. 4. It is a sensory organ. 5. It produces and absorbs vitamin D through the action of ultraviolet rays from sun which activities vitamin D precursor present in the skin.Skin
Are all on body surfaces except the lips and parts of the genitals Most numerous on the palms of the hands and the soles of the feet The body has from 2-5 M, which are all present at birth Two types of it: 1. Apocrine glands 2. Eccrine glandsSudoriferous (sweat) glands
Skin: Assessment:Nursing history Physical Assessment of the skin Identification of clients at risk for developing skin impairments
Physical exam: A: best assessed under natural light and on areas not exposed to the sun)Inspect skin color
Physical exam: Inspect skin color: Normal findings:Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive.
Physical exam: Deviations from normal skin color:1. Pallor 2. Jaundice 3. Cyanosis 4. Erythema
Physical exam: Deviations from normal skin color:Pallor
Physical exam: Deviations from normal skin color:Jaundice
Physical exam: Deviations from normal skin color:Erythema
Physical exam: Deviations from normal skin color:Cyanosis
Physical exam: BInspect uniformity of skin color
Physical exam: Normal findings:Generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nail beds) in dark-skinned people
Physical exam: Deviations from normal:1. Hyperpigmentation 2. Hypopigmentation (e.g., vitiligo, albinism, edema)
Physical exam: Deviations from normal: 1:Hyperpigmentation
Physical exam: Deviations from normal: 2: e.g., vitiligo, albinism, edemaHypopigmentation
Physical exam: c: If present (i.e., location, color, temperature, shape and the degree to which the skin remains indented or pitted when pressed by a finger)Assess edema
Physical exam: Is the extravasation and accumulation of interstitial fluid in tissues. Edema is gravitational and will develop in dependent areas of the body, for example, in feet and legs when one is standing for prolonged periods. Is a type of edema in which the skin surface, when pressed by a finger, leaves an indentation.Pitting edema
Physical exam: Scale for describing edema: 1+Barely detectable
Physical exam: Scale for describing edema: 2+Indentation of less than 5 mm
Physical exam: Scale for describing edema: 3+Indentations of 5 to 10 mm
Physical exam: Scale for describing edema: 4+Indentations of more than 10 mm
Physical exam: Scale for describing edema:1+ Barely detectable 2+ Indentation of less than 5 mm 3+ Indentation of 5 to 10 mm 4+ Indentation of more than 10 mm
Describing skin lesions: 1: Type or structure: Aprimary type
Describing skin lesions: 1: Type or structure: BSecondary
Describing skin lesions: 2:Color
Describing skin lesions: 3:Distribution
Describing skin lesions: 4:Configuration
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A flat, circumscribed area of color with no elevation of its surface; 1mm to 1cm Examples: Freckles, flat neviMacule
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A circumscribed, solid elevation of skin, less than 1 cm Examples: Warts, acne, pimplesPapules
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A vesicle or bulla filled with pus Example: Acne vulgaris, impetigoPustules
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: Small as macule but larger than 1 cm Example: portwine birthmarkPatch
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: Same as papule but larger than 1 cm Example: EczemaPlaque
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A relatively reddened, elevated, localized collection of edema fluid, irregular in shape Example: Mosquito bites, hivesWheal
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A solid mass that extends deeper into the dermis than does a papule Example: Pigmented neviNodule
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A solid mass larger than a nodule Example: EpitheliomasTumor
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A circumscribed elevation containing serous fluid or blood; less than 1 cm Example: Blister, chickenpoxVesicle
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: A larger, fluid-filled vesicle Example: Blister, second-degree burnsBulla
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: Dilated capillary; fine red lines Example: Seen chiefly in pregnancy and cirrhosis of the liverTelengiectasia
Describing skin lesions: 1: Type or structure: A: Primary type of lesion: Pinpoint red spots Example: May indicate a problem in blood-clotting mechanismPetechiae
Is part of the new WHO case definition for dengue. The test is a marker of capillary fragility and it can be used as a triage tool to differentiate patients with acute gastroenteritis, for example, from those with dengue.Tourniquet test
Even if a tourniquet test was previously done, it should be repeated if:It was previously negative There is no bleeding manifestation
How to do a Tourniquet test: 1Take the patient's blood pressure and record it, for example, 100/70.
How to do a Tourniquet test: 2Inflate the cuff to a point midway between SBP and DBP and maintain for 5 minutes (100+70) divided by 2 = 85 mm Hg
How to do a Tourniquet test: 3Reduce and wait 2 minutes
How to do a Tourniquet test: 4: A positive test is 10 or more petechiae per 1 square inchCount petechiae below antecubital fossa. See image at right
Bath guidelines:Provide privacy Maintain safety Maintain warmth promote independence Anticipate needs
Describing skin lesions: 1: Type or structure: B: Thickened epidermal cells that flake off Example; Dandruff, psoriasisScale
Describing skin lesions: 1: Type or structure: B: A linear crack Example: Athlete's footFissure
Describing skin lesions: 1: Type or structure: B: Dried serum or pus on the skin surface Example: Impetigo, scab on abrasionCrust
Describing skin lesions: 1: Type or structure: B: Loss or all part of the epidermis Example: Chicken pox and small pox following rupture.Erosion
Describing skin lesions: 1: Type or structure: B: Linear or hollowed out crusted area exposing dermis Example: Scratch, abrasionExcoriation
Describing skin lesions: 1: Type or structure: B: An excavation extending into the dermis or below Example: Stasis ulcerUlcer
Describing skin lesions: 1: Type or structure: B: A decrease in the volume of epidermis Example: Striae, aged skinAtrophy
Describing skin lesions: 1: Type or structure: B: A formation of connective tissue Example: Healed woundScar
Describing skin lesions: 2: Color: 1:Ecchymosis
Describing skin lesions: 2: Color: 1: Ecchymosis: 1:Circumscribe
Describing skin lesions: 2: Color: 1: Ecchymosis: 2:Diffuse
Describing skin lesions: 3: Distribution: 1: Affecting one side of the body but not the other. Example: Fixed drug eruptionAsymmetrical
Describing skin lesions: 3: Distribution: 2: Occurring or appearing on both sides of the body. Example: Stasis dermatitisBilateral
Describing skin lesions: 3: Distribution: 3: Dispersed or spread widely through out the whole body. Example: Viral exanthemDisseminated
Describing skin lesions: 3: Distribution: 4: Widespread, affecting many body regions. Example: Generalized pustularGeneralized
Describing skin lesions: 3: Distribution: 5: Limited to a discreet area of the body. Example: Bowen's diseaseLocalized
Describing skin lesions: 4: Configuration: 1: CircularAnnular
Describing skin lesions: 4: Configuration: 2:Grouped
Describing skin lesions: 4: Configuration: 3:Linear
Describing skin lesions: 4: Configuration: 4:Targetoid
Describing skin lesions: 4: Configuration: 5:Reticular
Describing skin lesions: 4: Configuration: 6:Follow the course of cutaneous nerves; or meshed in the form of a network
Describing skin lesions: 4: Configuration:1. Annular 2. Grouped 3. Linear 4. Targetoid 5. Reticular 6. Follow the course of cutaneous nerves; or meshed in the form of a network
Describing skin lesions: 5: Observe and palpate skin moisture: NormalMoisture in skinfolds and the axillae (varies with environmental Temperature and humidity, body temperature
Describing skin lesions: 5: Observe and palpate skin moisture: Deviations from normal:Excessive moisture (hyperthermia) Excessive dryness (in dehydration)
Describing skin lesions: 6: Palpate skin temperature: Compare the?two feet and the two hands
Describing skin lesions: 6: Palpate skin temperature: In palpation, Use the back of?your hands
Describing skin lesions: 6: Palpate skin temperature: Normal:Uniform; within normal range
Describing skin lesions: 6: Palpate skin temperature: Deviations from normal:Generalized hyperthermia (in fever); Localized hyperthermia (in infections); Localized hypothermia (in arteriosclerosis)
Describing skin lesions: 7: Note skin turgor:fullness or elasticity by lifting and pinching the skin on extremity
Describing skin lesions: 7: Note skin turgor: Normal:When pinched, skin springs back to previous state
Describing skin lesions: 7: Note skin turgor: Deviations from normal:Skin stays pinched or tented or moves back slowly (in dehydration)
Diagnosis: 1:Self-care Deficit: bathing/hygiene
Diagnosis: 2:Self-Care Deficit: Dressing/Grooming
Diagnosis: 3:Self-Care Deficit: Toileting
Diagnosis: 4:Self-Care Deficit: Feeding
Implementation: Abrasion:Superficial layers of the skin are scraped or rubbed away. Area is reddened and may have localized bleeding or serous weeping.
Implementation: Abrasion: Nursing implications: 1:Prone to infection; therefor, wound should be kept clean and dry.
Implementation: Abrasion: Nursing implications: 2:Do not wear rings or jewelry when providing care to avoid causing abrasions to clients
Implementation: Abrasion: Nursing implications: 3:Lift, do not pull, a client across a bed
Implementation: Abrasion: Nursing implications: 4:Use two or more people keme keme
Implementation: Excessive dryness:Skin can appear flaky and rough
Implementation: Excessive dryness: Nursing implications: 1:Prone to infection if the skin cracks; therefore, provide alcohol-free lotions to moisturize the skin and prevent cracking.
Implementation: Excessive dryness: Nursing implications: 2:Bathe client less frequently; use no soap, or use nonirritating soap and limit its use. Rinse skin thoroughly because soap can be irritating and drying.
Implementation: Excessive dryness: Nursing implications: 3:Encourage increased fluid keme keme permits to prevent dehydration
Implementation: Ammonia Dermatitis (Diaper rash):Caused by skin bacteria reacting with urea in the urine The skin becomes reddened and is sore
Implementation: Ammonia Dermatitis (Diaper rash): Nursing implications: 1:Keep skin dry and clean by applying protective ointments containing zinc oxide to areas at risk (e.g., buttocks and perineum).
Implementation: Ammonia Dermatitis (Diaper rash): Nursing implications: 2:Boil an infant's diaper or wash hem with an antibacterial detergent to prevent infection. Rinse diapers well because this is irritating to an infant
Implementation: Acne:Inflammatory condition with papules and pustules
Implementation: Acne: Nursing implications:1. Keep the skin clean to prevent secondary infection 2. Treatment varies widely.
Implementation: Erythema:Redness associated with a variety of conditions such as rashes, exposure to sun, elevated body temperature.
Implementation: Erythema: Nursing implications:1. Wash area carefully to remove excess microorganisms 2. Apply antiseptic spay or lotion to prevent itching, promote healing, and prevent skin breakdown
Implementation: Hirsutism:Excessive hair on a person's body and face, particularly in women
Implementation: Hirsutism: Nursing implications:1. Remove unwanted hair by using depilatories, shaving, electrolysis, or tweezing 2. Enhance client's self concept
are essential for ambulation and merit attention even when people are confined to bedFeet
Each foot contains ???, which functions together for both standing and walking:26 bones, 107 ligaments, and 19 muscles
Feet: Assessment:1. Nursing Health History 2. Physical Assessment
Common Foot Problem: 1:Callus
Common Foot Problem: 2:Corn
Common Foot Problem: 3:Plantar warts
Common Foot Problem: 4:Fissures
Common Foot Problem: 5:Athlete's Foot, or Tinea Pedis
Common Foot Problem: 6:Ingrown toenail
Feet: Diagnosis:Self-Care Deficit: Hygiene (foot care) r/t: Risk for Impaired Skin Integrity r/t: Risk for Infection r/t: Deficient Knowledge (diabetic foot care) r/t:
Feet: Diagnosis: Self-Care Deficit: Hygiene (foot care) r/t:a. Visual Impairment b. Impaired hand coordination
Feet: Diagnosis: Risk for Impaired Skin Integrity r/t:a. Altered Tissue Perfusion: peripheral (associated with edema, inadequate arterial circulation) b. Poorly fitting shoes
Feet: Diagnosis: Risk for infection r/t:a. Impaired skin integrity (ingrown toenail, corn, trauma) b. Deficient nail or foot care
Feet: Diagnosis: Deficient knowledge (diabetic foot care) r/t:a. lack of teaching/ learning activities about diabetic foot care b. Newly established medical diagnosis (diabetes) and necessary foot hygiene
Feet: Planning:(a) Help the client maintain or restore healthy foot care practices (b) Establishing desired outcomes for each client
Implementing: Foot Care:Wash the feet daily, and dry them well, especially between the toes Use warm after for foot soak, to soften the nails and loosen debris under them Caution: soaking the feet of diabetic clients is no longer encouraged because excessive moisture can contribute to skin breakdown. Use cream or lotion to moisten the skin and soften calluses Use deodorant sprays or foot powder to prevent or control unpleasant odor. File toenails straight across to avoid tissue injury Change socks or stocking daily Wear comfortable, well-fitted pair of shoes Do not go barefooted Exercise the feet to improve circulation Avoid using constricting clothing which may decrease circulation Avoid crossing the legs Avoid self-treatment for corns and calluses
Are normally present at birth They continue to grow throughout life and change very little until people are older At the time, they tend to be tougher, more brittle, and in some cases thicker. The ??? of an older person normally grow less quickly than those of a younger person and may be ridged and groovedNails
Nail: Assessment: 1:Inspect nail plate shape to determine its curvature and angle
Nail: Assessment: 1: Inspect nail plate shape to determine its curvature and angle: Normal findings:Convex curvature; angle between nail and nail bed of about 160 degrees
Nail: Assessment: 1: Inspect nail plate shape to determine its curvature and angle: Deviations:From normal: Spoon nail; clubbing (180 degrees or greater)
Nail: Assessment: 2:Inspect nail texture
Nail: Assessment: 2: Inspect nail texture: Normal findingsSmooth texture
Nail: Assessment: 2: Inspect nail texture: Deviations from normal:Excessive thickness (e.g., result of poor circulation, iron deficiency anemia) (ONYCHAUXIS) Excessive thinness or presence of grooves; or furrows (e.g., in iron deficiency anemia) Beau's lines (transverse white lines or grooves)
Nail: Assessment: 2: Inspect nail texture: Deviations from normal: are horizontal lines of darkened cells and linear depression.Beau's lines
Nail: Assessment: 3:Inspect nail color
Nail: Assessment: 3: Inspect nail color: Normal findingshighly vascular and pink in light skinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks
Nail: Assessment: 3: Inspect nail color: Deviations from normal:Bluish or purplish tint (may reflect cyanosis), pallor (may reflect poor arterial circulation)
Nail: Assessment: 4:Inspect tissue surrounding nails
Nail: Assessment: 4: Inspect tissue surrounding nails: Normal findingsIntact epidermis
Nail: Assessment: 4: Inspect tissue surrounding nails: Deviation from normal:hangnails, paronychia (inflammation of the tissue surrounding nails)
Nail: Assessment: 5: Press two or more nails between your thumb and index finger; look for blanching and return of usual color to nail bed.Perform blanch test to test capillary refill.
Nail: Assessment: 5: Perform blanch test to test capillary refill: Normal findings:prompt return of pink or usual color
Nail: Assessment: 5: Perform blanch test to test capillary refill: Deviations from normal:Delayed return of pink or usual color (may indicate circulatory impairment)
Nail: Diagnosis: Self-Care Deficit: Grooming related to:Impaired Vision
Nail: Diagnosis: Risk for infection around the nail bed related to:Impaired integrity of cuticles
Nail: Planning:Maintain healthy nail care practices Establish a schedule of Nail Care
Nail: Implementing: Nail Care:Trim nails straight across, or follow the contour of the fingers. File nails to have smooth edges Do not trim nails at the lateral corners to prevent ingrown. Diabetic clients are advised against cutting hangnails or cuticles. Ingrown is also called unguis incarnate Separation of the nail form the nailbed is onycholysis
Nail: Evaluating: Demonstrate healthy nail care practices, as evidenced by:a. Clean, short nails with smooth edges b. Intact cuticles and hydrated surrounding skin Demonstrate nail care as instructed
The appearance of the hair often reflects a person's?feelings of self-concept and sociocultural well-being.
Growth, distribution, and pattern indicate general health status. Hormonal changes, nutrition, emotional stress, physical stress, aging, infection, and other illnesses can affect hair characteristics. The shaft itself is lifeless, and physiological factors do not directly affect it. However, hormonal and nutrient deficiencies of the hair follicle cause changes in hair color or conditionHair
Hair: Assessing: 1:Inspect the evenness of growth over the scalp
Hair: Assessing: 1: Inspect the evenness of growth over the scalp: Normal findings:Evenly distributed hair
Hair: Assessing: 1: Inspect the evenness of growth over the scalp: Deviations from normal:patches of hair loss (alopecia)
Hair: Assessing: 2:Inspect hair thickness or thinness
Hair: Assessing: 2: Inspect hair thickness or thinness: Normal findings:Thick hair
Hair: Assessing: 2: Inspect hair thickness or thinness: Deviations from normal:Very thin hair as in hypothyroidism
Hair: Assessing: 3:Inspect hair texture and oiliness
Hair: Assessing: 3: Inspect hair texture and oiliness: Normal findings:Silky, resilient hair
Hair: Assessing: 3: Inspect hair texture and oiliness: Deviations from normal:brittle hair (in hypothyroidism); excessively oily or dry
Hair: Assessing: 4:Note presence of infections or infestations by parting the hair in several areas
Hair: Assessing: 4: Note presence of infections or infestations by parting the hair in several areas: Normal findings:No infection or infestation
Hair: Assessing: 4: Note presence of infections or infestations by parting the hair in several areas: Deviations from normal:Flaking, sores, lice, nits (louse eggs) and ringworm
Hair: Assessing: 5:Inspect amount of body hair
Hair: Assessing: 5: Inspect amount of body hair: Normal findings:Variable
Hair: Assessing: 5: Inspect amount of body hair: Deviations from normalhirsutism (excessive hairiness) in women and in children
Hair: Implementing: hair care:The appearance of the hair may reflect a person's sense of well being and health status Brushing and combing the air stimulate secretion of blood in the scalp; distribute the oil along the hair shaft; help arrange the hair.
Hair: Implementing: hair care:Shaving, mustache, and beard care
Quick quiz: A young girl with long hair is experiencing a problem with matting. The most appropriate action to take would be: A. cutting the matted hair away. B. braiding the hair to reduce tangles C. Using a grease-type product to tame the hair. D. Keeping the hair oil free by applying powder every morningC. using a grease-type product to tame the hair.
Each tooth has 3 parts:The crown, the root and the pulp cavity
Each tooth has 3 parts: Is the exposed part of the tooth, which is outside the gum. It is covered with a hard substance called ENAMEL. DENTIN is the ivory-colored internal part of itCrown
Each tooth has 3 parts: Is embedded in the jaw and covered by a bony tissue called CEMENTUMThe root
Each tooth has 3 parts: contains the blood vessels and nervesThe pulp cavity in the center of the tooth
Is lined with mucous membranes Normal oral mucosa is light pink, soft, moist, smooth, and without lesions Medications, exposure to radiation, and mouth breathing can impair salivary secretion.The oral cavity
The oral cavity: dry mouthXerostomia
The oral cavity: Inflammation of the gumsGingivitis
The oral cavity: Tooth decayDental caries
Mouth care:Brush the teeth thoroughly after meals and at bedtime. Floss the teeth daily. Ensure adequate intake of food rich in Calcium, Phosphorus, Vitamins A, C, and D and fluoride. Avoid sweet foods and drinks between meals Eat coarse, fibrous foods (cleansing foods) such as fresh fruits and raw vegetables. Have dental check up every 6 months Have topical fluoride applications as prescribed by the dentists. Brushing and Flossing the Teeth
Mouth care: Purposes:(a) To remove food particles from around and between the teeth (b) To remove dental plaque (c) To enhance the client's feeling of well-being (d) To prevent sordes and infection of the oral tissues
Nursing Interventions When Providing Oral CareInform the client and explain purpose of the procedure Provide privacy Assist in sitting or side-lying position Place towel under the client's chin. Moisten bristles of toothbrush and apply dentrifice. Hold kidney basin under the chin. Allow the client to brush his teeth, if possible. Use downward strokes for upper front teeth; upward strokes for lower front teeth; back and forth strokes for the biting surfaces of the teeth; and hold the brush against the teeth with bristles at 45 degrees angle to penetrate and clean under the gingival margins. Rinse the mouth with adequate amount of water. Floss the teeth. Keep the client comfortable. Do after-care of equipment and articles. Document relevant data
Common Problems of the Mouth: An invisible soft film of bacteria, saliva, epithelial cells and leukocytes that adhere to the enamel surface of the teeth.Plaque
Common Problems of the Mouth: A visible, hard deposit of plaque and bacteria that forms at the gum linesTartar
Common Problems of the Mouth: Bad breathHalitosis
Common Problems of the Mouth: Inflammation of the tongueGlossitis
Common Problems of the Mouth: Inflammation of the gumsGingivitis
Common Problems of the Mouth: Inflammation and dryness of the oral mucosaStomatitis
Common Problems of the Mouth: Inflammation of the parotid salivary glands (mumps)Parotitis
Common Problems of the Mouth: Accumulation of foul matter (food, microorganisms, and epithelial elements) on the gums and teethSordes
Common Problems of the Mouth: Cracking of the lipsCheilosis
Common Problems of the Mouth: Teeth have darkened area, may be painfulDental carries