Funda skills

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Created by
Kimberly

Cards (38)

  • Personal Hygiene

    Measures for personal cleanliness and grooming
  • Personal Hygiene

    • Promotes physical and physiological well-being
    • Care must be carried out conveniently and frequently enough to promote comfort for individual
    • Practices vary among people; nurses should respect individual patient preference
    • Nurses should give only the care that patient cannot or should not provide for themselves
  • Factors influencing Hygiene

    • Room environment
    • Equipment
    • Safety factors
    • Bedside stand
    • Bed
    • Over table
    • Chairs
    • lights
  • Hygiene care schedule

    • Early AM
    • After breakfast
    • Afternoon
    • PM care
    • Provide as needed
    • For a person in coma
    • Incontinent person
    • Diaphoretic person
  • Intact Skin

    • Defense against infection
    • Defense of awareness
    • Controls body temperature
  • Daily skin inspection and documentation is an important part of skin care and prevention of decubitus ulcers
  • Meeting Bathing Needs of Patients with Dementia

    • Focus on comfort, safety, autonomy and self esteem, in addition to cleanliness
    • Individualize patient care
    • Consider what can be earned about the needs and preferences of the patient
    • Consider other methods for bathing
    • Maintain a relaxed demeanor; use calming language
  • Assessment made when giving a bed bath
    • Patient's knowledge of hygiene practices and bathing preferences
    • Frequency, time of the day, type of hygiene products used
    • Any physical activity limitations
    • Patient's ability to bathe himself or herself
    • Patient's skin for dryness, redness, or areas of breakdown
  • Order of Bathing

    • Eyes/Face
    • Neck & ears
    • Arms
    • Chest/abdomen
    • Legs
    • Back
    • Buttocks
    • Perineal area
  • Methods of Bathing

    • Complete bath
    • Partial bath
    • Shower or tub bath
    • Bed bath – alternative bag bath
    • Sitz Bath
  • If using a water basin to bath a patient, water should be changed after washing front of the person and prior to cleaning the back and buttocks, and again prior to perineal care
  • Bathing Patient with reduced mobility or with Intravenous fluid
    • Remove from unaffected side first
    • Unaffected to Affected side
    • Hang the fluid container to IV pole
  • How to mitt the wash/bath cloth
  • Bathing Patient: Steps
    • Gather all materials needed
    • Assess client's preferences for bathing practices, frequency of bathing, time of day preferred, type of hygienic products used
    • Consider client's condition and review orders for precautions concerning client's movement for positioning
    • Explain procedure and ask client for suggestions or ways to prepare supplies. If partial bath is to be performed, ask how much bath client wishes to complete
    • Adjust room temperature and ventilation, and close room doors and windows. Close curtain around bed
    • Offer client bedpan or urinal. Provide towel and washcloth for client
    • Wash hands. Optional. Apply gloves if required by institution's policy procedures.
    • Fill wash basin two thirds full, with at 43°-46°C (110-115°F). Have client place fingers in water to test temperature tolerance. Option. Place plastic container of bath lotion in bath water.
    • Bring client toward side closer to you.
    • Remove pillow if allowed and raise head of the bed 30-40 degrees. Place bath towel under clients head.
    • Loosen top covers at foot of the bed. Place bath blanket over top sheet. Fold and remove top sheet from under blanket. If possible, have client hold bath blanket while you withdraw sheet.
    • Remove client's gown or pajamas while maintaining privacy. If extremity is injured or has reduced mobility, begin removal from affected side. If client has intravenous (IV) tube, remove gown from arm without IV first, and then lower IV container and slide gown covering affected arm tubing and container. Rehang IV.
    • Place the bath towel over client's chest under the chin.
    • Wash client's eyes with plain warm water. Use different section of mitt for each eye. Move mitt from inner to outer canthus. Soak encrustation on eyelids for 2-3 minutes with damp cloth before attempting removal. Dry eye thoroughly but gently.
    • Ask client about preference for using soap for face. Wash, rinse and dry well forehead, cheeks, nose, neck, and ears.
    • Remove bath blanket from over client's arm that is farthest from you. Place bath towel lengthwise under arm.
    • Lower side rails if removed to opposite side. Bath arm with soap and water using long firm strokes from distal to proximal areas (finger to axilla). Raise and support arm above (if possible) while thoroughly washing axilla.
    • Rinse and dry arm and axilla thoroughly. If client's prefers, apply deodorant or talcum powder.
    • Fold bath towel in half and lay it on bedside client. Place basin on towel. Immerse client's hand in water. Option. Allow hand to soak 3-5 minutes before washing hand and fingernails. Remove basin and dry hand well.
    • Repeat steps for other arm. Change temperature of bath water and change if necessary.
    • Change client's chest with bath towel and fold bath blanket down to the umbilicus.
    • With one hand, lift edge of towel away from chest. With mitted hand, bathe chest using long firm strokes. Take special care to wash skin folds under female client's breast, lifting breast in unnecessary. Keep chest covered between wash and rinse periods. Dry well.
    • Expose far leg by folding blanket over toward midline. Be sure perineum is draped.
    • Bend client's leg at knee by positioning your arm under the leg. While grasping client heel, elevate leg from mattress slightly and slide brain towel lengthwise under leg.
    • Ask client to hold still. Please bath basin on towel on bed and secure its position next to foot to be washed.
    • Unless contraindicated, use long, firm strokes in washing fro ankle to knee, knee to thigh. Dry well.
    • Do the same with leg near you.
    • With one hand supporting lower leg, raise it and slide basin under lifted foot. Immerse one foot at a time. Make sure foot is firmly placed on bottom of basin.
    • Soap foot, making sure to bathe between toes. Rinse and dry well. If skin is dry. Apply lotion.
    • Cover client with bank blanket, raise side rail for client's safety, and change bathwater.
    • Lower side rail. Assist client in assuming prone or side lying position (as applicable). Place towel lengthwise along client's side.
    • Keep client draped by sliding bath blanket over shoulders and thigh.
    • Apply disposable gloves (if not done yet).
    • Wash, rinse and dry back from neck to buttocks using long, form strokes. Pay special attention to folds of buttocks and anus. Give back rub.
    • Change bath towel and washcloth.
    • Assist client in assuming side-lying or supine position. Cover chest and upper extremities with towel and lower extremities with bath blanket. Expose only genitalia. (If the client can help, covering the entire body with bath blanket may be preferable). Wash, rinse and dry the perineum. Grave special attention to skin folds. If client is able to do the perineal care, leave wash cloth basin and soap within easy reach and leave are.
    • Dispose gloves in a receptacle.
    • Apply any additional body lotion or oil as desired.
    • Help the client to put on a clean gown. If one extremity is injured or immobilized always dress affected side first.
    • Comb client's hair. Woman may want to apply makeup. Straighten client's bed.
    • Remove soiled linen and place in dirty linen bag. Cleanse and replace bathing equipment. Replace call light and personal possessions. Leave room as clean and comfortable as possible.
    • Wash hands. Observe client's behavior and ask if fatigue or discomfort is felt.
    • Note areas on skin that were previously soiled or reddened or showed early signs of breakdown.
    • Record type of bath and client's tolerance of bathing. Also note condition of skin and any significant findings such as reddened skin areas or joint or muscle pain. Record level of assistance required by the client.
  • Providing perineal Care to Female patient: Steps
    • Assemble supplies at bedside
    • Identify clients at risk for developing infection of genitalia, urinary tract or reproductive tract (e.g. presence of indwelling catheter, fecal and urinary incontinence)
    • Explain procedure and purpose to the client. Wash hands
    • Pull curtain around bed or close room door. Raise bed to comfortable working position.
    • Lower side rail and assist client in assuming dorsal recumbent (female) or supine (male) position
    • Position water proof pad under client's bottoms.
    • Place a bath towel under the client's hips so that the lower end can be used to dry anterior perineum, while the upper end can dry the rectal area
    • Place bedpan under client
    • Diamond drape client by placing bath blanket with one corner between clients legs, one corner pointing toward each side of bed and one corner over chest. Tuck side corner around legs and under hips
    • Fold top linen down toward of bed and raise client gown up above genital
    • Raise side rail. Fill wash basin with warm water
    • Place wash basin and toilet tissue on over bed table. Place washy cloths in basin.
    • Lower side rail and help client flex knees and spread legs apart (dorsal recumbent position
    • Wear gloves, wash and dry client's upper inner thighs
    • Wash labia. Then use non dominant hand to gently retract labia from thighs; with dominant hand, wash carefully in skin folds. Wipe in direction from perineum to the anus. Repeat on opposite side, using separate section of washcloth. Rinse and dry area thoroughly.
    • Separate labia with non dominant hand to expose urethral meatus and vaginal orifice. With dominant hand, wash downward from pubic area toward anus in one smooth stroke. Cleanse thoroughly around labia minora, clitoris and vaginal orifice
    • If client is on bedpan, pour warm water over perineal area. Dry perineal area thoroughly
    • Fold lower corner of bath blanket back between client's legs and over perineum. Ask client to lower legs and assume side-lying position for anal care.
  • Clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. Wash the shaft of the penis using downward stokes toward the pubic area. Always proceed from the least contaminated area to the most contaminated area. Rinse the washed areas well with plain water.
  • Bed Shampoo: Steps

    • Verify the chart for a written order
    • Gather all materials needed
    • Wash hands. Explain the procedure and offer the bedpan or urinal
    • If able, assist the patient to sitting position. Arrange pillow and line with rubber sheet
    • Line the rubber sheet with the first towel
    • Place Kelly pad or rolled rubber sheet and line it with the second towel
    • Assist patient to recumbent position with the Kelly pad under the patient's shoulder
    • Brush the hair thoroughly
    • Place cotton ball to each ear
    • Place the third towel over the chest. Place damp wash cloth over eyes
    • Test the temperature of the water
    • Wet the hair and apply shampoo. Rinse well
    • Remove the Kelly pad or rolled rubber sheet and place it in the pail
    • Return pillow to its proper position under the head. Remove ear plugs and damp wash cloth
    • Dry and comb the hair. Tidy up the place
    • Observe the reaction of the client and document
  • Oral Hygiene Assessment

    • Patient's oral hygiene preferences
    • Frequency, time of day, type of hygiene products
    • Patient's oral cavity and dentition
    • Patient's lips for dryness or cracking
    • Patient's ability to perform own care – any physical activity limitations
  • Oral Care (Dependent Patient)
    • Correct head position: on its side and tilted forward, raised 30-45 degrees
    • Rinsing the mouth of a dependent person: carefully squirt a small mount of water using irrigating syringe being sure to avoid the back of the throat, immediately suction water out with a yankaur suction device
    • Use of toothette or suction toothette
  • Expected Outcomes When performing Oral Care
    • The patient's mouth and teeth will be clean
    • The patient will not experience impaired oral mucous membranes
    • The patient will participate as much as possible with oral care
    • The patient will demonstrate improvement of body image
    • The patient will verbalize an understanding about the importance of oral care
  • Cognitive Impairment

    • Choose a time of day when the patient is most calm
    • Enlist the aid of a family member or significant other
    • Break the task into small steps
    • Provide distraction
    • Allow the patient to participate
    • If the patient strongly refuses care, withdraw
    • Document effective and ineffective intervention
  • When assisting with shaving, shave the direction of hair growth on male facial hair
  • Oral Care

    1. Void the back of the throat
    2. Immediately suction water out with a yankaur suction device
    3. Use of toothette or suction toothette
  • Expected Outcomes When performing Oral Care
    • The patient's mouth and teeth will be clean
    • The patient will not experience impaired oral mucous membranes
    • The patient will participate as much as possible with oral care
    • The patient will demonstrate improvement of body image
    • The patient will verbalize an understanding about the importance of oral care
  • Cognitive Impairment

    • Choose a time of day when the patient is most calm
    • Enlist the aid of a family member or significant other
    • Break the task into small steps
    • Provide distraction
    • Allow the patient to participate
    • If the patient strongly refuses care, withdraw
    • Document effective and ineffective intervention
  • Assisting with Shaving

    1. Male facial hair – shave the direction of growth
    2. Female leg hair – shave against the direction of hair growth (against the grain)
  • When should shaving a patient with a straight edge razor be avoided and electric razor used instead?
    • Significant immunocompromise (low WBC)
    • Anticoagulant therapy (blood thinners)
    • Bleeding disorders
    • Low platelet
  • Tepid Sponge Bath

    1. Explain to the patient what you will be doing
    2. Record the temperature before beginning the bath
    3. Gather the needed supplies: bath basin, several washcloths, towels and a bath sheet
    4. Fill the bath basin with tepid water, 80 to 90 degrees Fahrenheit
    5. Place one washcloth under each of the patient's arms and one on each side of his groin
    6. Allow several minutes for his body to adjust to the temperature of the water
    7. Sponge each of the patient's limbs for five minutes using patting motion
    8. Sponge the back and buttocks for ten minutes
    9. Replace the tepid water if chilled
    10. Continue to monitor the patient's temperature at intervals throughout the bath procedure
  • Foot and Nail Care
    1. Soak and soften cuticles
    2. Cleanse and dry the feet thoroughly
    3. Trim nails straight across (agency policy)
    4. Inspect for lesions, dryness, and signs of infection
  • Clients with diabetes mellitus or peripheral vascular disease (PVD)

    Are at risk for impaired circulation
  • Bed Making

    A step by step approach in preparing bed according to the client's needs which involves application of scientific principles in nursing
  • Occupied Bed

    Making a comfortable, neat bed for patient who cannot get out of bed
  • Assessments Made when making an Occupied Bed
    • Assess the patient's preferences regarding changes
    • Assess for precautions or activity restriction of the patient
    • Check for evidence of body secretions or fluids on the linens
    • Check the bed for patient belongings
    • Note the presence and position of any tubes or drains
  • Equipment needed for Occupied Bed
    • Gloves
    • Laundry bag
    • Bottom sheet
    • Rubber drawsheet
    • Cotton drawsheet
    • Top sheet
    • Two pillowcases
    • Bath blanket
  • Steps for Occupied Bed

    1. Assess the general condition of the patient
    2. Identify the patient and the patient's diagnosis and extend of self help; and arrange assistance from others when needed
    3. Check the physician order for any restricted movements
    4. Wash hands thoroughly and put on gloves
    5. Arrange linen at bedside in order of use
    6. Observe proper folding of linen
    7. Explain to the patient how he can assist and the sequence of the procedure
    8. Provide privacy. Offer the client a bedpan
    9. Lock the bed for safety
    10. Remove all pillows if the patient does not object to its being removed
    11. Loosen the linen on all side of the bed
    12. Turn the patient on his left side
    13. Remove the spread and blanket while leaving the top sheet over the client
    14. Place the bed in the flat position if the client's health permits
    15. Grasp the mattress lugs and observing good body mechanics, move the mattress up to the head of the bed
    16. Assist the client to turn on the side facing away from the side where the clean linen is
    17. Loosen linen on the side of the bed near the linen supply. Fanfold the draw sheet and the bottom sheet at the center of the bed, as close to the client as possible
    18. Place the new bottom sheet at foot part of the bed, lengthwise fold at the center of the bed
    19. Place the rubber or plastic drawsheet over the bottom sheet
    20. Place the clean draw sheet in the same manner on top of the rubber or plastic drawsheet
    21. Assist the client to roll over toward you onto the clean side of the bed
    22. Move the pillows to the clean side for the client's use
    23. Move to the other side of the bed, and lower the side rail
    24. Remove the used linen by folding it into bundle or square with soiled side turned in and place it in the portable hamper
    25. Smooth out the mattress cover to remove any wrinkles. Unfold the fanfolded sheets from the center of the bed
    26. Facing the side of the bed, use both hands to pull the bottom sheet, rubber or plastic drawsheet, and cotton drawsheet, so that it is smooth
    27. Unfold the drawsheets fan-folded at the center of the bed, and pull it tightly with both hands
    28. Change pillowcase (if needed) or reposition the pillows at the center of the bed
    29. Assist the client to the center of the bed. Determine what position the client requires or prefers, and assist the client to that position
    30. Spread the top sheet over the client, and ask the client to hold the top edge of the sheet or tuck it under the shoulders
    31. Stay at the foot part of the bed. Adjust top sheet and tuck at foot part and miter the corners
    32. Place patient in a comfortable position. Raise side rails and place the bed in low position
    33. Remove and discard gloves properly
    34. Wash hands
    35. Document and report pertinent data
  • Unoccupied Bed

    It is closed bed when the unit is preparing the bed for new client
  • Purpose of Unoccupied Bed
    • To promote client's comfort
    • To reduce the risk of infection by maintaining a clean environment
    • To provide a smooth, wrinkled-free bed to minimize sources of skin irritation
  • Steps for Unoccupied Bed
    1. Assemble all materials at bedside
    2. Collect clean linen to change and bring them to bedside
    3. Place linen in a clean surface
    4. Arrange linen at bedside in order of use
    5. Wash hands (Remove jewelries on hands) and put on gloves
    6. Raise the bed for body mechanics
    7. Lock bed for safety
    8. Strip or remove linen. Roll each piece away from you and place each piece in a laundry bag or pillowcase
    9. Clean the bed frame and mattress when necessary
    10. Remove and discard the gloves. Wash hands
    11. Move the mattress to the head of the bed
    12. Put the mattress pad on the mattress
    13. Place the bottom sheet on the mattress pad
    14. Open the sheet, Fan-fold it to the other side of the bed
    15. Tuck the head part of the sheet under the mattress and miter corner
    16. Place the rubber drawsheet on the bed
    17. Open the rubber drawsheet and fan-fold it to the other side of the bed
    18. Open the cotton drawsheet and fan-fold it to the other side of the bed
    19. Place cotton drawsheet on top of the rubber drawsheet
    20. Put the top sheet on the head part of the bed
    21. Place the bedspread on the bed
    22. Tuck in bedspread at the foot of the bed. Smooth, tighten and miter corner
    23. Go to the other side of the bed. Pull the bottom sheet tight so there are no wrinkles and tuck under mattress and miter top corner
    24. Pull drawsheets tight so there are no wrinkles. Tuck simultaneously with palm facing upward
    25. Working from the head of the bed to the foot, straighten all top linen
    26. Tuck in top linen and bedspread simultaneously at the foot of the bed and miter corner
    27. Put the pillowcase on the pillow
    28. Place the pillow on bed. The open end of the pillowcase is away from the door and the seam is toward the head of the bed
    29. Discard used linen properly
    30. Wash hands