FUNDA RLE

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Created by
Gilaine

Cards (42)

  • Cleansing bath

    Given for hygienic purposes
  • Types of cleansing baths
    • Complete bed bath
    • Self help bed bath
    • Partial bath (abbreviated bath)
    • Bag bath
    • Tub bath
    • Sponge bath
    • Shower
  • Therapeutic bath

    • Given for physical effects
    • To soothe the skin
    • To treat an area (perineum)
    • Use medications
    • Taken in a tub 1/3 or 1/2 full
    • Client remains for 20-30 minutes
  • Bath temperature

    • Cleansing bath: 43C - 46C (110F - 115F)
    • Therapeutic bath: 37.7C - 46C (100F - 115F) for adults
    • 40.4C (110F) for infants
  • Equipment needed

    • Basin or sink with warm water (43C - 46C or 110F - 115F)
    • Soap and soap dish
    • Bath blanket
    • 2 bath towels
    • Washcloth
    • Clean gown/pajamas/clothes
    • Gloves
    • Personal hygiene articles
    • Shaving equipment
    • Table for bathing equipment
    • Laundry hamper
  • Bed bathing procedure

    1. Introduce self
    2. Explain procedure to patient
    3. Assemble equipment
    4. Perform hand hygiene
    5. Provide for client privacy
    6. Offer bedpan or urinal
    7. Lower side rail on side close to you
    8. Keep other side rail up
    9. Assist client to move near you
    10. Place bath blanket over top
    11. Remove top sheet
    12. Loosen and remove gown
    13. Make bath mitt with washcloth
    14. Wash face then dry
    15. Wash neck then dry
    16. Wash arms and hands then dry
    17. Wash chest and abdomen then dry
    18. Wash legs and feet then dry
    19. Wash back then perineum then dry
    20. Assist with grooming aids
    21. Assist to put on clean gown/pajamas
    22. Perform aftercare
    23. Document procedure
  • Bathing sequence

    • Eyes
    • Face
    • Ears
    • Neck
    • Arms
    • Hands
    • Chest
    • Abdomen
    • Back
    • Buttocks
    • Legs
    • Feet
    • Always start at the farthest side
    • Linens are placed lengthwise
    • Wet, rinse, dry
    • Distal to proximal
    • Expose one area/part at a time
  • Tepid sponge bath (TSB)

    • Considered one of the best cooling treatments
    • Recommended for febrile individuals with fever 39C or higher
    • Effective in relieving fever by reducing high temperature
    • Helpful in alleviating pain or discomfort
  • Equipment for tepid sponge bath
    • Ice cap
    • Bath basin
    • Washcloths (face towel)
    • Towels
    • Bath sheet (blanket)
    • Cotton balls or OS
    • Gloves
  • Tepid sponge bath procedure
    1. State purpose and bring equipment to bedside
    2. Explain procedure to patient or watcher
    3. Screen bed and turn off fan/AC
    4. Record temperature before beginning
    5. Pour tap water into basin and check temperature (27-37C or 80-90F)
    6. Replace top sheet with bath blanket
    7. Remove gown, remove pillow, place ice cap on forehead
    8. Sponge face in patting motion extending to neck, then pat dry
    9. Sponge arms from distal to proximal, emphasizing axilla, then dry and cover
    10. Place wet cotton balls or OS in axilla or use cold wet face towel
    11. Sponge chest and abdomen, then dry
    12. Sponge legs from distal to proximal, emphasizing popliteal and groin, then dry
    13. Turn patient and sponge back, then pat dry
    14. Change gown and linens as needed, leave ice cap on forehead
    15. Take TPR after 30 minutes
    16. Perform aftercare (change linens, lower bed, remove gloves, wash hands, document)
  • Textbook of Basic Nursing advises that the tepid sponge bath must be administered for at least 30 minutes to be effective
  • Foot care nursing materials
    • Washbasin
    • Washcloth
    • Hand towel
    • Nail clippers, emery board, orangewood stick
    • Lotion
    • Disposable bath mat
    • Disposable gloves
  • Bed shampoo or hair shampoo on bed
    1. Massaging the scalp
    2. Shampooing the client's hair on bed
  • Reasons for bed shampoo or hair shampoo
    • To wash the hair from dirt and oil
    • To wash scalp and stimulate the circulation of blood in the scalp
    • To prevent the infestation of lice
    • To wash the hair after the application of lice exterminator
    • To increase the client's sense of well-being
    • To assess or monitor hair or scalp problems
  • Abnormalities
    • Dandruff (Seborrheic Dermatitis) - diffuse scaling of the scalp often accompanied by itching
    • Alopecia - hair loss
    • Hirsutism - excessive growth of hair in the body
    • Pediculosis - infestation of lice
  • Pediculosis

    • Pediculosis capitis - head lice
    • Pediculosis corporis - body lice
    • Pediculosis pubis - crab lice
    • Scabies - a contagious skin infestation by mites
  • Treatment of scabies

    Thorough cleansing of the body with soap and water to remove scales and debris from crusts
  • Equipment

    • Soap or liquid shampoo
    • Bath towel (2)
    • Face Towel
    • Cotton Balls (Dry)
    • Rubber Sheet
    • Large Pitcher (2)
    • Basin
    • Pail
    • Kelly Pad (inflated)
    • Comb or Brush
    • Newspaper
  • Procedure

    1. Verify Agency policy and the Physician's order
    2. Determine the best time of the day for the procedure. Discuss this with the client
    3. Assemble all equipment and arrange them conveniently at the client's bed side
    4. Explain the procedure to the client
    5. Wash hands and observe other appropriate infection control procedures if needed
    6. Provide privacy by drawing the curtains around the bed or using the screen if necessary
    7. Loosen the Gown of the client
    8. Fold the top sheet down to the middle and replace it with a bath blanket
    9. Cover the chest with bath towel crosswise
    10. Remove the pillow and bring the patient's head diagonal across the bed
    11. Protect pillow with a rubber sheet and cover it with a bath towel
    12. Place the pillow under the patient's shoulder
    13. Place the inflated Kelly pad under the patient's head and place the pail on the floor supported by newspapers
    14. Comb the hair carefully
    15. Place the damp face towel or wash cloth over the face covering the eyes
    16. Place the cotton balls on the ear canal
    17. Moisten the hair thoroughly with lukewarm water
    18. Apply soap or shampoo on hair and scalp. Massage using the nail pads
    19. Rinse properly with warm water. And repeat the process until the hair is rinsed thoroughly
    20. Rinse finally with cool water
    21. Drop the Kelly Pad
    22. Squeeze the hair from excess water
    23. Dry hair in a turban manner
    24. Position the patient in comfortable position
  • Cleansing bath
    Given for hygienic purposes
  • Types of cleansing baths
    • Complete bed bath
    • Self help bed bath
    • Partial bath (abbreviated bath)
    • Bag bath
    • Tub bath
    • Sponge bath
    • Shower
  • Therapeutic bath
    • Given for physical effects
    • To soothe the skin
    • To treat an area (perineum)
    • Use medications
    • Taken in a tub 1/3 or 1/2 full
    • Client remains for 20-30 minutes
  • Bath temp for adults is 37.7C - 46C (100F - 115F)
  • Bath temp for infants is 40.4C (110F)
  • Assessment
    • Condition of the skin (color, texture and turgor, presence of pigmented spots, temperature, lesions, excoriations, abrasions, and bruises)
    • Physical or emotional factors (fatigue, sensitivity to cold, need for control, anxiety or fear)
    • Presence of pain and need for adjunctive measures (analgesic) before the bath
    • Range of motion of the joints
    • Any other aspects of health that may affect the client's bathing process (mobility, strength, cognition)
    • Need for use of clean gloves during the bath
  • Equipment
    • Basin or sink with warm water (43C - 46C or 110F - 115F)
    • Soap and soap dish
    • Bath blanket
    • 2 bath towels
    • Washcloth
    • Clean gown/pajamas/clothes as needed
    • Gloves
    • Personal hygiene articles
    • Shaving equipment
    • Table for bathing equipment
    • Laundry hamper
  • Preparation
    • Purpose and type of bath the client needs
    • Self care ability of the client
    • Any movement or positioning precautions specific to the client
    • Other care the client may be receiving such as x-rays in order to coordinate all aspects of care and prevent unnecessary fatigue
    • Client's comfort level
    • Necessary equipment and linens
  • Bed bathing procedure
    1. Introduces self
    2. Explains procedure to patient
    3. Assembles equipment
    4. Performs hand hygiene
    5. Provides for client privacy
    6. Offers a client a bedpan or urinal
    7. Lowers the side rail on the side close to you
    8. Keeps the other side rail up
    9. Assists the client to move near you
    10. Places bath blanket over the top
    11. Removes the top sheet
    12. Loosens and removes gown
    13. Makes a bath mitt with the washcloth
    14. Washes the face then dry
    15. Washes the neck then dry
    16. Washes the arms and hand then dry
    17. Washes the chest and abdomen then dry
    18. Washes the legs and feet then dry
    19. Washes the back and then the perineum then dry
    20. Assists the client with grooming aids
    21. Assists the client to put on a clean gown or pajamas
    22. Performs after care
    23. Documents the procedure
  • Sequence of bathing
    • Eyes
    • Face
    • Ears
    • Neck
    • Arms
    • Hands
    • Chest
    • Abdomen
    • Back
    • Buttocks
    • Legs
    • Feet
  • Always start at the farthest side
  • Linens are placed lengthwise
  • Wet, rinse, dry
  • Distal to proximal
  • Expose one area/part at a time
  • Tepid sponge bath (TSB)
    • Considered as one of the best cooling treatments
    • Recommended for febrile individuals, especially those with fever ranging from 39 degrees Celsius or higher
    • Highly effective in relieving fever by reducing high temperature and helpful in alleviating pain or discomfort
  • Equipment for tepid sponge bath
    • Ice cap
    • Bath basin
    • Washcloths (Face Towel)
    • Towels
    • Bath sheet (Blanket)
    • Cotton balls or OS
    • Gloves
  • Tepid sponge bath procedure
    1. State the purpose of the procedure and bring all the equipment to the bedside
    2. Explain the procedure to the patient or the watcher
    3. Screen the bed and turn off electric fan or aircon
    4. Pour tap water into the basin
    5. Replace the top sheet with a bath blanket
    6. Remove the gown, remove the pillow unless contraindicated and place ice cap on the forehead
    7. Sponge the face in a patting motion extending to the neck using the "S" method then pat dry
    8. Starts with the farther arms, fold the blanket diagonally exposing the arm and place towel under it
    9. Sponges from distal to proximal in a patting motion giving emphasis to the axilla, then dry and cover
    10. Wet cotton balls or OS and place it in the axilla or use a face towel soaked in cold water
    11. Place the towel across the patient's chest band fold the blanket down to the midline of the patient's abdomen. Sponge and pat dry
    12. Expose the farther leg by folding the blanket diagonally and placing the towel underneath. Sponge leg in a patting motion giving emphasis on the popliteal and groin. Pat dry
    13. Do the same in the other leg. Place cotton balls or OS and use face towel soaked in cold water for groin
    14. Turn the patient towards the nurse and place the towel lengthwise along the back and sponge then pat dry
    15. Changes the gown and linen as needed. Leave the ice cap on the forehead and take TPR after 30 minutes
  • After care for tepid sponge bath
    1. Change bed linens and remove the equipment away from the bed to prevent transmission of microorganisms
    2. Lower the patients' bed back to a safer height
    3. Remove gloves
    4. Wash your hands thoroughly
    5. Document the procedure done along with the patient's vital signs, response to treatment, and complications if any
  • The bath must be administered for at least 30 minutes to be effective