Fundaec

• Homeostasis


  Delicate balance of fluids, electrolytes, acids, and bases that maintains the body
• Almost every illness has the potential to threaten this balance
• Factors such as excessive temperatures or vigorous activity can disturb homeostasis if adequate water and salt intake are not maintained
• Therapeutic measures, such as the use of diuretics or nasogastric suction, can also disturb the body's homeostasis unless water and electrolytes are replaced
• Body water


  Approximately 60% of the average healthy adult's weight
• Hygiene


  The science of health and maintenance
• Personal hygiene


  Self-care which people attend to functions such as bathing, toileting, general body hygiene and grooming
• Hygiene is a highly personal matter that is determined by an individual values and practices
• Nurses must know how much assistance a client needs for hygienic care
• Types of hygienic care

  • Early morning care
  • Morning care
  • Hour of sleep or PM care
  • As-needed (pm) care
• Skin


  • Body's first line of defense protects underlying tissues from injury by preventing the passage of microorganisms
  • Regulates body temperature
  • Secretes sebum
  • Transmits sensations through the nerve receptors which are sensitive to pain, temperature, touch and pressure
  • Produces and absorbs vitamin D ultraviolet rays from the sun activate a vitamin D precursor present in the skin

  
• Water


  • A medium for metabolic reactions within cells
  • A transporter for nutrients, waste products, and other substances
  • A lubricant
  • An insulator and shock absorber
  • A means of regulating and maintaining body temperature
• Assessing the client's skin and hygienic practices

  1. Nursing health history

  2. Physical assessment- inspection and palpation
• Intracellular fluid (ICF)


  Found within the cells of the body, constitutes approximately two thirds of the total body fluid in adults
• Skin care practices


  • Usual showering or bathing times
  • Hygienic products routinely used
  • Facial cosmetic products used
  • How and when clean makeup applicators and puffs
  • Hygienic or cosmetic products that cause skin problems
• Extracellular fluid (ECF)


  Found outside the cells, accounts for about one third of total body fluid
• Intravascular fluid (plasma)


  Accounts for approximately 20% of ECF, found within the vascular system
• Interstitial fluid


  Accounts for approximately 75% of ECF, surrounds the cells
• Self-care abilities


  • Problems managing hygienic practices
  • How can the nurses best help
• Skin problems


  • Skin dryness, itchiness, rashes, bruising, excessive perspiration, or lack of perspiration
  • Skin or scalp lesions in the past
  • Allergic tendencies

  
• Abrasion


  Superficial layers of the skin are scrapped or rubbed away. Area is reddened and may have localized bleeding or serous weeping

  
• Excessive dryness


  Skin appears flaky and rough
• Ammonia dermatitis (diaper rash)


  Caused by skin bacteria reacting with urea in the urine. Skin become reddened and sore
• Examples of transcellular fluid

  • Cerebrospinal
  • Pericardial
  • Pancreatic
  • Pleural
  • Intraocular
  • Biliary
  • Peritoneal
  • Synovial fluids

  
• Acne


  Inflammatory condition with papules and pustules
• Erythema


  Redness associated with a variety of conditions, such as rashes, exposure to sun, elevated body temperature
• Hirsutism


  Excessive hair on person's body and face, particularly in women
• Feet


  • Essential for ambulation (standing and walking). Each foot contains 26 bones, 107 ligaments and 19 muscles
• Intracellular fluid


  Vital to normal cell functioning, contains solutes such as oxygen, electrolytes, and glucose, provides a medium in which metabolic processes of the cell take place
• Extracellular fluid (ECF)


  Transport system that carries oxygen and nutrients to, and waste products from, body cells
• Assessing the feet


  1. Nursing health history

  2. Physical assessment of the feet involves inspection of each foot and toe for shape, size and presence of tenderness, edema, and circulatory status

  3. Identifying clients at risk for foot problem
• Foot care practices


  • How often wash feet and cut toenails
  • Hygiene products usually used on feet
  • Type of shoes and socks worn
  • How often change socks or put on clean socks
  • Going barefoot
• Fluid intake


  During periods of normal activity at moderate temperature, the average adult drinks about 1,500 mL/day, despite the fact that they need 2,500 mL/day for normal functioning
• Self-care abilities


  • Problems managing foot care
  • How can the nurses best help
• Additional fluid intake


  750 mL/day from food, 200 mL/day from water as a by-product of food metabolism
• Foot problems and risk factors

  • Foot odor
  • Foot discomfort
  • Problems with foot mobility
  • Diabetes, circulatory problems with feet or prolonged exposure to chemicals or water
• Thirst mechanism


  Primary regulator of fluid intake, located in the hypothalamus of the brain, triggered by osmotic pressure of body fluids, vascular volume, and angiotensin
• Callus


  Mass of keratotic material and is the thickened portion of the epidermis which are mostly painless and flat
• Thirst is normally relieved immediately after drinking a small amount of fluid, but this relief is only temporary, and thirst returns in about 15 minutes
• Corn


  Keratosis caused by friction and pressure from a shoe. It is common on the fourth or fifth toe and usually on the bony prominence