Hygiene
What is the purpose of performing a bed bath for a client?
To maintain skin integrity, promote comfort, and prevent infection.
What is the initial phase of wound healing involving clot formation?
Hemostasis
What is a pressure ulcer?
Localized injury to skin and underlying tissue due to pressure.
What should you teach a client about maintaining dry and clean skin?
Change linens and clothing regularly, and dry skin after bathing.
What principles should guide hygiene care for a hospitalized patient?
Individualize care based on patient preference and needs.
Name two areas that require special attention during hygiene care.
Oral and perineal area
What is blanching, and why is it assessed?
Blanching is whitening of the skin when pressed; it assesses capillary refill and pressure ulcer risk
Name one method to prevent skin breakdown.
Frequent position changes
How can clients prevent pressure ulcers at home?
Reposition frequently, use cushions, inspect skin daily.
Before providing oral care to an unresponsive patient, what is the priority assessment?
Assess for gag reflex to prevent aspiration during oral care.
What should you assess before providing hygiene care?
Self-care ability and client preferences
Name two signs of wound infection.
Redness, swelling, warmth, purulent drainage.
What is shearing force?
Force created when skin moves in one direction and bone in another.
What dietary advice supports wound healing?
Eat foods high in protein, vitamins A and C, and zinc.
Name factors that increase the risk for pressure injury development?
Impaired cognition (Altered Mental Status), immobility, nutrition.
Why is it important to dry skin thoroughly after bathing?
To prevent skin breakdown and fungal infections
What documentation is required after a wound assessment?
Size, appearance, drainage, odor, and client response.
Why is nutrition important for skin integrity?
Adequate protein and vitamins are needed for tissue repair.
Why is it important to teach about shear forces?
To prevent skin injury during movement.
What is the primary purpose of repositioning a patient every 2 hours?
To reduce pressure, prevent ischemia, and pressure injuries.
What is the order of performing a bed bath?
Face, eyes, chest, arms, abdomen, legs, perineum, change water, back, buttocks
What is the first step in performing a sterile dressing change?
Gather supplies, perform hand hygiene, and put on sterile gloves.
What is the Braden Scale used for?
Assessing risk for pressure ulcers.
What should clients know about signs of infection?
Report redness, swelling, pain, or drainage to a healthcare provider.
A nurse documents a wound with full-thickness skin loss and visible subcutaneous tissue. How should this pressure injury be staged?
Stage 3 - full-thickness tissue loss with exposure of subcutaneous fat but no bone or muscle visible.