Nursing 152 Foundations of Nursing Practice

- Critical care- every day and freshen at night - Long Term Care (LTC) - 1X/week

- Negotiate a different time - Different staff - Partial bath

To prevent excessive moisture which can increase skin break down and growth of bacteria.

No. - Clots may be dislodged - Damage to legs

- Avoid drafts - Use warm water - Prevent chilling - Soap - sproam (hypoallergenic) - Tub/ Shower safety - Eye care- inside to out - Ear care- Wash outer and behind ear - Mouth care - q2h if NPO, brush during bath - Hair care - Foot care - do not cut nails of a diabetic foot care nurse can do that - Shaving - do not share razors, bring their own, do not do on diabetic or person on blood thinners - Back care - lotion, back rub - Perineal care - every time you change a benefit, and morning and evening (partial). Retract foreskin. Wipe front to back.

- Color - pallor, flush, cyanosis - Temperature - Texture - moisture - Lesions - distribution and location

Client: - Cleanliness - Self-esteem, wellbeing - Circulation - ROM Nurse: - Assessments and observations - Build therapeutic relationship - Teaching

1) Bed Bath: - Complete - head to toe - Partial - face, hands, pits, perineal (Evenings) - Assisted - pt do most, assistance when needed 2) Tub Bath - not people with seizures or decreased mobility 3) Showers - w/c showers 4) Whirlpool

Daily -Sween24 - For mild to moderate dry, itchy, flaky, red skin; use once a day after bath - Atrac-Tain Cream- For severly dry, cracked, fissured skin (heels), apply Am and Pm, recommended for daily use on diabetic clients feet

- Non-rinse cleanser - Skin sealant - Barrier- zinc, petrolatum and wafer barriers - Disposable briefs - Condom catheters - Drainage pouches - Abscorbent Dressings

1) Sensory perception 2) Moisture 3) Activity 4) Mobility 5) Nutrition 6) Friction and Shear < 14 = interventions

1) Prevent skin breakdown- avoid massaging it, moisturize, avoid hot water or drying out, protect from friction (T&P, dressings) 2) Reduce Pressure- pressure relief or reduction 3) Reposition- TLR, T&P q2h, foam and pillows 4) Manage moisture- toileting schedule, absorbent briefs, barrier creams 5) Maximize nutrition- dietitian, speech therapy, OT 6) Enhance mobility and activity - rehabilitation

1) Kidneys, ureters 2) Bladder, urethra

1) Filtration - filters 20-25% of cardiac output per miute 2) Excretion 3) Fluid and electrolyte balance - 99% that is filtered is reabsorbed, 1% excreted 4) RBC production- produces erythropoietin 5) BP regulation - produces renin 6) Bone mineralization- vitamin D conversion

Nephron Glomerulus- inside the nephron, filtrs blood and begins urine formation