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A nurse is teaching a nursing student how to perform perineal care for patients. What actions are appropriate when performing this procedure? Select all that apply.
- A. For male and female patients, wash the groin area with a small amount of soap and water and rinse.
- B. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area.
- C. For male and female patients, always proceed from the most contaminated area to the least contaminated area.
- D. For male and female patients, use a clean portion of the washcloth for each stroke.
- E. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward.
- F. In an uncircumcised male patient, avoid retracting the foreskin (prepuce) while washing the penis.
Correct Answer: A,D,E
Rationale: Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis and return it to its original position when finished.
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A home care nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure?
- A. Adding bath oil to the water to prevent dry skin
- B. Allowing the patient to lock the door to guarantee privacy
- C. Assisting the patient in and out of the tub to prevent falling
- D. Keeping the water temperature very warm because older adults chill easily
Correct Answer: C
Rationale: Safe nursing practice requires that the nurse assists a patient with an unsteady gait in and out of the tub. Adding bath oil to the bath water poses a safety risk because it makes the patient and tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43?° to 46?°C. Older adults have an increased susceptibility to burns due to diminished sensitivity.
A nurse in a memory care unit is assisting a patient with dementia with bathing. Which nursing action will enhance patient comfort and prevent anxiety?
- A. Shifting the focus of the interaction to the 'process of bathing'
- B. Washing the face and hair at the beginning of the bath
- C. Using music to soothe anxiety and agitation
- D. Avoiding towel baths or forms of bathing with which the patient is unfamiliar
Correct Answer: C
Rationale: The nurse use music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the 'task of bathing' to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. Wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider methods for bathing aside from showers and tub baths. Towel baths, washing under clothes, and bathing 'body sections' one day at a time, as well as dry shampoo or 'shower cap' shampoos, are additional options.
When assessing the skin, nurses use techniques to provide complete data and correct documentation. Which actions are appropriate during the skin assessment? Select all that apply.
- A. Comparing bilateral parts for symmetry
- B. Proceeding in a toe-to-head, systematic manner
- C. Using standard terminology to communicate and document findings
- D. Avoiding using data from the nursing history to direct the assessment
- E. Documenting only skin abnormalities on the health record
- F. When risk factors are identified, following up with a related skin assessment
Correct Answer: A,C,F
Rationale: During skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to communicate and document findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, using cues/data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.
An RN in a long-term care facility supervises APs as they provide hygiene to older adults. What action by the AP will the nurse correct?
- A. When providing perineal care, washing the area from front to back
- B. Insisting the older adult must take a bath or shower each day
- C. Telling the patient to avoid soaking feet, helps the patient dry between the toes
- D. Covering areas not being bathed with a bath blanket
Correct Answer: B
Rationale: Older adults tend to develop dry skin; bathing frequency will change accordingly. Soaking adults' feet is not recommended. It is appropriate to keep a patient warm with bath blankets and provide perineal care washing from front to back.
A nurse assisting a patient with a bed bath observes the older adult has dry skin, which the patient states is 'itchy.' Which intervention is appropriate?
- A. Bathe the patient more frequently.
- B. Use an emollient on the dry skin.
- C. Explain that this is expected as people age.
- D. Limit the patient's fluid intake.
Correct Answer: B
Rationale: An emollient soothes dry skin, whereas frequent bathing increases dryness. Telling the patient this is normal with aging and does not help resolve the issue. Limiting fluid intake can promote dehydration and exacerbate dry skin.