Nursing Skills Test #2

Foot and Nail Care

Necessary to prevent infection, odors, pain, and injury to soft tissue.

Peripheral Vascular Disease (PVD)

A condition often seen in patients with diabetes, increasing foot care risks.

Peripheral Neuropathy

A loss of sensory, motor, and autonomic nerve function that affects foot sensation.

Foot Ulcers

Result from deformities or trauma, can lead to infection and gangrene.

Nursing Diagnosis for Foot Care

Includes ineffective tissue perfusion and self-care deficits related to foot care.

Assessment of Feet & Nails

Inspect integrity, color, temperature, and capillary refill of toes, feet, and fingers.

Self-Care Ability Assessment

Evaluates patient's ability to care for their feet and nails, and their knowledge of foot care.

Implementation of Foot Care

Involves hand hygiene, providing privacy, and safe foot soaking methods.

Risk Factors for Foot Problems

Include poor vision, lack of coordination, diabetes, and age-related changes.

Patient Education for Foot Care

Teach patients to keep feet clean and dry, wear appropriate footwear, and inspect feet regularly.

Personal Hygiene

The maintenance of cleanliness to promote comfort, safety, and well-being.

Oral Hygiene

Thorough care of the oral cavity to maintain the integrity of its structures.

Bathing Guidelines

Procedures for bathing that include considerations for patient comfort, safety, and hygiene.

Complete Bath

A bath administered to a totally dependent patient in bed.

Partial Bed Bath

Cleaning body parts that would cause discomfort if unwashed, such as the hands, face, axilla, and perineal area.

Sponge Bath

Cleansing with a washcloth or sponge without submerging the body in water.

Tub Bath

Preferred method for washing the entire body, offering therapeutic benefits.

Bag Bath

A disposable bathing system containing no-rinse washcloths, often warmed before use.

Incontinent Systems

Products designed to absorb moisture, promote independence, and protect linens.

Patient Identification

The process of confirming a patient's identity using a name band.

Hand Hygiene

The practice of cleaning hands to reduce the transmission of microorganisms.

Warm Water Benefits

Promotes comfort, prevents chilling, and relaxes muscles during bathing.

Washing Technique

Using long firm strokes from distal to proximal to promote venous return.

Perineal Care

Hygiene care for the perineal area that requires sensitivity and privacy.

Avoiding Skin Massage

Do not massage reddened areas on the skin to prevent irritation or injury.

Indwelling Catheter Care

Specific nursing skills for the management of patients with catheterization.

Intake & Output (I&O)

A nursing measure to assess and record fluid intake and output to determine the fluid status of a patient.

Electrolytes

Minerals in the body that carry an electrical charge and are essential for balancing body fluids, regulating heart rhythm, and supporting nerve and muscle function.

Fluid Volume Deficit (FVD)

Also referred to as dehydration, it is a condition resulting from loss of fluid and electrolytes leading to output greater than intake.

Fluid Volume Excess (FVE)

Also known as over-hydration, it is a condition where intake exceeds output, leading to an excess of fluid and electrolytes.

Hemovac

A type of drainage system used for collecting fluids from surgical sites.

Oliguria

A medical condition characterized by low urine output, defined as less than 30 mL/hr.

Congestive Heart Failure (CHF)

A chronic condition that affects the heart's ability to pump blood and can result in fluid retention.

Insensible Fluid Losses

Fluid losses that occur unnoticed, such as through evaporation from the skin and respiration.

Gastrostomy Tube

A tube inserted directly into the stomach for patients requiring long-term enteral nutrition.

Delegation in Nursing

The process of assigning tasks or responsibilities to other healthcare team members while maintaining accountability.

Epidermis

The outermost layer of skin, providing a barrier to infection.

Dermis

The layer of skin beneath the epidermis, containing collagen, blood vessels, and nerves.

Decubitus Ulcers

Also known as pressure ulcers, these are areas of localized tissue damage due to prolonged pressure.

Ischemia

A condition resulting from insufficient blood flow to tissue, leading to tissue damage or death.

Braden Scale

A tool used to predict pressure injury risk, assessing sensory perception, moisture, activity, mobility, nutrition, and friction.

Pressure Injury Staging

Classification system for pressure injuries that includes stages 1 to 4, indicating severity and tissue involvement.

Moisture

A factor that can contribute to skin breakdown, especially in areas prone to incontinence or perspiration.

Friction

The resistance encountered when moving over a surface, which can contribute to skin injury.

Shearing

A force that occurs when layers of skin slide over each other, potentially causing damage to deeper tissues.

Therapeutic Surfaces

Specialized surfaces designed to relieve pressure and prevent pressure injuries.

Stage 1 Pressure Injury

An area of nonblanchable erythema with intact skin, indicating early tissue damage.

Stage 2 Pressure Injury

Partial thickness loss of skin involving the epidermis and possibly the dermis, presenting as a blister or shallow sore.

Stage 3 Pressure Injury

Full thickness skin loss involving subcutaneous tissue, may have slough or eschar.

Stage 4 Pressure Injury

Extensive tissue loss with exposure of muscle, bone, or supporting structures.

Stage 1 Ulcer

Non-blanchable area of skin; appears red in lighter skin and blue/purple in darker skin.

Non-blanchable

Skin stays red when pressed, indicating little to no blood flow.

Blanchable

Skin turns white when pressed and returns to red upon release, indicating normal blood flow.

Stage 2 Ulcer

Partial thickness loss of dermis and epidermis; may appear as abrasion, blister, or shallow crater.

Foul smell

Characteristic of Stage 3 and 4 ulcers, indicating potential infection.

Debridement

The medical removal of dead, damaged, or infected tissue to improve healing.

Stage 3 Ulcer

Full thickness loss extending into subcutaneous tissue; does not involve muscle or bone.

Stage 4 Ulcer

Full thickness tissue loss, extending into muscle, tendon, or bone; significant tissue loss with slough or eschar.

Unstageable Ulcer

Full thickness tissue loss where the base of the ulcer is covered by slough or eschar, preventing stage determination.

Negative pressure wound therapy

A treatment for ulcers that uses suction to promote healing by creating a vacuum over the wound.