Nursing Hygiene, Positioning, Transfers, ROM, and VTE Prevention – Vocabulary Flashcards

Objectives and patient-centered care

• Begin with clear lesson objectives from the plan; emphasize understanding what we must know and what is important from PowerPoints.
• Hygiene care is the focus: complete bed bath, partial bed bath, hair care, nail care, oral care (including dentures), and how to make an occupied bed.
• Central theme: patients are humans with feelings; respect, communication, and psychosocial care are essential during hygiene tasks.
• Patients often prefer to care for themselves (autonomy); hygiene moments (e.g., bed bath) are opportunities to assess and connect with the patient.
• Bed baths are a chance to assess the patient, build rapport, and meet psychosocial needs in addition to performing skills.
• When caring for patients, balance practical skills with empathy and patient preferences; avoid making everything about the task and not the person.
• Promote dependence and family involvement appropriately: involve family in hygiene tasks if desired, but do not force involvement.
• Assessment is critical during hygiene: self-care ability, environment, preferences, and cultural factors.
• Understanding and applying core principles supports patient-centered care and safe practice.

Hygiene principles and patient factors

• Hygiene is a basic human need and must be patient-centered.
• Assess and document patient preferences (e.g., nighttime vs daytime baths) and their health considerations when planning care.
• Consider that factors influencing hygiene include:
  • Social practices, personal preferences, and cultural sensitivity.
  • Not everyone baths daily; some prefer a nighttime bath.
  • Body image, socioeconomic status, health beliefs, cultural variables, and developmental stage.
  • Physical condition (e.g., left-sided weakness after stroke) affects independence and needs.
• Examples: nighttime bath preference may be respected unless health factors require a different timing; oral care is typically recommended twice daily, but patient preference matters.
• Psychosocial responses to illness: helplessness, perceived uselessness, depression; address这些 feelings during care.
• When planning care, consider safety and dignity (privacy, modesty, and covering areas not being bathed).

Bath types and CHG (chlorhexidine) concept

• Bath options include:
  • Complete bed bath (client totally dependent; nurse does everything) including fair and nail care as appropriate.
  • Partial bed bath (clean only parts that cause discomfort if not cleaned).
  • Sponge bath, tub bath, shower, and disposable bed bath (wipes).
  • Therapeutic baths (e.g., oatmeal or Epsom salt baths for specific conditions).
• CHG (chlorhexidine gluconate) is used to reduce microbial growth and hospital-acquired infections; hospital policy drives CHG use, especially for patients with Foley catheters, central lines, ventilators, or undergoing surgery.
• CHG is often delivered via wipes or solution; practice varies by hospital policy and patient needs.
• Historical note: soda-water baths were once common; current evidence supports CHG to prevent nosocomial infections.
• CHG is part of evidence-based practice to reduce organisms such as MRSA, VRE, Acinetobacter, etc.
• Important nuance: CHG for skin is different from CHG used in oral care; only use appropriate formulation for the intended site.

Highlights for complete vs partial bed bath (operational points)

• When removing clothing, do so from the unaffected side first; avoid disconnecting IV lines unnecessarily to prevent infection risk.
• Check water temperature to prevent scalding; some patients (children, those with diabetic neuropathy) may not feel heat well.
• For eye care: avoid rubbing; if crust in eyes, soak for 2–3 minutes; avoid using CA sheet on face or eyes.
• Clean under skin folds and dry thoroughly to prevent moisture-related bacteria.
• Do not massage red, irritated, or wound areas as it can worsen injury.
• Perineal care requires positioning and privacy; female and male differences in technique; handle urinary catheters and CHG appropriately.
• Oral care: encourage patient involvement; ensure the patient is in a safe position, suction available if needed; consider special needs for unconscious patients (no gag reflex, elevation of head, etc.).
• Dentures: treat dentures as patient property; store and label carefully; dentures may require adhesive; ensure proper cleaning and storage.
• Unconscious patients: prioritize airway protection and prevention of aspiration; maintain head of bed elevation; sideline position for oral care whenever not contraindicated; avoid placing solutions in the mouth that are not intended for oral care.

Oral care and dentures

• Oral care should be performed twice daily regardless of bath timing; good oral health supports overall health.
• For unconscious patients, use a side-lying (sideline) position to reduce aspiration risk; elevate head of bed; use oral airway if needed.
• When performing oral care on an unconscious patient, check gag reflex first (tongue blade test, etc.).
• Suction setup should be ready if needed; maintain patient comfort and safety.
• Dentures should be handled with care: respect dentures as personal property, store and label; ensure dentures are clean and adhesive as needed.

Perineal care: female vs male

• Privacy and positioning are essential.
• Female: clean from inner to outer labia; ensure proper cleaning sequence and keep privacy.
• Male: account for circumcised vs uncircumcised status; manage catheter or urinary devices as needed; CHG is used for perineal areas as per policy.

Shaving and hair care

• Shaving may be necessary in hospital settings; assess bleeding risk (history of blood thinners/anticoagulants).
• Positioning often employs a sideline approach; neck/spinal contraindications must be considered before repositioning (e.g., neck injury or spinal immobilization).
• Hair care: use disposable shampoo packs; ensure appropriate head support; remove hearing aids before shampooing; elderly patients may have sensitive scalps or hearing impairment requiring gentler care.
• Shaving technique: for patients with bleeding risk, use caution with razors; shave in direction of hair growth; note differences between large vs. short strokes as published in some texts (your book may call for short strokes).
• Diabetic or peripheral vascular disease patients require extra caution due to loss of sensation and delayed wound healing; avoid soaking diabetic feet if sensation is reduced; teach foot care and infection prevention.

Nail and foot care

• Nail care requires provider order in many hospitals; some patients require podiatry referrals (e.g., diabetics, peripheral vascular disease).
• Foot/toe care considerations:
  • Diabetics and PVD patients may have reduced sensation and poor healing; avoid soaking if sensation is lost.
  • Trim nails according to hospital policy; inspect feet daily for ulcers, redness, or lesions.
  • Inspect footwear; ensure shoes protect feet and avoid injuries.
  • Educate patients with neuropathy to wear appropriate shoes and inspect feet daily.
• Foot and nail care requires careful positioning; ensure patient comfort and safety during the procedure.

Occupied bed: assessment and safety

• Occupied bed tasks require environment assessment: spills, bed function, battery/plug status, and whether the bed is compatible with patient needs.
• Consider lines and tubes (ET tube, IV lines, catheters) before moving to prevent pulling devices.
• Watch for aspiration precautions if head elevation is limited; consider the patient’s risk factors when turning.
• Avoid rubbing or shaking the linen on the patient (i.e., avoid rough handling with soiled linen).
• Turn and reposition plan: ensure patient comfort after turning; ensure proper body alignment and that all lines stay safe.
• The goal is to leave the patient in a comfortable and safe position with access to call light and necessary items.

Positioning and safety in care

• ADLs (Activities of Daily Living): patient-specific; goal is to return to optimal functioning; assess what the patient can do and what is feasible.
• Gait and mobility concepts:
  • Gait: describes walking pattern; assess whether it is steady or unsteady; consider broader aspects of mobility.
  • ROM (Range of Motion): initial and ongoing assessment to preserve joints, prevent contractures, and maintain function.
• Mobility risk factors: poor nutrition, poor circulation, loss of sensation (e.g., diabetes), bone/joint issues, and impaired muscle development can increase injury risk.
• Assessment helps identify risk factors and triggers a team-based response (PT/OT involvement, safety planning).
• Body mechanics for nurses are crucial to prevent injuries; plan each move; use knees, not back; avoid heavy lifting or awkward reaches; use assistive devices when needed.
• Body alignment and posture: ensure that the head, shoulders, hips are aligned; assess for asymmetry; document significant findings (e.g., unequal shoulders).
• Proper positioning principles:
  • Keep head midline; ensure shoulders and hips align; avoid propping in awkward angles.
  • Small spaces between backs of knees and chair promote circulation and reduce risk of compression on the popliteal artery.
  • Sideline position is often used for oral care; ensure the head is protected and turned to one side to prevent airway obstruction.
  • Sims position (semi-prone, with abdomen toward bed) used for enemas or procedures; ensure elbows/knees and supportive pillows avoid pressure points.
  • Supine: common for general care but requires pillow support to protect pressure points.
  • Prone and lateral positions: maintain head alignment and protect airway; use pillows to prevent limb strain and pressure.
• When leaving a patient, verify: side rails up (as appropriate), call light within reach, bed in lowest position, patient on aspiration precautions, correct head-of-bed angle, and joints supported with cushions or pillows.
• Positioning plan requires preparation and anticipation; plan for the patient’s comfort and safety for every transfer.

Transferring and mobility devices

• Transfers require planning and crew coordination; minimize risk by using appropriate devices and proper technique.
• Moving up in bed:
  • Allow patient to participate as much as possible (e.g., push with heels); use one arm under the head and one under the thigh for a lift.
  • With two caregivers, use a draw sheet to slide the patient up; ensure IV lines and devices have slack and are not tethered.
  • If head-of-bed is elevated, lower it before moving if not contraindicated; use a friction-reducing device under the patient (air mattress/slide sheet) if available.
• Moving from bed to chair/wheelchair:
  • Lower bed to the lowest position; ensure wheels are locked on the chair; place chair at a 45-degree angle for safe transfer; align patient with the chair and plan the transfer direction.
  • Place gait belt on patient for control; ensure patient is educated about the transfer and knows what to expect (e.g., count to three before moving).
  • If patient is a fall risk or experiences orthostatic hypotension, sit at the edge of the bed for 2–3 minutes before standing to allow dizziness to subside.
  • Keep lines secure and intact; confirm safety barriers (side rails, locks) before transfer.
• Bed to stretcher transfer:
  • Align bed and stretcher; ensure patient is secured; use a draw sheet or a friction-reducing device to move in unison.
  • Verify IV/Foley lines are managed to prevent traction or dislodgement.
  • Use appropriate assistance and ensure staff knowledge before operating equipment.
• Transfer devices:
  • Friction-reducing devices (air mattress) can facilitate sliding; ensure staff are trained on operation before use.
  • Mechanical lifts (e.g., BOY Lift) may be used for patients who cannot be safely moved without assistance; ensure proper operation and safety checks before use.

Ambulation and weight bearing status

• Not all patients can ambulate; check weight-bearing status before ambulating:
  • FWB: Full weight bearing; no restriction.
  • PWB: Partial weight bearing; approximately 50% weight bearing.
  • NWB: Non-weight bearing; no weight on affected limb.
  • WBAT: Weight bearing as tolerated; patient bears weight as tolerated.
  • The physician establishes weight-bearing status; expect orders like FWB, PWB, NWB, or WBAT.
• Ambulation devices and usage:
  • Gait belt used to provide control and safety during ambulation.
  • Crutches, walkers, canes as alternatives; ensure proper fit and patient education.
  • Walkers: avoid use on stairs; use handrails; ensure proper weight bearing and device fitting; if unilateral weakness, advance the weaker leg first.
  • Crutches: fit under arms (not directly under axilla); elbow flexion about a slight bend; check bottom tips for grip; avoid injury to axilla.
  • Proper walker/crutch use depends on weight bearing and the patient’s strength; ensure safe ambulation with staff assistance if necessary.
• Stair and ascent considerations: use appropriate devices and ensure patient safety; teach and supervise ambulation on appropriate surfaces.

Range of motion (ROM) assessment and documentation

• ROM is often the first assessment for potential injury or functional limitation.
• ROM goals: maintain joint integrity, preserve function, minimize contractures; aim for full ROM without pain.
• Stopping rules: stop ROM if patient reports pain or if resistance is met; nonverbal cues (grimacing, withdrawal) indicate pain or discomfort; if resistance is encountered unexpectedly, stop.
• ROM types:
  • Active ROM (AROM): patient performs movements independently.
  • Passive ROM (PROM): practitioner moves joints for the patient (no active muscle use by patient).
  • Active-assisted ROM (AAROM): patient performs movement with some assistance.
• ROM technique: perform complete ROM in a hand-to-toe fashion; repeat movements at least five times; monitor for discomfort and resistance; document results (full ROM, limited ROM, ARROM, PROM, or AAROM).
• Documentation is critical to track changes over time and communicate patient status to the care team.
• Do not delegate ROM assessment to CNAs; assessment and ROM require professional clinical judgment.

Venous thromboembolism (VTE) risk and prevention

• Immobile patients are at risk for DVT due to Virchow’s Triad factors: hypercoagulability, venous wall abnormalities, and blood flow stasis.
• Virchow's Triad components (outline):
  • Hypercoagulability
  • Venous wall abnormalities
  • Blood flow stasis
    ext{Virchow's Triad} = igrace ext{Hypercoagulability}, ext{Venous wall abnormalities}, ext{Blood flow stasis} igrace
• Risk factors include immobility, high BMI, peripheral vascular disease, and congestive heart failure.
• Signs of DVT to monitor (unilateral): swelling, tenderness, redness, warmth, color changes, cramping.
• Important to avoid massaging reddened areas; massage could dislodge a clot (DVT) and cause embolism.
• Prevention strategies:
  • Use antithrombotic therapies (e.g., anticoagulants) when indicated; use compression devices as prescribed.
  • Use graded compression devices (SCDs) or TED stockings with proper sizing and application.
  • Turn devices on and ensure breaks; assess skin integrity and circulation regularly; remove stockings for skin checks per policy.
• TED stockings: come in knee-high and thigh-high variants; ensure proper fit (size matters) and evaluate for skin issues during shifts.
• SCDs (sequential compression devices): ensure they are in the correct position, turned on, and used with breaks to prevent skin issues and to promote circulation.
• Skin assessment and circulation monitoring include color, warmth, capillary refill time (CR):
  • Capillary refill time: ext{CR} < 30 ext{ seconds} (as noted in the material).
• Bedside Mobility Assessment Tool (BMAT): used to assess a patient’s mobility and capacity to perform activities; not required to memorize, but to understand its purpose and use in bed mobility planning.

Do’s and Don’ts; safety and ethics in care

• Do prioritize patient dignity, consent, and preferences; involve family when appropriate but not forced.
• Do plan ahead, ask for help when needed, and ensure safety devices and lines are secured before transfers.
• Do assess risk factors and communicate findings to the care team; involve physical therapy (PT) or occupational therapy (OT) as needed.
• Don’t rush or perform tasks that jeopardize patient safety or your own safety (risk of injury to caregiver or patient).
• Do educate patients about devices and care plans; ensure they understand what is happening and why.
• Do not massage reddened or suspect wound areas; avoid causing tissue injury.
• Do not perform ROM without proper training or outside of scope; document changes and continue to monitor.
• Always ensure privacy during hygiene tasks; maintain moisture-free skin and avoid leaving patients exposed unnecessarily.

Practical connections and real-world relevance

• Hygiene and positioning practices directly impact patient comfort, dignity, infection risk, and overall recovery trajectory.
• Proper handling of lines and devices during repositioning minimizes iatrogenic injury and line dislodgement.
• Understanding weight-bearing status and gait training informs safe ambulation and reduces fall risk.
• Early involvement of family can improve patient morale and adherence to care, while preserving patient autonomy.
• The integration of rotation through positions (supine, Fowler’s, sideline, Sims, prone) supports airway protection, skin integrity, and comfort during procedures.
• Knowledge of Virchow’s Triad and VTE prevention has real-world implications for stroke, immobility, and post-surgical patients.

Summary tips for exams

• Be able to distinguish complete vs partial bed bath, and know perineal care differences for male vs female patients.
• Remember CHG usage and policy considerations for infection control.
• Know key safety checks before any transfer: bed height, call light, side rails, locked wheels, device management, and patient education.
• Be able to describe the steps and rationale for a log roll (minimum of three staff).
• Understand ROM terminology (AROM, PROM, AAROM), and when to stop for pain or resistance.
• Know weight-bearing statuses (FWB, PWB, NWB, WBAT) and who prescribes them (physician).
• Recognize Virchow’s Triad and common DVT signs; know prevention strategies (SCDs, TED stockings, anticoagulants) and when not to apply stockings.
• Acknowledge ethical considerations: patient autonomy, dignity, privacy, and safe family involvement.
• Practice positioning basics (head midline, shoulders and hips aligned, 30° elevation of Fowler’s as needed, avoidance of pressure on bony prominences).
• Understand the importance of documentation to monitor changes over time and communicate needs to the healthcare team.
• Prepare for lab/skills checks by articulating steps clearly and demonstrating patient safety, proper device use, and appropriate communication with the patient.

Quick reference formulas and key notations

• Virchow's Triad components: ext{Hypercoagulability}, ext{Venous wall abnormalities}, ext{Blood flow stasis}
• Capillary refill time threshold: ext{CR} < 30 ext{ seconds}
• Weight-bearing status: ext{WB status}
  i ext{ FWB}, ext{PWB}, ext{NWB}, ext{WBAT}
• Chair transfer angle: ext{Wheelchair angle} = 45^ ext{°}
• ROM repetition guideline: typically at least five repetitions per movement
• Dangling time after sitting up: 2-3 ext{ minutes}