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Theory 4th test

Stage 1 pressure ulcer. Intact skin
Red or purple, unbalancing skin. Skin may be warm. Stage 1 pressure ulcer
Stage 2 pressure ulcer. Partial skin loss.
Abrasion, blister or shallow crater. Stage 2 pressure ulcer.
Stage 3 pressure ulcer. Full thickness skin loss, damaging or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia.
An ulcer that present as a deep crater with or without undermining or adjacent tissue. Stage 3 pressure ulcer.
Stage 4 pressure ulcer. Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (tendon or joint capsule).
Undermining and sinus tracts, osteomyelitis. Stage 4 pressure ulcer.
Dehiscence Separation or splitting open of layers of a surgical wound.
Spilling out of the intestines from a wound. Evisceration.
Slough Moist, stringy, white/yellow/tan/gray
Beefy red, granular Granulation tissue
Hard, dry, black Eschar
Debridement Mechanical, autolytical, chemical, or surgical/sharp
Protects the wound from surface contamination. Hydrocolloid dressing
Maintains a moist surface to support healing. Hydrogel dressing
Uses negative pressure to support healing. Wound V.A.C.
Before changing dressing ... Gently cleanse wound, use normal saline, administer analgesics before starting.
Use heat therapy for ... Arthritis, degenerative joint disease, localized muscle strain, hemorrhoids.
Use cold therapy for ... Direct trauma such as sprain, strain, fracture, joint trauma, application after an injection (steroid injection into a joint).
Primary wounds Sutures or staples (wound is manually closed).
Secondary wounds Granulation-contraction (healed from the inside out)
Tertiary wounds Wound is left open to heal from the inside out (may be closed later).
Delayed Primary Closure Tertiary wound
First phase of wound healing: Inflammatory
Second phase of wound healing: Proliferation
Third phase of wound healing: Maturation
0-3 days Inflammatory stage of healing
3-21 days Proliferation stage of healing
21 days - 1.5 years Maturation stage of healing
Perform a pressure point/skin assessment Check skin within 12 hours of admission.
If a pressure ulcer is found following admission Be sure to document finding and notify physician when a pressure ulcer is found.
Factors effecting wound healing .. Rheumatoid disease (increased inflammation), medications impair healing, hepatic failure (altered clotting factors, impaired glucose production), lymphedema (increased infection risk, reduction of 02 & nutrients).
Pressure Ulcer Risk Factors Chronic illness, dehydration/malnutrition, DM, steroid use, incontinence, paralysis, diminished sensation, obese/frail, age, lack of mobility, anemia.
This is a cause of tissue ischemia. Death or lack of 02 causes this ...
When tissue stays blanched, that means the tissue does not have ... Lack of good blood flow causes skin to stay ...
When the skin turns red and stays red (purple) Stage 1 pressure ulcer
Most common sites for pressure ulcers include ... Sacrum and heels
Shear force is When the skin is pulled (can be from a person sliding or being pulled up or down in bed). Skin adheres to the bed. Going down a hot slide.
Friction is Two surfaces rubbing against each other.
Which one of these is a risk factor for developing a pressure ulcer? Impaired sensory perception, alteration in level of consciousness, impaired mobility, shear, friction, moisture (all of these).
Stage 1 Intact skin with nonblanchable redness
Stage 2 Partial-thickness skin loss involving epidermis, dermis, or both
Stage 3 Full thickness tissue loss with visible fat
Stage 4 Full thickness tissue loss with exposed bone, muscle, or tendon
Use a natural or halogen light to assess ulcers in people with darker skin tones. Checking for pressure ulcers
Shallow open ulcer with red/pink wound bed, presents as an intact or ruptured serum-filled blister. Stage II
Deep crater with possible undermining of adjacent tissue. Depth of ulcer varies by anatomic location. Stage III
Full thickness loss can extend to muscle, bone, or supporting structures. Bone, tendon, or muscle may be visible or palpable. Undermining & tunneling may occur. Stage IV
Masceration Skin is mushy & milky.
Cellulitis Infection of the skin
Osteomyelitis Infection of the bone
An injury happens: Vascular response Brief vasoconstriction followed by arteriole vasodilation (blood rushes into capillaries causing hyperemia - tissue redness), then edna and warmth.
Cellular response WBC's travel to the injured site, neutrophils arrive first and engulf the bacteria. They die within 24-48 hours. The dead digested bacteria and neutrophils makes up the pus. Then macrophages come in and clean up the site before healing can be started.
Exudate formation follows Cellular response
Healing follows Exudate formation
Inflammation response occurs in this time frame 0-3 days following an injury
Proliferation phase occurs in this time frame 3-21 days
Maturation phase occurs in this time frame 21 days - 1.5 years
Chronic wounds get stuck between these phases. . . Inflammatory and proliferative phase
Hematoma Collection of blood under the skin
Penrose drain A Penrose drain, is a surgical drain which is left in place after a procedure to allow the site of the surgery to drain. Used in wound care to collect exudate, measure it, protect the surrounding skin.
Jackson-Pratt A Jackson-Pratt drain is rubber tubing that may be placed after surgery. It may also be used with infections or injury that can cause a buildup of fluid. A JP drain has one function, to drain smaller amounts of fluid and blood from a surgical site.
Reason to have a Jackson-Pratt The JP drain allows fluids to move out of the body. The drain may be placed: After surgery if large amounts of drainage are expected To drain fluids from an abscess or other infected areas To drain fluids from injury associated with fluid build up
Sleeping with a JP Sleep on the side opposite of the drain. This will help you to avoid blocking the tubing or pulling it out of the suction bulb.
Problem with staging pressure ulcers on heels? May be difficult if eschar is present on part of the wound. The edges of the wound could be stage 2 & or 3.
Hemovac A hemovac has a larger capacity, can collect blood in order to give back to the patient. It can have an initial setup for an autologous re-transfusion, then after a certain period of time it's converted to simply a collection device. Uses suction.
Duoderm DuoDerm is a brand name for a form of dressing called a hydrocolloid dressing. It contains a gel-forming agent in an adhesive compound combined with a flexible, water-resistant outer layer.
Duoderm is used on Pressure ulcers, leg ulcers, diabetic ulcers, traumatic wounds (including superficial wounds, minor abrasions and lacerations), surgical wounds and dermatological excisions.
Applying Duoderm Cut the DuoDERM approximately 1/2 to 1 inch beyond the wound’s margin. After peeling off the adhesive backing, apply the sticky side of the dressing to the wound.
Caution to be considered with Duoderm The dressing should not be used on excessively oozing wounds or where infection is present and it should be used with extreme caution for treating diabetic ulcers on the feet.
Hydrogel A Hydrogel Dressing is highly absorptive, contours to a wound site, and maintains the wound in a moist state to promote healing.
First Aid for wounds: 1st step Control the bleeding (allow the wound to bleed, do not remove penetrating objects)
First Aid for wounds: 2nd step Clean the wound (gentle, normal saline)
First aid for wounds: 3rd step Protect the wound
Purposes for dressings (select all) Protect the wound from microorganisms, aid in homeostasis, promote healing (absorbing drainage/debriding), support or splint, promote thermal insulation, hide the wound if pt is disturbed by the sight of the wound.
Hydrocolloid dressing Protects the wound from surface contamination
Don't do this to wounds!! Wet to dry! Pulls off newly formed skin.
What to do with a transparent dressing. Measure the wound, chart the appearance, write the date, label, and initial
Before changing dressings 1. Evaluate the pt's pain level (give meds to pt if needed) 2. Tell the pt what you are going to do 3. Gather supplies 4. Recognize normal signs of healing 5. Assess the skin 6. Hand hygiene 7. Glove (not sterile)
Amount of O2 in the air 20 - 21%
Purpose of irrigation To remove exudates. Use sterile technique with 35mL syringe and 19 gauge needle.
When removing staples ... Remove every other staple and check to make sure the wound doesn't dehiss.
Purpose of bandages and binders ... To create pressure, immobilize and or support a wound, reduce or prevent edema, secure a splint, and secure dressings.
Cold therapy is for ... vaso-constriction
Heat therapy is for ... vaso-dialation
Cold therapy is contraindicated when ... 1. The site of the injury is edematous 2. There is a presence of neuropathy 3. If the patient is shivering 4. If the patient has impaired circulation
Heat therapy is contraindicated when ... 1. There are areas of active bleeding 2. Acute, localized inflammation 3. Over large areas when the patient has cardiovascular problems
A surgical wound requires a hydrogel dressing. The advantage of this dressing is that it provides ... Moisture needed for wound healing
Stage 1 of stress Alarm or acute stress : Fight or flight. Increases sympathetic activity (increased heart rate, respirations, & blood pressure) to enhance strength & speed.
What is stress? A negative emotional and or physical and or psychological response.
Pupils dilate, blood is shunted away from the digestive tract and kidneys and endorphins are released when people are in this stage of the stress response. Stage 1: flight or flight (sympathetic system)
The body prepares for a threatening situation when it is in this stage... Stage 1: fight or flight
Stage 2 of stress The resistant or adaptation stage. The person is trying to cope with the stress.
Stage 3 ... The person's continued efforts to cope with the stress proves futile. Depression, melancholy, even death can occur.
GAS Generalized Adaptation Syndrome. Males respond more with fight or flight (GAS) while women tend to befriend and tend (more nurturing). Wounds heal slower.
Lack of serotonin ... Can affect appetite.
Benson's relaxation technique Close eyes, repeat a word or phrase for ten minutes. Work on slowing breathing, brings down blood pressure, works to reign in the fight or flight response (calms the sympathetic system by switching to the parasympathetic system).
Progressive muscle relaxation Tensing & relaxing
AGing does not mean Automatically developing depressive disorders
Substance abuse & ADD Substance abuse and ADD bot fit under the umbrella of mental health
Delirium Is short term and can be treated so that the person returns to previous functional state
Dementia Is progressive and the person will not return to previous levels of functioning
Major Depressive Disorder One or more major depressive episodes, no manic or hypomania, symptoms interfere with social or occupational functioning, may include psychotic features. 6 months or more in duration.
SAD Seasonal affective disorder (light therapy helps)
Dysthymic Disorder Chronic depressive syndrome Present for most of the day More days than not Has symptoms for at least 2 years Can usually work, go to class & function May seek counseling
Feeling what the patient is feeling Counter transference
Anhedonia The inability to experience any joy or pleasure
Milieu Therapy Using the entire environment for therapy
Cognitive Behavioral Therapy (CBT) Think differently to act & be different. Think Cognitive reframing
Endorphins are produced Exercise produces endorphins
Delirium Always secondary to another physiological condition (sundowning)
Some causes of delirium Medications, medication withdrawal, fecal impaction, MI, UTI, dehydration (deficient fluid volume)
Delirium comes with Changes in cognition, disturbances in consciousness, common in older hospitalized patients
Four cardinal features of delirium 1. Acute onset & fluctuating course 2. Inattention 3. Disorganized thinking 4. Disturbance of consciousness These people may sleep a lot or drift off to sleep during conversation
A pt was alert two days ago but now seems inattentive and disorganized Check labs. Pt's WBC may be high due to a UTI
Illusions A coat on a hanger is perceived to be a bear. Perception is off
Global impairment is seen Dementia
Aphasia Can't talk. Can be expressive or receptive
Apraxia Lack of coordination
Agnosia Doesn't recognize people, including family members or self
Alzheimer's has 4 stages
Stage 1 of Alzheimer's Mild - forgetfulness
Stage 2 of Alzheimer's Moderate - confusion
Stage 3 of Alzheimer's Moderate to Severe - unable to identify familiar objects or people (agnosia)
Stage 4 of Alzheimer's Late - end stage
Huge issue when caring for Alzheimer's patients Caregiver strain
Diseases associated with stress DM, cancer, hypertension, CVA, MI
SBAR Situation, Background, Assessment, Recommendation
SOAP Subjective note Objective note Assessment/diagnosis Plan
Consultation A professional caregiver giving formal advice to another caregiver
A nurse can give patient information to the following Team members who have access to the patients chart, family members authorized by the patient to receive information
Nurses can make the decision to call the following ... Wound care, dietician, pt. education
Legal guidelines for recording notes: Correct all errors promptly Facts only No blank spaces Unclear order, document that clarification was sought Don't chart for other people Start each entry with date and time End each entry with a signature
If an error in medication is chated Discontinue medication charted in error and record correct medication with starting information
Narrative documentation is Freestyle (more conversational in nature)
SOAPIE Subjective Objective Assessment Plan Intervention Evaluation
PIE Problem Intervention Evaluation
Focus charting - DAR Data Action Response
CBE Charting By Exception: focuses on documenting deviations
Variances, Incident or occurrence reports Like an incident report. Something happened that is not unusual
A nurse records that the pt stated his abdominal pain is worse now (worse than last night). This is an example of Narrative chating
Common record-keeping forms Admission nursing history form: guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems Flow sheets & graphic records Pt care summary or Kardex
Additional common record-keeping forms Standardized care plans Discharge summary forms Acuity records: how severe the pt is compared to the rest of the floor
Hand off report Occurs with transfer of pt Provides continuity & individualized care Reports are quick & efficient
Benefits of NIS - Nursing Information Systems Increased time with pts Better access to information Enhanced quality of information Reduced errors of omission Reduced hospital costs Common clinical database Security
Created by: Block 1 Theory