test 3 study guide pdf

8/3/2019 Test 3 Study Guide PDF

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NU 226: INTRODUCTION TONURSINGTHEORY ANDPRACTICE

Exam III Study Guide

Chapter Topic APPROXIMATE number of questionsChapter 44 Nutrition 8Chapter 48 Skin Integrity and Wound Care 10Chapter 41 Fluid, electrolytes, acid and base 10

Chapter 41 IV Therapy and Blood transfusions 8Chapter 43 Pain management 10

Medication calculations 4Total 50

General Reminders:

There is a lot of information in the skills boxes. Unless otherwise stated, review these for the critical decision points, andat the end of each you should be familiar with the Unexpected Outcomes and Interventions.

Chapter 41: Fluid, Electrolytes, Acid-Base balance and IV therapies

Distribution of body fluids

Movement of body fluids

Type of Movement Definition/Example

OsmosisMovement of a solvent across a semi-permeable membrane from anarea of lesser to one of greater concentration.

DiffusionRandom movement of a solute through a semi-permeable membranefrom higher to lower concentration.Example oxygen & carbon dioxide

FiltrationMovement of water and diffusable substances across a membranetogether, under pressure, from higher to lower pressure

Active transportMovement of ions against osmotic pressure to an area of higherpressure. Takes energy.


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Regulation of body fluids, electrolytes and acid-base balance

Normal range and function for each electrolyte (table 41-1) Specifically, potassium, sodium and magnesium


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Electrolyte imbalanceso Focus the sodium ( Na ) (hyper/hyponatremia) and potassium ( K) (hyper/hypokalemia). (table 41-3)


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Lab values and treatments of Hypokalemia, hyperkalemia, hyponatremia and hypernatremia

o Hypokalemia Lab Values

o Decrease in K+ in blood/extra-cellular fluid,Lab: K below 3.5 mEq/L

Treatmentso Replacement of K+: Oral or IV

o Hyperkalemia Lab Values

o Lab: K Above 5mEq/L (increase of K+ in serum: extra cellular fluid.) Treatments

o IV /parenteral therapy to shift K+ into cells (Nabicarb, insulin, hypertonic dextrose),o Kayexalate: oral or enema that eliminates excess K+

o Hyponatremia Lab Values

o Lab: Serum Na+ below 135 mEq/L (Less than normal concentration of sodium in the blood - ECF). Treatments

o Goal: restore normal sodium levels Excess fluid with decrease Na+=restricting fluids

Sodium replacement through diet Normal fluid balance with decreased Na+= isotonic saline (0.9% NaCl) or lactated ringers

solution.

o Hypernatremia Lab Values

o Lab: Serum Na+ greater than 145mEq/L Treatments

o Fluid replacement therapy with isotonic solution (0.9%NaCl) or hypotonic solution (0.45% NaCl)o Sodium restricted diet

Prevent More Sodiumo P=processed foods ( canned, frozen)o M= moo (milk, cheeses, butter, ice cream)o S=sodium ( salty: nuts, chips, ham, bacon)

Clinical manifestations to know for each of the following: o Hypokalemia muscle weakness, cardiac dysrhythmiaso Hyperkalemia hyperkalemia, nausea, vomiting and cardiac dysrhythmias o Hyponatremia abdominal cramps, nausea, vomiting, diarrhea, tachycardia and postural hypotension o Hypernatremia Thirst, dry mucous membranes, fever, postural hypotension

Safety considerations when administering intravenous potassiumo Safety measures!!!

Never give IV PUSH Always dilute as directed Be sure KCL mixes thoroughly Do not add to a hanging container Monitor clients ECG


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Regulation of Acid Base balance - pH, Bufferso Normal values of ABG (arterial blood gas) - specifically, the pH, CO2 and HCO3 levels

o Be able to identify types of imbalances (pp. 977)

Respiratory Acidosiso PaCO2, excess carbonic acid, H+ pH 7.35o Results from HYPOventilationo Neuro changeso Hypoxemia due to respiratory depressiono Hyperkalemia and hypercalcemiao Kidneys compensate by conserving bicarb and releasing H+ in urineo Process may take up to 24 hrs

Respitatory Alkalosiso PaCO2 and pH above 7.45o Results from HYPERventilationo Anxiety, asthma, salicylate overdoseo pH may return to normal before kidneys can respondo Kidneys will compensate increase excretion of bicarb

Metabolic Acidosiso Results from high acid content in blood (pH 7.35), causes loss of bicarb (bicarb deficit)o Related to: severe diarrhea, renal disease, starvation, diabetic ketoacidosis, drug useo Calculating the anion gap helps identify cause (see Table 41-6)o Respiratory compensation: CO2 excretion by resp rate/depth

Metabolic Alkalosiso Result of heavy loss of acid or bicarb levelso Related to: vomiting and gastric suctioning, overcorrection of met acidosis, K+ deficiency,

thiazide therapy, excess aldosteroneo Respiratory compensation : resp rate, renal loss of bicarb (if no renal disease)


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Assessment risk factors (summary on slides)o Pathologies that affect homeostatic regulators of fluid balanceo Diabetes, congestive heart failure, renal failureo Abnormal losses of body fluidso Prolonged vomiting, diarrhea, draining wounds,o Burns , traumao Therapies that disrupt fluid, electrolyte balanceo Meds, (diuretics, steroids), IVs, blood transfusions .

Assessment - prior medical history (p. 979-980) Specifically, be familiar with the following general condition andhow it may affect fluid and electrolytes

o Cardiovascular Cardiovascular disease may result in a diminished cardiac output, which reduces kidney perfusion,

causing the client to experience a decrease in urinary output. The client will retain sodium and water,resulting in circulatory overload, and run the risk of developing pulmonary edema.

o Renal Kidney disease alters fluid and electrolyte balance by causing an abnormal retention of sodium, chloride,

potassium, and water in the extracellular compartment. The plasma levels of metabolic waste productssuch as blood urea nitrogen (BUN) and creatinine are elevated because the kidneys are unable to filterand excrete the waste products of cellular metabolism. Metabolic acidosis results when hydrogen ionsare retained due to decreased renal function. Because of impaired renal function, the usual renalcompensatory mechanisms such as bicarbonate reabsorption are not available, so the body loses abilityto restore normal acid-base balance.

o Respiratory Many alterations in respiratory function predispose the client to respiratory acidosis, for example,

changes involved in pneumonia and sedative overdose interfere with the elimination of carbon dioxide.Pneumonia causes pulmonary congestion,which leads to CO retention fromhypoventilation. Cardondioxide is retained during hypoventilation. As the cardon dioxide continues to build up in thebloodstream, the bodys compensatory mechanisms can no longer adapt and the pH decreases.Similarily, hyperventilation that occurs with conditions such as fever or anxiety causes the client to

experience respiratory alkalosis by blowing off too much carbon dioxide with the increased respiratoryrate.

Assessment - environmental factors information on the slides o Environment factors

extreme temp excessive exercise

Assessment - medications (Box 41-2)Specifically, be familiar with the effects of thefollowing medications:

o Diuretics (Lasix/furosemide)o Respiratory depressants (opiods)o Antibiotics

Nephrotoxicty of Vancomycin

Assessment - physical examinationo Daily weights;

Same time & scale, after client voids, calibratescale, same amt clothes or sheets on bed scale

o Intake and output: Hourly/24 hour, when important, all sources

o Laboratory studies: provide obj data.


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Daily weights, intake/output and Box 41-3

Fluid disturbances: FVD and FVE (Table 41-8) know the definition, possible causes and clinicalmanifestations of each of these disturbances. On table 41-8, pay particular attention to the cardiovascularsystem, respiratory system and renal systems.


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Implementation - enteral replacement , restricting fluids, parenteral fluids, TPN, IV therapyo Oral replacement may be contraindicatedo Feeding tubes: gastrostomy, jejunostomy, nasogastrico Restriction of fluids: FVE, types of fluids (jello, ice chips, popsicles), divide over 24 hours , frequent

mouth careo Parenteral replacement of fluids/electrolytes:o Total parenteral nutrition:

Nutritionally adequate hypertonic solution via central IV catheter

Fluid restriction (from class and slides)o As a nurse what do you need to plan?

Document strict I & O Patient and family teaching Communication at shift report, sign on door thirsty all the time - use ice chips, swabs, oral care, lip moisturizer Planning schedule of fluids (meals & meds) Work with Dietician

o Fluid Restrictions: Key Considerations Patient and family education Allot amounts throughout the day the total during 7AM 3 PM Frequent mouth care When are medications given?

Intravenous Therapy Types of IV therapy (table 41-9) and handout posted on BB


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Summary points of Intravenous (IV) solutions

HYPOTONIC SOLUTIONSreplace fluid in intracellular spaces

Used when there is a fluid loss in the intracellular space Include NS (0.45% sodium chloride) and 0.33% sodium chloride (1/3 NS) Normal Saline = NS

HYPERTONIC SOLUTIONSreplace fluid from the intracellular space

Used if there is a fluid excess in intracellular space Need to use cautiously because the fluid is drawn from the intracellular space to the intravascular

space and can cause circulatory overload Include 3-5% NS, D 5NS (D50.9% Sodium chloride)or D 5NS (D50.45% Sodium chloride)

ISOTONIC SOLUTIONSused to replace intravascular (ECF) volume

Includes NS (0.9% sodium chloride), Lactated Ringers and D 5W (5% Dextrose in water)

TO DETERMINE WHAT KIND OF ACID-BASE IMBALANCE, please follow the following steps. The first three steps areessential. You do NOT need to know the fourth in terms of specific blood gases (ABGs arterial blood gases).I do want you to know there are 2 compensatory mechanisms (respiratory and renal) that respond toimbalances that Is covered on the other slides.

Four Key Steps1. Look at the pH: Is it acidic, normal or alkalotic?2. Is the PCO 2 normal or abnormal?

1. This will help you to determine if the condition isrespiratory acidosis or alkalosis

3. Is the HC0 - 3 is normal or abnormal;1. This will help you determine if the condition is

metabolic alkalosis or metabolic acidosis

4. Determine whether compensation is occurring


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Initiating intravenous therapy (skill 41-1)

Assessment and maintenance of IV

Procedure for discontinuing an IV

Infiltration vs. phlebitis and appropriate nursing interventions


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Blood Transfusion

Purpose of transfusionso The purposes of blood replacement are to:

Increase circulating volume after surgery, trauma, or hemorrhage Increase the number of RBCs and maintain hemoglobin levels Provide replacement therapy of clotting factors, platelets, or albumin.

Autologous transfusionso Collection and reinfusion of persons own blood o Obtained up to 5 weeks before surgeryo Safer option

Transfusion processo PRE-TRANSFUSION

Signed informed consent Patent IV site with large gauge cannula (i.e. 18/19 gauge) Must use special tubing with in-line filter Prime tubing with 0.9% NS to prevent hemolysis Asessment: hx, procedure, sx, baseline vital signs. Checking blood order, patient identification & blood component: 2 nurses (agency policy)

o INITATING & MONITORING TRANSFUSION Start with slow infusion Stay with patient for first 15 minutes Assess vital signs and signs of transfusion reaction Continue frequent vital signs and checks throughout the transfusion

Components of a transfusion ordero Physician order must specify:

Blood component Date and rate specified

o Unit transfused over 2 hrs, lengthened to 4 hrs if client at risk for FVE (beyond 4 hours risk of contamination

o IV push Furosemide may be prescribed before or between PRBCs to prevent fluid overload


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Blood Reactions: know clinical manifestations and management from slides and Table 41-12 includingcirculatory overload

o Transfusion Reactions Systemic response by the body to incompatible blood

o Acute Hemolytic: Febrile Mild allergic

AnaphylacticSTOP TRANSFUSION IMMEDIATELY

o Intervention: Transfusion Reaction Stop transfusion Keep IV line open, infuse 0.9% NS directly into IV line (not through y connector on blood adm set

as some blood will remain) Notify physician Remain with client, vital signs every 5 mins Prepare to adm emergency drugs, CPR Obtain urine spec Save blood container, tubing, labels


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Chapter 43: Pain Management Nature of Pain

o A form of sufferingo Pain is highly personal experienceo Can interfere with all aspects of an individuals life & overall well being

Perception of Paino Definition of Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage (IASP) International Association for the Study of Pain

Pain is Whatever the experiencing person says it is (McCaffrery) Author of Nursing the Patient in Pain.

Defined from clients perspective

Responses to pain (table 43-1)

Types of Pain differentiate between acute, persistent (chronic), chronic episodic and cancer pain

Type Description

Acute Protective, identifiable cause; Short duration, limited tissue and emotional damage

Persistent Serves no purpose; last longer than anticipated, no identifiable cause; leads to great personalsuffering

Chronic,episodic

Sporadic pain over an extended time (e.g. migraine headaches)

Cancer Usually related to tumor progression, pathology; or treatment; 90% can be managed;

Patholog-ical Nociceptive (muscular skeletal); visceral (internal organs); neuropathic

Idiopathic Chronic pain with no identifiable source


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Factors influencing pain

Myths and misconceptions about pain(Box 43-2 & Table 43-4)


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Acute and cancer care pain guidelines including quality indicators

Assessment Clients expressions, characteristics (e.g. responses to pain)

Attitudes and assumptions about pain including cultural


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Cultural effects of pain assessment and managemento Stoicism vs. Expressivityo Decisions about managing paino Language and interpretation problemso Nonverbal communication problemso Culturally inappropriate assessment toolso Under-reporting of paino Reluctance to use pain medicationso Access to pain medicationso Providers fears of drug abuseo Prejudice and discrimination

o Culturally sensitive pain assessment include tools that have been translated and validated in manylanguages

o Explanatory Model Interview* with items such as: What do you think is causing your pain? When did it start? What do you fear most about the pain? What problems has it caused for you?

What have you used to help? Who else have you consulted?

Be able to distinguish between acute pain, persistent pain and cancer painAcute Pain vs. Persistent Pain

o Acute- A transient state, usually linked to tissue pathology. Usually with well focused sensory characteristics;

lasts or is expected to last no more than 6 monthso Persistent-

Lasts or expected to last longer than 6 months because it is related to a chronic illness or condition

(Also see above table on Types of Pain)

Interventions: Non-pharmacological nursing interventions

o Distractiono Humoro Musico Guided imagery & Relaxation responseo Cutaneous stimulation

Massage, TENS units,cold/heat application

o Acupunctureo Hypnosis

Environment (Box 43-12)


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Acute Care - Pharmacological Pain Relief o Non-Opoid Analgesics

Analgesics know the information on the slides (non-opiods and opiods medications). Alos know whichmedications are used to manage neuropathic pain


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Nursing principles (Box 43-13)

Comparative potencies & range orders Patient-controlled analgesics

Top ical analgesics & local and regional anesthetics


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Nursing implications

Cancer pain management

Know common side effects of opiods o Constipationo Sedationo Respiratory Depression or Sedation

Respiratory rate less than 8/min, SpO2 less than 90% Naloxone (Narcan) cautious administration (while providing resp support and supplemental

O2), will cause opioid reversal/paino Nausea and Vomiting

Know name of reversal agent for opiods o Naloxone (Narcan) will cause opioid reversal/pain


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Definitions related to Opiod Pain Treatment(Box 43-17)

Barriers to effective pain relief (box 43-16) and slides

Treating pain associated with Cancer WHO ladder


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Evaluation strategies

I will also post the Pain Case studies we discussed in class with some notes that may help you.


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Chapter 44: Nutrition Anatomy and Physiology of Digestive system

Dietary guidelines Food pyramid (p. 1091) & Box 44-2

Anorexia and bulimia (Box 44-3)


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Considerations for older adults (p. 1094 and box 44-4)

Drug nutrient interactions (see slide) and remember our conversation about Coumadin, and being awareof whether or not a medication should be given with food.


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Assessment: Mini Nutritional Assessment tool recognize this as one of the better nutrition-specific assessment tools.

Theres a figure in the book.


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Physical signs (Table 44-4)


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Dysphagia and aspiration precautionso Dysphagia

Causes Box 44-7 (p. 1101)

Nutrition and older adults (slides) that is, why is it more of a concern with this population? o Access to Foods

Homebound individuals have higher nutritional riskso Economic Concerns, fixed income difficult choiceso Meat (source of protein $$)

Alternatives Cheese, Eggs, Peanut Buttero Chronic Illness (diabetes, renal disease, cancer) impacting nutritional intake.o Cognitive Impairments (delirium, dementia, depression)o Readmission to hospital often are related to poor oral intake especially with the elderly population

Topic More Details

Definition Difficulty when swallowing

Causes Myogenic, neurogenic, obstructive and other

(see Box 44-7 for examples)Signs A cough while eating, change in voice tone or quality after swallowing

Complications Aspiration pneumonia, dehydration, impaired nutrition, weight loss

Screening Assess holding, leakage, coughing, choking, breathlessness and quality of voice.Speech therapist should be consulted!


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Implementation: Aspiration precautions (Skill 44-1)

Acute Care - Advancing diets (Box 44-10, p. 1111),specifically clear and full liquid,soft mechanical and low sodium

Acute Care Promote appetite and assist with oral feeding

Promote Appetiteo Keep free of odorso Provide oral hygieneo Maintain client comforto Minimize medication side effectso Promote socialization during mealso Appropriate use of appetite stimulantso Appropriate proportions (not too much!)

Assisting With Oral Feedingo Protect clients safety, dignity and independence o Assess risk for aspirationo Client with dysphagia

30 min rest period before eating Upright position (high fowlers) Flex head to chin down position If unilateral weakness place food on

stronger side of mouth Determine the viscosity that client can tolerate;

thicker liquids usually easier Liquid types: thin, nectar-like, honey-like and spoon-thick

o Dysphagia Slowly, smaller size bites Freq chewing/swallowing assessments Match feeding speed to client readiness Include clients food preferences, requests and order of eating

o Visually impaired: orient to plate as if food were on a clocko Adaptive equipment

Acute Care - Enteral tube feedings know the different types of tubes (anatomically) and any specialconsiderations.

o Enteral Nurtrition Providing nourishment by means of a tube in the GI tract Client is unable to ingest food but can digest and absorb nutrients Receive formula via nasogastric, gastric or jejunal (when risk of aspiration) tubes Indications for enteral and parenteral nutrition know the major categories/reasons


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o Enteral Tube Feeding Nasogastric Nasointestinal Gastrostomy Jejunostomy PEG PEJ

o Nasogastric Tube

o Gastrostomy Tube

o Jejunostomy Tube


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Testing gastrointestinal pH (Box 44-12, p. 1117).

General indications for enteral or parenteral nutrition (Box 44-11, p.1112)

Administering enteral feeding (Skill 44-3) and preventing complications (Table 44-7). On Table 44-7, focuson pulmonary aspiration, diarrhea, constipation, tube occulusion, tube displacement.

o Administering Enteral Feeding Administering feeding can be delegated to CNA ( after tube placement verification) with proper

instruction Elevate HOB at least 30 degrees or sitting up in chair Check order for formula, rate, route and frequency (formula at room temperature) Verify tube placement whats the procedure?

o Testing pH Check for residual/ return aspirate unless over 200 ml (or agency policy) Hold feeding if residual > 200 ml, maintain upright, recheck in 1 hour Infuse slowly, increase amount and rate


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Parenteral nutrition - initiating & preventing complicationso Parentral Nutrition

Administered to clients who are unable to digest or absorb enteral nutrition(sepsis, head injury, burns)

Nutrients provided intravenously through:o Peripheral (short-term)o Central line

Requires close clinical & lab monitoring by team Goal to discontinue and use GI tract (enteral or oral)


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o Initiating Parentral Nurtition (PN) Initiating PN: check policy/procedures, needs dedicated line Verify order, inspect solution (do not confuse with enteral formula) Must use an infusion pump, initially 40-60 ml/hr, gradually increased Lipid emulsions administered through separate peripheral line or Y connector tubing

o Preventing Complications PN Air embolism during catheter insertion or tubing change

Have patient bear down in a left lateral position to prevent air embolism Catheter occlusion Temporarily stop infusion & flush per agency policy Catheter sepsis Change tubing every 24 hours. PN not to hang beyond 24 hours; use sterile technique dressing

change Metabolic complications Monitor electrolytes, blood sugar

Chapter 48: Skin Integrity and Wound Care Understand skin structure

Skin associated changes with aging (Box 48-1)


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Pressure ulcers (Figure 48-2), pathophysiology, pathogenesis, risk factors, shear (figure 48-5) and classification of pressure ulcers (including when unstageable). Be able to distinguish between the different stages. o Definition: Localized areas of cellular necrosis of the skin and subcutaneous tissues as a result of unrelieved

pressure in combination with shear and/or friction Other terms: pressure sores, bedsores or decubitis ulcers

o Pressure ulcers (Figure 48-2) Pressure ulcer with tissue necrosis.

o Pathophysiology Unrelieved pressure on the skin interrupts normal circulation by occluding cutaneous and subcutaneous

blood vessels. This leads to tissue ischemia, and necrosis (tissue death)o Pathogenesis

Three elements contribute to development of pressure ulcerso Intensity of the pressure and capillary closing pressureo Duration and maintenance of pressureo Tissue tolerance

o Risk Factors Immobility: Patients who are unable to change position Age: Thinning of the skin, decreased turgor impaired sensory or motor function Impaired cognition/sensory impairment: Someone who has a dementia or a delirium who is unable to

understand, follow, or make position changes. EX: a paraplegic who cannot feel sensation, pain, ordiscomfort of pressure

Moisture: Excessive moisture of the skin increases the susceptibility to damage when force is exerted Decreased nutritional state: patients with low albumin are at great risk for poor wound healing, anemia

reduces oxygen to tissues Friction: the mechanical force exerted when skin is dragged across a coarse surface such as bed

linens..affects the epidermis. Two surfaces rubbing together Lying on wrinkled sheets Shearing : pressure exerted against the skin in a direction parallel to the bodys surface

o Occurs when one layer of tissue slides over another layer o Can occur while moving a patient in bed, or when a patient slips down in the bed. Skin and

subcutaneous layers adhere to the surface of the bed, and the layers of muscle slide in the direction of body movement

o Occurs when patients are pulled rather than liftedo Shear (Figure 48-5)

As you elevate the head of the bed, the skeleton slides down while the skin stays fixed, resulting in shearing


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Classification of Pressure Ulcers (including when unstageable). Be able to distinguish between the different stages.

o An unstageable ulcer is a full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow,tan, gray, green, or brown) and /or eschar (tan, brown, or black) in the wound bed. Until enough slough and/oreschar is removed to expose the base of the wound, the true depth and therefore the stage cannot bedetermined. (pg. 1282)


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Characteristics of dark skin at risk (Box 48-2)

Wound classifications (table 48-1 & figure 48-7)

o Fig 48-7 Wounds classified by color assessment.A, Black wound. B, Yellow wound. C, Red wound. D, Mixed-color wound.


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Process of wound healing and (figure 48-8)

Wound repairWound Healingo Healing is the tissues response to injury and the process is the same for all woundso Two types of wounds: Those with loss of tissue and those without

A surgical incision has little tissue loss Heals by primary intention where the skin edges come together and risk of infection is low.

o Wounds with tissue loss (such as a pressure ulcer, arterial or venous ulceration, a burn, or severe laceration)heal by secondary intention

o Takes longer, as wound edges do not approximate and the wound is left open until it is filled with scar tissue.Chances of infection are greater.

Terminology and characteristics of (a) slough, (b) eschar and (c) granulation tissue and understand how you wouldcleanse each

a) Slough - Soft yellow or white tissue (stringy substance attached to wound bed), you will need to remove thisbefore wound is able to heal.

b) Eschar - Black or brown necrotic tissue, which you will also need to remove before healing can proceed.c) Granulation tissue - red moist tissue composed of new blood vessels, the presence of which indicated

progression toward healing. (New tissue that forms the foundation for scar tissue development. Highlyvascular, red and bleeds easily.)

Figure 48-8 A,Wound healing by primary intentionsuch as a surgical incision. Wound healing edges are

pulled together and approximated with sutures orstaples, and healing occurs by connective tissuedeposition. B, Wound healing by secondaryintention. Wound edges are not approximated, andhealing occurs by granulation tissue formation andcontraction of the wound edges.


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Risk assessment, specifically the Braden scale and how it is scored(Table 48-4) Not the Norton scale

Complications of wound healing pay particular attention to WHEN these complications are most likely to occur o Bleeding : Normal after original trauma, buts stops within minutes. Bleeding that occurs later can be due to a

slipped suture, a clot, infection, or erosion of a blood vessel. Look for distension or swelling or the change in theamount and type of drainage

o Hematoma localized collection of blood underneath the tissues o Surgical incisions are at greatest risk for bleeding within the first 24-48 hrs after surgeryo Dehiscence : When a wound fails to heal and the layers of skin and tissue separate. Patients

with abdominal wounds who may be straining to cough, moving around in bed, vomiting Partial or total disruption of wound layers Patients will say that they feel something give

o Evisceration: total separation of wound layers where the organs protrude Medical emergency Cover extruding tissue with sterile towel soaked in saline

o Fistula : Abnormal tract between 2 organs or between an organand the outside of the body

Chronic drainage, risk of infection Name of fistula designates the site of the tract

o Infection : When purulent material drains from it even if culture is negative or not taken. All wounds containbacteria but infected wounds have a higher colony count: greater than 100,000 org/ml

Inhibits wound healing Surgical wounds may show signs of infection on post op days 4 or 5.. Signs and symptoms: fever, pain, tenderness, and elevated white blood cell count Drainage may be yellow, green, brown, and be odorous

o Types of wound drainage (Table 48- 2)


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Prevention of pressure ulcerso Pressure Ulcer: Prevention

1st Question: What are risk factors? Immobility : Turn patients, reduce shear and friction, provide pressure relief surface, provide assistive

devices to increase activity Incontinence : Keep patient clean and dry, toileting schedules Malnutrition : Provide adequate hydration and nutrition, nutritionist referral Impaired skin integrity : Lubricate skin, avoid pressure, do not massage reddened areas, educate

patient/familyo Pressure Ulcer: Three Prevention Strategies

1. Excellent skin hygiene2. Mechanical loading & support3. Education

o Prevention: Topical Skin Care Avoid soaps and hot water Use nonionic solutions Completely dry skin & moisturize Contain/manage incontinence Use absorbent pads only if they wick away the moisture

Use moisture barrierso Prevention: Mechanical Loading

Proper positioning to reduce pressure and shear forceso Schedule at least every 90 minutes 2 hourso Recommend using 30 degree positioningo Use transfer devices to reduce friction

Support surfaces specialized deviceo Mattresseso Specialty beds

o Prevention: Education Shift weight every 15 minutes

Use foam/gel pads toredistribute weight Do NOT use donut shaped

cushions or rigid pads Reason for interventions Never massage the area

General understanding of nutrients,sources and role not specific doserecommendations, (Table 48-5)


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Factors influencing pressure ulcer formation and wound healing(See above Wound Repair and Risk Factors )

Pressure ulcers (pp. 1293-1294) and Skill 48-1o Because pressure ulcers have multiple etiological factors, assessment for pressure ulcer risk (Skill 48-1) includes

several important factors. These include using an appropriate predictive measure and assessing the clientsmobility , nutrition , presence of body fluids , and comfort level . (pg . 1293)

Sites of pressure points (Figure 48-12)

Wound types, appearance and character of drainage and wound assessment

Figure 48-12 A, Body prominences most frequently underlying pressure ulcer.B, Pressure ulcer sites.


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Nursing Assessment of Woundso Describe appearance

Are edges closed? Are edges inflamed? Is there any bruising? Is the surrounding skin macerated or irritated Measure and record length/width

o Drainage Note amount, color odor, consistency(serous, purulent,

seosanguineous, sanguineous, see p 1287) Look at removed dressing

Strong odor=possible infection

Nursing Process: Assessing Woundso Inspection : sight and smell

Appearance: color, wound edges, signs of dehiscenceevisceration, drainage (amount/color/odor), woundbed, periwound surface

o Palpation: edema, skin temp, tenderness, indurationo Pain: Increased/constant . Associated with increased

drainage, etc.o

Lab data: increased WBC, wound culture

Wound Classificationso Intentional : surgical incision, IV siteo Unintentional : trauma, fall, accident Increased risk of infectiono Open : skin surface is brokeno Closed : skin is not broken, but there is tissue damage/internal bleeding or injuryo Acute : heal within days to weekso Chronic : does not progress, delayed healing

Wound Assessmento Types of emergency wounds

Abrasions vs. lacerations vs. punctureo Size & location of woundo Wound appearance (e.g. closed)o Wound drainage

Serous, serosanguineous, sanguineouso Removal of dressing

Careful of healing tissue or drains Premedicate 30 minutes ahead of change

o Drains check placement & drainageo

Wound closures Staples (stronger, less irritation) or sutures First 2-3 days, suture/staple line is edematous If becomes too tight risk for dehiscence

o Palpation of woundo Wound culture

Clean wound first with normal saline Gold standard is tissue biopsy

Wound cultures; How to obtain (Box 48-7)


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Quick guide for pressure ulcer prevention (Table 48-7)

Positioning, Safety alert (p 1304) and support surfaces

o Support Surfaces (Therapeutic Beds and Mattresses) A support surface is a specialized device for pressureredistribution designed for management of tissue loads, microclimate, and/or other therapeutic functions (i.e.,mattresses, integrated bed system, mattress replacement, overlay or seat cushions, or seat cushion overlay).There are a variety of support surfaces, including specialty beds and mattresses that reduce the hazards of immobility to the skin and musculoskeletal system.

Acute Care - management of pressure ulcers.Wound Careo Goal: to promote tissue repair and regenerationo Draining wounds, infected wounds and open wounds.o General principles:

Aseptic technique cleansing the wound usually with normal saline(0.9% sodium chloride)

Dressing application Record findingsWound Managemento Great diversity in practice regarding wound healing and types of dressings.o Certified wound specialists and enterostomal therapist who have develop guidelines for evidence-based

practice.o Some facilities have specific protocols regarding wound care.

Acute Care - treatment of pressure ulcers (skill 48-2)know the different types of dressings (i.e enzymes,hydrogel, calcium alginate) and their specific purposes.

o Assess and document: Location Size Stage Exudate Surrounding skin condition

o Reassess & evaluate treatment of acute woundsevery 8 hours or every dressing change

Safety Alert Incorrect positioning of an immobile client will possibly create a shearing injury. Whenrepositioning the client, place a transfer sliding board under the clients body. Obt ain assistance forrepositioning, and with at least one other caregiver, use the board to slide the client up and toward the newposition. Dragging the client on bed sheets will place the client at high risk for shearing and friction injuries.


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Dressings for pressure ulcers (table 48-9)


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Acute care - Wound managemento Goal = maintain physiological local environment to promote healingo Key components:

Prevent and manage infection Cleanse wound Remove non-viable tissue Manage exudate Maintain the wound in moist environment Protect the wound (cover & stabilize)

o Great diversity in practice regarding wound healing and types of dressings.o Certified wound specialists and enterostomal therapist who have develop guidelines for evidence-based

practice.o Some facilities have specific protocols regarding wound care.

Debridement: know the different typesWound Debridement

Definition: removal of necrotic tissueThree types:

Mechanical wet to dry dressingso Not used as often because removes viable tissue

Autolytic synthetic dressings (dsg)o Wound base dry use dsg to add moistureo Wound base wet use dsg to absorb moisture

Surgical debridement o May be done by trained advance nurses check state practice acto Quickest method

Reminder: wound will not heal unless contributory factors addressed

Purposes of dressingso Protectiono Aids hemostasiso Promotes healingo Supports or splints the siteo Visual protectiono Thermal insulationo Provides moist environment

Wound dressing orders and remember our class discussion about post-operative dressings (the first one is usuallychanged by the surgeon). o Sterile vs. clean techniqueo Health provider order is needed:

Frequency Type

Solutiono Surgical dressing reinforce prn o Administer analgesico Describe procedure to patient


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Phases of wound healing (slides) o Inflammatory phase

Starts at time of injury and prepares wound for healing Exudate is created from plasma and blood components that leak into the area White blood cells arrive to ingest bacteria and cellular debris: macrophages Generalized body response, mildly elevated temp, leukocytosis, and malaise.

o Proliferative phase Begins 2-3 days after the injury New tissue starts to fill in the wound space, capillaries grow across the wound, and Blood flow is reinstituted New tissue is called granulation tissue forms the foundation for scar tissue development.

o Highly vascular, red and bleeds easily.o Remodeling or maturation phase

Begins about three weeks after the injury Collagen continues to be deposited and gain strength Wounds that heal by secondary intention take longer to remodel and form scar tissue Healed wound does not recover tensile strength of tissue it replaces.

Factors affecting wound healingo Age: children and healthy adults heal more rapidly.o Tissue perfusion/oxygenation : delivery of nutrients/removal of toxinso Nutritional status : proteins and vitamins help with the healing processo Wound condition : large, contaminated, etc.o Health status: chronic illness, medications

Complications of wound healing and pay particular attention to WHEN these complications are most likely to occur(See Above Slides)

WOCN Recommendations (Box 48-12)


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Applying dry and moist dressings (skill 48-3)

Changing dressings, packing wounds and securing dressings

Vacuum assisted closures

Basic skin cleansing (p 1324)

Basic Skin Cleansing.Cleanse surgical or traumatic wounds by applying noncytotoxic solutions with sterile gauze orby irrigation. The following three principles are important when cleansing an incision or the area surrounding a

drain:1. Cleanse in a direction from the least contaminated area, such as from the wound incision to the

surrounding skin or from an isolated drain site to the surrounding skin.2. Use gentile friction when applying solutions locally to the skin.3. When irrigating, allow the solutions to flow from the least to most contaminated area. (Skill 48-5)

Wound Cleansingo Use non-cytotoxic cleansers

Normal saline Commercial cleansers

o Do NOT use cytotoxic cleansers in clean, granulating wounds Dakins solution Betadine (povidone-iodine)

o Be careful of pressure with irrigationo Use 19 gauge needle & 35 mL syringe

Performing wound irrigations (skill 48-5)


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Heat and cold therapy Focus on the slides


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Risk and safety of heat/cold therapy ( Table 48-10 & Box 48-15)

As reminder (and based on questions Ive received), you need to be familiar with sterile vs. clean dressing changes.As you may remember, we talked about this in class. Clean dressing technique can be used in the home setting andsterile dressings are done in acute care settings.


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Medication Calculations: There will be four questions that include oral medications, IV rates via pump or gravityand parenteral injections (subcutaneous and/or intramuscular).

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