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122 Cards in this Set

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Abrasion- (p. 701)
superficial layers of the skin are scraped or rubbed away. Area is reddened and may have localized bleeding or serous weeping
Bacteremia- (p.630)
a condition when a culture of the person's blood reveals microorganisms; (p. 1447) bacteria in the blood.
Contusion- (p. 857)
type of wound caused by a blow from a blunt instrument.
Excoriation- (p. 537)
linear erosion induced by scratching; (p. 858) area of loss of the superficial layers of the skin also known as denuded area
Iatrogenic- (p. 631)
These infections are nosocomial infections that are the direct result of diagnostic or therapeutic procedures. The diseases are unintentionally cause by medical therapy.
Incision- (p. 857)
type of wound caused by a sharp instrument (e.g., knife or scalpel).
Infection- (p. 629)
is an invasion of body tissue by microorganisms and their proliferation there. If the microorganism produces no clinical evidence of disease, the infection is called asymptomatic or subclinical
Ischemia- (p. 857)
deficiency of blood supply caused by obstruction of circulation to the body part.
Laceration- (p. 857)
type of wound caused by tissues torn apart, often from accidents (e.g., with machinery).
Maceration- (p. 858)
tissue softened by prolonged wetting or soaking; (p. 1458) the wasting away or softening of a solid as if by the action of soaking; often used to describe degenerative changes and eventual disintegration.
Necrosis- (Medical Dictionary p. 1160)
localized tissue death that occurs in groups of cells in response to disease or injury. In coagulation necrosis, blood clots block the flow of blood, causing tissue ischemia distal to the clot; in gangrenous necrosis, ischemia combined with bacterial action causes putrefaction to set in.
Nosocomial infection- (p. 631)
infections associated w/delivery health care services in a health care facility. Can develop during client's stay or after discharge. May also be acquired by health personnel & can cause significant illness/time lost from work. Most common settings are hospital surgical or medical intensive care units. The urinary/respiratory tract, bloodstream, and wounds are the most common sites. Many can be prevented using proper hand washing techniques, environmental controls, sterile techniques when warranted, and identification and management of clients at risk for infection.
Reactive hyperemia- (p. 857)
is the body's mechanism for preventing pressure ulcers. After the skin has been compressed (it appears pale like the blood has been squeezed out of it) and the pressure released the skin takes on a bright red flush; (p. 1464) a bright red flush on the skin occurring after pressure is relieved.
Septicemia- (p. 630)
when bacteremia results in systemic infection; (p. 1465) occurs when bactermia results in systemic infection.
freedom from disease-causing microorganisms.
Medical asepsis
includes all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and transmission of microorganisms. Objects are referred to as clean, which means likely to have microorganisms. Some of which may be capable of causing infection.
Surgical asepsis (Vicki’s lecture notes 9-19-05 & p 630)
(also called sterile technique) is keeping an area or object free of all microorganisms; whereas, medical asepsis is intended to confine a specific organism to a specific area which decreases the transmission rate. Objects are referred to as clean (absence of almost all microorganisms) or dirty (contaminated and soiled with microorganisms).
Proper application of PPE
1. Explain to the client.
2. Wash Hands.
3. Don a clean gown.
4. Don a face mask.
5. Don protective eye wear.
6. Don clean/sterile gloves
Proper application of PPE
2. Wash hands.
How do you don a clean gown?
a. Pick up a clean gown, & allow it to unfold in front of you without allowing it to touch any area soiled with body substances.
b. Slide the arms & the hands through the sleeves.
c. Fasten the ties at the neck to keep the gown in place.
d. Overlap the gown at the back as much as possible, & fasten the waist ties or belt.
How do you don the face mask?
a. Locate the top edge of the mask.
b. Hold the mask by the top two strings or loops.
c. Place the upper edge of the mask over the bridge of the nose, & tie the upper ties at the back of the head or secure the loops around the ears.
d. Secure the lower edge of the mask under the chin, & tie the lower ties at the nape of the neck.
e. If the mask has a metal strip, adjust this firmly over the bridge of the nose.

Wear the mask only once, & do not wear any mask longer than the manufacturer recommends or once it becomes wet.
When do you don protective eyewear?
If it is not combined with the face mask.
How do you don clean disposable gloves?
a. No special technique is required.

If you are wearing a gown, pull the gloves up to cover the cuffs of the gown. If you are not wearing a gown, pull the gloves up to cover the wrists.
To remove soiled PPE-Step One
What and how do you remove the first item?
1. remove the gloves 1st since they are the most soiled.
a. If wearing a gown that is tied at the waist in front, undo the ties before removing gloves.
b. Remove the 1st glove by grasping it on its palmer surface just below the cuff, taking care to touch only glove to glove.
c. Pull the first glove completely off by inverting or rolling the glove inside out.
d. Continue to hold the inverted removed glove by the fingers of the remaining gloved hand. Place the 1st two fingers of the bare hand inside the cuff of the 2nd glove.
e. Pull the 2nd glove off to the fingers by turning it inside out. This pulls the 1st glove inside the 2nd glove. Using the bare hand, continue to remove the gloves, which are now inside out, & dispose of them in the refuse container.
To remove soiled PPE-Step 2?
2. Wash your hands.
To remove soiled PPE-Step 3-what and how?
3. Remove the mask.
a. If using a mask with strings, 1st untie the lower strings of the mask.
b. Untie the top strings & while holding the ties securely, remove the mask from the face. If side loops are present, lift the side loops up & away from the ears & face.
c. Discard a disposable mask in the waste container.
d. Wash the hands again if they have become contaminated by accidentally touching the soiled part of the mask.
To remove soiled PPE-Step 4 What and How?
4. Remove the gown when preparing to leave the room.
Unless a gown is grossly soiled with body substances, no special precautions are needed to remove it.
If a gown is grossly soiled :
a. Avoid touching soiled parts on the outside of the gown, if possible.
b. Grasp the gown along the inside of the neck & pull down over the shoulders.
c. Roll up the gown with the soiled part inside, & discard it in the appropriate container.
Remove protective eyewear & dispose of properly or place in the appropriate receptacle for cleaning.
Know the various forms of isolation/infectious precautions (standard, airborne, droplet, & contact) and the personal protective equipment needed for each. Page 649 Box 29-1
What are the most important risk factors for infection?
host susceptibility, which is affected by age, heredity, level of stress, nutritional status, current medial therapy, & preexisting disease processes.
Why is age a risk factor for infection?
Newborns & older adults have reduced defenses against infection
Why is heredity a risk factor for infection?
some people have a genetic susceptibility to certain infections.
Why is Stress level a risk factor for infection?
Stressors elevate blood cortisone. Prolonged elevation of blood cortisone decreases anti-inflammatory responses, depletes energy stores, leads to a state of exhausion, & decreases resistance to infection.
Why is nutritional status a risk factor for infection?
Because antibodies are proteins, the ability to synthesize antibodies may be impaired by inadequate nutrition, especially when protein reserves are depleted.
Why are mediacal therapies included as a risk factor for infection?
Some medical therapies predispose a person to infection. (ex. radiation treatments for cancer destroy normal cells along w/the cancerous cells, thereby rendering them more vulnerable to infection)
Why are diagnostic procedures a risk factor for infection?
May predispose the client to an infection, especially when the skin is broken or sterile body cavities are penetrated during the procedure.
Why are medications a risk factor for infection?
Certain medications also increase susceptibility to infection. Anticancer medications may depress bone marrow function, resulting in inadequate production of WBC necessary to combat infections. Anti-inflammatory med. inhibit the inflammatory response, an essential defense against infection. Antibiotics may kill resident flora, allowing the proliferation of strains that would not grow & mult. in the body under normal conditions. Certain antibiotics can also induce resistance in some strains of organisms.
Why is disease considered a risk factorfor infection?
It can lessen the body's defense against infection & place the client at risk. (ex: chronic pulmonary disease, impairs ciliary action & weakens the mucous barrier; peripheral vascular disease, restricts blood flow; burns impair skin integrity; chronic or debilitating diseases as leukemia & aplastic anemia, alter the production of WBC; diabetes mellitus is a major underlying disease predisposing clients to infection because compromised peripheral vascular status & increased serum glucose levels increase susceptibility).
Proper procdure for hand washing-medical tech.-Step 1?
If you are washing your hands in front of client explain what you are doing.
Proper procdure for hand washing-medical tech.-Step 2?
Turn on water and adjust flow
Proper procdure for hand washing-medical tech.-Step 3?
Wet hands thoroughly by holding them under the running water and apply soap to hands. Hold hands lower than the elbows so that the water flows from the arms to the fingertips. (water should flow from least contaminated to most) If the soap is liquid, apply 2 to 4 mL(1tsp). If it is a bar, granules, or sheets, rub them firmly between the hands.
Proper procdure for hand washing-medical tech.-Step 4?
Thoroughly wash & rinse hands. use firm, rubbing, and circular movements to wash the palm, back, & wrist of each hand. Interlace the fingers & thumbs & move the hands back and forth. (continue this motion for 10 sec.) Rub the fingertips against the palm of the opposite hand. Rinse the hands
Proper procdure for hand washing-medical tech-Step5?
Thoroughly dry the hands and arms.
Proper procdure for hand washing-medical tech.-Step 6?
Turn off the water. use a new paper towel to grasp the control.
Variation: Hand washing for sterile tech.
Apply the soap & wash as described in step 4, but hold hands higher than the elbows during this hand wash. Wet the hands and forearms under the running water, letting it run from the fingertips to the elbows so that the hands become cleaner than the elbows. Apply soap and wash as described in step 6. After washing & rinsing use a towel to dry one hand thoroughly in a rotating motion from the fingers to the elbow. Use a new towel to dry the other hand and arm.
What do you do with a contaminated Sterile field?
Once a sterile field becomes unsterile, it must be set up again before proceeding.
Laboratory data indicative of an infection
1. Elevated leukocyte (white blood cell or WBC) count (4,500-to11,000/mL is normal).
2. ^ sp types of leukocytes in diff WBC count. increase/decrease of sp. leukocytes depends on certain infections.
3. Elevated erythrocyte sedimentation rate (ESR). Red blood cells normally settle slowly, rate ^ in the presence of an inflammatory process.
4. Urine, blood, sputum, or other drainage cultures (lab cultivations of microorganisms in a special growth medium) that indicate the presence of pathogenic microorganisms.
Forms of Immunity-B lymphocytes
Humoral (Antibody-Mediated)Immunity the B lymphocyte cells form antibodies to respond to the body's attackers.These responses defend against the extracellular phases of bacterial/viral infections. two types immunity: active immunity-host produces antibodies in response to natural antigens (e.g., infectious microorganisms) or artificial antigens (e.g., vaccines)
Passive immunity-host receives natural (mother) or artificial (Immune serum injection) antibodies produced from another source than the client.
Forms of Immunity-T cells
Cell-Mediated Defenses, or cellular immunity, occur through the T-cell system. On exposure to an antigen, the lymphoid tissues release large numbers of activated T cells into the lymph system. These T cells pass into the general circulation. There are three main groups of T cells: (a) helper T cells, which help in the functions of the immune system; (b) cytotoxic T cells, which attack and kill microorganisms and sometimes the body’s own cells: and (c) suppressor T cells, which can suppress the functions of the helper T cells and the cytotoxic T cells. When cell-mediated immunity is lost, as occurs with HIV infection, an individual is “defenseless” against most viral, bacterial, and fungal infections.
Nosocomial infections-prevention?
Proper hand washing techniques, environmental controls, sterile technique when warranted, and identification and management of clients at risk for infections.
Nosocomial infections-what factors?
Iatrogenic infections are the direct result of diagnostic or therapeutic procedures. One example of an iatrogenic infection is bacteremia that results from an intravascular line. Not all of these are iatrogenic infections are not all are preventable. Another factor is the compromised host, that is, a client whose normal defenses have been lowered by surgery or illness
Nosocomial infections-what microorganisms?
Escherichia coli, Staphylococcusaureas, and enterococci are the most common infecting microorganisms.
Nosocomial infections-what?
infections that are associated with the delivery of health care services in a health care facility. can either develop during the client’s stay in a facility or manifest after discharge. The microorganisms (e.g., tuberculosis and HIV) may also be acquired by health personnel working in the facility and can cause significant illness and time lost from work.
Nosocomial infections-where?
The most common settings are hospital surgical or medical intensive care units. Reports from NNIS have revealed that the urinary tract, the respiratory tract, bloodstream, and wounds are the most common infection sites
Nosocomial infections-who?
the microorganisms that cause these infections can originate from the clients themselves (an endogenous source) or from the hospital environment and hospital personnel (exogenous sources). Most of these infections appear to have endogenous sources.
Aseptic techniques to prevent infection
Hand Washing p641-645; Cleaning, Disinfecting, and Sterilizing p646-647; Donning and Removing Personal Protective Equipment p651-653; Sterile Technique (maintaining sterile field p655-660), (donning and removing sterile gloves and gown p661-664)
Proper terms for various types of drainage-Serous
clear, watery, skin blisters, pericarditis, clear drainage
Proper terms for various types of drainage-Fibrinous
Increased amount of fibrinogen, adhesions following surgery
Proper terms for various types of drainage-Catarrhal
cloudy mucous, runny nose as with common cold
Proper terms for various types of drainage-Purulent
yellow opaque or green discharge (pus), absesses, boils, infection
Proper terms for various types of drainage-Hemorrhagic (sanguineous)
presence of RBCs, fulminating infection
Proper terms for various types of drainage-Purosanguineous
presence of pus & blood
Cardinal signs of infection
redness, swelling, heat, pain, may also see fever, drainage, & loss of function
Chain of Infection-Link 1
Infectious Agent--Bacteria -Fungi -Viruses -Rickettsiae -Protozoa Break chain: Rapid accurate identificaiton of organisms
Chain of Infection-Link 2
Reservoirs--People -Equipment -Water -Animals Break chain: employee health, environmental sanitation, disinfection/sterilization
Chain of Infection-Link 3
Portal Of Exit--Excretions -Secretions -Skin -Droplets Break chain: hand washing, control of excretions and secretions, trash and waste disposal
Chain of Infection-Link 4
Means Of Transmission--Direct Transmission (Immediate, direct transmission of microorganism through person to person contact (touching or sexual intercourse), and droplet spread (sneezing or coughing within 3 feet of host and source) -Direct contact Indirect Transmission Vehicle-borne (Substance serving as a transport agent, (ingestion, food water, infectious materials on bandages, blood, serum, & plasma) or vector-borne (Animal or insect serves as means of transport of infectious agent (Avian flu, reabies, malaria) -Airborne (May involve deoplets nuclei (residue of evaporated droplets or dust (spores, etc) which transmits the agent through air currents. Break chain: isolation, food handling, air flow, universal precautions, sterilization, hand washing
Chain of Infection-Link 5
Portal Of Entry--Mucous Membrane -GI tract -Gu tract -Respiratory tract -Broken skin Break chain: wound care, catheter care, aseptic technique
Chain of Infection-Link 6
Susceptible Host--Immunosuppression -Diabetes -Surgery -Burns -Elderly Break chain: recognition of high-risk patients, treatment of underlying diseases
Nursing actions to prevent infection
Ensure that articles are correctly cleaned and disinfected or sterilized before use
Dispose of feces and urine in appropriate receptacles
Wash hands between client contacts, after touching body substances and before touching open wounds
Use sterile technique when exposing open wounds or handling dressings
Ensure that client receives a balanced diet
Maintain the integrity of the client’s skin and mucous membranes
Dispose of damp, soiled linens appropriately
Transmission routes for infection
Contact (direct) Vector-borne (indirect), vehicle-borne (indirect), airborne
Additional nursing diagnoses may be appropriate for clients with existing impaired skin or tissue integrity.
Risk for Infection if the skin impairment is severe, the client is immunosuppressed, or the wound is caused by trauma.
Pain r/t nerve involvement within the tissue impairment or as a consequence of procedures used to treat the wound.
Common nursing diagnoses for the client with infection or altered skin integrity
Risk for Impaired Skin Integrity: At risk for skin being adversely altered (e.g. [from p. 868] Risk for Impaired Skin Integrity r/t incontinence and immobility/At risk for skin being adversely altered).
Impaired Skin Integrity: Altered epidermis and/or dermis (e.g. [from p. 868] Impaired Skin Integrity (stage II pressure ulcer) r/t friction/Altered epidermis and/or dermis. Impaired Skin Integrity commonly applies to pressure ulcers and to wounds extending through the epidermis but not through the dermis.
Impaired Tissue Integrity: Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues. Impaired Tissue Integrity applies to pressure ulcers and to wounds extending into subcutaneous tissue, muscle, or bone
RYB Color Code-"R"
Red wounds-late in the regeneration phase of tissue repair (developing granulation tissue). The nurse protects red wounds by (a) gentle cleansing (i.e., use of an approved wound cleanser applied without pressure) (b) avoiding the use of dry gauze or wet-to-dry dressings (c) applying a topical antimicrobial agent (d) applying an appropriate dressing such as gauze, transparent film, or hydrocolloid dressing (e) changing the dressing as infrequently as possible
RYB Color Code-"Y"
Yellow wounds-liquid to semi-liquid “slough”, often accompanied by purulent drainage. The nurse cleanses yellow wounds to remove nonviable tissue. Methods may include: (a) applying wet-to-damp dressings (b) irrigating the wound (c) using absorbent dressing materials such as impregnated nonadherent, hydrogel dressings, or other exudate absorbers, (d) and consulting with the physician about the need for a topical antimicrobial to minimize bacterial growth
RYB Color Code-"B"
Black wounds-covered with thick necrotic tissue (eschar). These wounds require removal of the necrotic material (debridement) in order for the wound to heal. When the eschar is removed, the wound is treated as yellow, then red. Debridement may be achieved in four different ways: (a) Sharp debridement-use of a scalpel or scissors to separate and remove dead tissue. Performed by specially trained nurses, physical therapists, and physician’s assisstants. (b) Mechanical debridement-accomplished through scrubbing force or wet-to-damp dressings. (c) Chemical debridement-more selective than sharp or mechanical techniques (Collagenase enzyme agents such as papain-urea are currently most recommended for this use. (d) Autolytic debridement-dressings that contain wound moisture (i.e. transparent films) trap the wound drainage against the eschar. The body’s own enzymes in the drainage break down the necrotic tissue. Most selective method, takes longer, but causes least amount of damage to surrounding healthy and healing tissue.
Clients most suseptible to infection
Age (the very young & the very old); clients receiving immune suppression treatment for cancer, chronic illness, or following a successful organ transplant; those with immune deficiency conditions.
Nursing management
Nursing management
Nursing management
Know and describe the stages of pressure ulcers and know nursing management: Nursing management: Page 862 (text)Beginning on page 8 of handout through last page. Sorry guys, it’s a lot of info. and too much to post. We’ll have to read it for ourselves!
Nursing management
Stages of pressure ulcers
Nonblanchable erythema (redness) signaling potential ulceration.
Stages of pressure ulcers
Partial thickness skin loss (abrasion “bruising”, blister, crater) involving epidermis and possibly the dermis.
Stages of pressure ulcers
Full thickness skin loss involving damage or necrosis (death) of Subcutaneous tissue that may extend down to, but not through underlying fascia. The ulcer presents clinically as deep crater with or without undermining of adjacent tissues.
Stages of pressure ulcers
Full thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule.
Why is immobility considered one of the risk factors for skin alterations or pressure ulcers?
refers to a reduction in the amount and control of movement a person has (paralysis, extreme weakness, pain, or any cause of decreased activity).
Why is inadequate nutrition considered one of the risk factors for skin alterations or pressure ulcers?
prolonged inadequate nutrition causes weight loss, muscle atrophy, and subcutaneous tissue loss. These three reduce the amount of padding between the skin and bones. Inadequate intake of protein, carbohydrates, fluids, and vitamin C. Abnormally low protein content in the blood (hyperproteinemia), die either to inadequate intake or abnormal loss, predisposes the client to dependent edema. Edema makes skin more prone to injury by decreasing its elasticity, resilience, and vitality. Edema increases the distance between the capillaries and the cells, thereby slowing the diffusion of oxygen to the tissue cells and of metabolites away from the cells.
Why is fecal/urinary incontnence considered one of the risk factors for skin alterations or pressure ulcers?
Tissue softened by prolonged wetting or soaking (maceration) makes the epidermis more easily eroded. Digestive enzymes in feces also contribute to skin excoriation (area of loss of the superficial layers of the skin also known as denuded area). Any accumulation of secretions or excretions is irritating to the skin, harbors microorganisms, and makes an individual pron to skin breakdown and infection.
Why is decreases mental status considered one of the risk factors for skin alterations or pressure ulcers?
Reduced level of awareness (i.e. unconscious or heavily sedated) increases risk for pressure ulcers because they are less able to recognize and respond to pain associated with prolonged pressure.
Why is diminished sensation considered one of the risk factors for skin alterations or pressure ulcers?
Paralysis, stroke, or other neurologic disease may cause loss of sensation in a body area. Loss of sensation reduces a person’s ability to respond ot injurious heat and cold and to feel the tingling (“pins and needles”) that signals loss of cirsulation.
risk factors for skin alterations or pressure ulcers
Excessive Body Heat-Elevated body temperature increases the metabolic rate, thus increasing the cells’ need for oxygen. This increased need is particularly severe in the cells of an area under pressure, which are already oxygen deficient. Sever infections with accompanying elevated body temperatures may affect the body’s ability to deal with the effects of tissue compression.
Why is advanced age considered one of the risk factors for skin alterations or pressure ulcers?
Several changes in the skin and its supporting structures make the older person more prone to impaired skin integrity. These changes include the following: (1) Loss of lean body mass; (2) Generalized thinning of the epidermis; (3) Decresed strength and elasticity of the skin due to changes in the collagen fibers of the dermis; (4) Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands; and (5) Diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch.
Whay are chronic medial conditions considered one of the risk factors for skin alterations or pressure ulcers?
Diabetes and cardiovascular disease are risk factors for skin breakdown and delayed healing. The conditions compromise oxygen delivery to tissues by poor perfusion and thus cause poor and delayed healing and increase risk of pressure sores.
How can secretions on skin surfaces be considered one of the risk factors for skin alterations or pressure ulcers?
mucous secretions and drainage from wounds (per Vicki’s notes)
Name risk factors for skin alterations or pressure ulcers.
Inadequate Nutrition
Fecal/Urinary Incontinence
Decreased Mental Status
Diminished Sensation
Advanced Age
Chronic Medical Conditions
Secretions on skin surfaces
Incorrect positioning
Poor lifting technique
Poor turning schedule
Repeated injection in one site
Hard support surfaces (per Vicki’s notes)
Nursing Management—Actions for Preventing Pressure Ulcer
Provide nutrition by Increase intake of calories, protein, vitamins, and iron. Monitor weight. Monitor laboratory data
Nursing Management—Actions for Preventing Pressure Ulcer
Maintain skin hygiene by Utilize skin assessment scale (i.e., Braden). Minimize skin force and friction when bathing, and positioning. Use mild cleaning agents when bathing. Keep skin dry and clean—if extremely dry, use a moisturizing lotion. Utilize skin preps to prevent moisture effects on skin surfaces DO NOT MASSAGE OVER BONY PROMINENCES
Nursing Management—Actions for Preventing Pressure Ulcer
Avoid skin trauma Provide wrinkle-free foundation to sit or lie. Correctly position and transfer clients. Use protective films (transparent dressings or skin sealants). HOB to only 30 degree position (No More). Teach client to shift postion every 15-30 minutes. Use lifting device when changing postion. Reposition at least every 2 hours and use written schedule for turning
Nursing Management—Actions for Preventing Pressure Ulcer
Provide supportive devices For client’s confined to bed, utilize the overlay mattress, replacement mattress (foam), and specialty beds (air-flow beds & kinetic therapy or clinitron bed). Use pressure-reducing devices (foam, get or air) pillows, heel protectore, & and wedges.
Nursing Management—Actions for Preventing Pressure Ulcer
Utilize RYB color code (see previous answer for more info).
Nursing Management—Implementation for Wounds
Encourage nutrition and fluids by Intake of 2500 ml of fluid daily unless contraindicated (cardiac disease. Diet consisting of high protein, & vitamin C, A, B1, B5 iron and zinc. Monitor laboratory data
Prevent infection by Proper hand washing & infection control procedures. Correct dressing procedure
Positioning by Position to keep pressure off of wound. Change positions q 1.5 to 2 hours. Enhance mobility (ambulating if possible). ROM and turning schedule if immobilized
reactive hyperemia and what is its signifigance to the nurse
it is the bright red flush after pressure has been relieved. it is the body's mechanism for preventing pressure ulcers. can also be from a bee sting. nurse needs to prevent pressure ulcers by turning patient every 2 hours.
How can the nurse reduce the effects of friction or shearing upon the skin?
Lift sheets off patient, don't let it rub the skin. Maintain good position in the bed.
separation/splitting open of layers of a surgical wound; prevent sudden strains such as coughing and sneezing.
extrusion of viscera or intestine through a surgical wound. Usually occurs 4-5 days postoperatively
evisceration risk factors
obesity, poor nutrituion, multiple trauma, suture failure, excessive coughing, vomiting, & dehydration
Nurse management-evisceration
Calm client. Cover & support wound quickly with large sterile dressings soaked in sterile normal saline. Place the client in bed with knees bent to decrease pull on the incision. Notify the surgeon because immediate surgical repair of the area might be necessary.
Nurse management-dehiscence
Cover & support wound quickly with large sterile dressings soaked in sterile normal saline. Place the client in bed with knees bent to decrease pull on the incision. Notify the surgeon because immediate surgical repair of the area might be necessary.
complications associated with wound healing
Hemorrhage-dislodged clot, slipped stitch; hematoma formation-Internal bleeding under wound surface (reddish-blue swelling)
Lab data associated w/skin integrity alterations or pressure uslcers.
A decreased leukocyte count can delay healing and increase the possibility of infection.
A low hemoglobin level indicates poor oxygen delivery to the tissues.
Blood coagulation levels can indicate excessive blood loss or slow absorption of wound. Prolonged coagulations times can result in excessive blood loss and prolonged clot absorption. Hypercoagulability can lead to intravascular clotting. Intra-arterial clotting can result in a deficient blood supply to the wound area.
Serum Albumin –(poor healing and infection) Serum protein analysis provides an indication of the body’s nutritional reserves for rebuilding cells. Albumin is an important indicator of nutritional status. A value below 3.5 g/dl indicates poor nutrition and may increase the risk of poor healing and infection.
Wound cultures can either confirm or rule out the presence of infection.
Sensitivity studies are helpful in the selection of appropriate antibiotic therapy.
Lab data associated w/skin integrity alterations or pressure uslcers-How do you obtain a wound culture?
(Obtaining a wound culture - Check medical order determine if specimen is collected for aerobic/anaerobic culture. Aerobic organisms-found on surface of the wound ( Aerobic - Clean the wound, swab back and forth over clean area of granulation tissue from the sides or base of the wound. Do not use pus or pooled exudates to culture. Avoid touching the swab to intact skin at the wound edges); anaerobic organisms-would be found in deep wounds, tunnels, and cavities. (To culture Anaerobic- instead of swab, insert a sterile syringe w/out needle into the wound and aspirate 1 to 5ml of drainage into the syringe, attach needle to syringe and expel air and inject drainage into anaerobic culture tube).
What action does the nurse take when bleeding occurs with a fresh surgical wound
Some bleeding from a wound is normal. Reinforce dressing. Do so without removing the first layer of dressing, because blood clots might be disturbed, resulting in more bleeding.
What action does the nurse take when massive bleeding occurs with a fresh surgical wound?
Hemorrhage (massive bleeding), however, is abnormal. The risk of hemorrhage is greatest during the first 48 hours after surgery. Hemorrhage is an emergency; the nurse should apply pressure dressings to the area and monitor the client’s vital signs. Notify physician. In many instances, the client must be taken to the operating room for surgical intervention.
nurse management of an untreated bleeding wound
Control bleeding - Use direct pressure to site and elevate extremity.
Prevent infection - Flush clean, cover with dressing (sterile preferred) and reinforce if needed. (If the first layer of dressing becomes saturated with blood, apply a send layer. Do so without removing the first layer of dressing, because blood clots might be disturbed, resulting in more bleeding.)
Control Swelling and pain - Apply ice over wound and surrounding tissues.
Assess for signs of shock if bleeding profusely or if internal bleeding is suspected. Signs of shock (Book -rapid thready pulse, cold clammy skin, pallor, lowered blood pressure. Handout -early signs normal B/P, increased pulse, skin color normal, skin cool and moist, anxious, increased rate and depth of respirations. Late signs decrease 90mmHg Systolic B/P, increase pulse/week, pale, cold, coma and increased respiration/shallow.)
factors that impair skin healing
Developmental Considerations –Slower healing with older adults and chronic disease.
Nutrition – Inadequate nutrition or obesity. Clients require a diet rich in protein, carbohydrates, lipids, Vit A & C and minerals such as iron, zinc and copper. Obese clients at increased risk of wound infection & slower healing because adipose tissue usually has a minimal blood supply.
ifestyle – Smoking, inactivity, and immobility.
Medications -Anti-inflammatory (steroids and aspirin)and anti-neoplastic(cancer fighting drugs) agents interfere with healing.
effect of moisture or extreme drying upon skin
Moisture from incontinence promotes skin maceration (tissue softened) by prolong wetting or soaking) and makes the epidermis more easily erodes and susceptible to injury.
effect of moisture or extreme drying upon skin
Digestive enzymes in feces also adds to skin excoriation (area of loss of superficial layers of the skin also known as denuded area) any accumulation of secretions or excretions is irritating to the skin & harbors microorganisms & makes the client prone to skin breakdown & infections.
effect of moisture or extreme drying upon skin
Extreme dryness also causes skin integrity- A nurse can avoid dryness by avoiding exposure to cold and low humidity. Add lotions to dry skin but caution they can cause skin infections – (pg 858) Extreme dryness I could not find much on. I will find out more tomorrow-Fri.
lowers the temperature of the skin & underlying tissues & causes vasoconstriction & reduces the supply of o2 & metabolites, pallor & coolness; often used for sports injuries (sprains, strains, fx.) to limit post injury swelling & bleeding. Caution-watch for tissue damage bluish purple mottled numbness, sometimes blisters & pain. Prolong exposure impaired circulation, cell deprivation & damage to tissue lack of o2 & nourishment. (pg 884)
causes vasodilatation & increase blood flow to the affected area, brings O2, nutrients, antibodies, leukocytes; promotes soft tissue healing & increase suppuration; often used for clients with musculoskeletal problems, joint stiffness for arthritis, contractures & low back pain. Possible disadvantage is it increases capillary permeability, which allows extracellular fluid & substances (plasma proteins) to pass through the capillary walls & may result in edema or an increase in preexisting edema.
When is heat or cold therapy used
Heat & cold are applied to the body for local & systemic effects.
When is heat or cold therapy contraindicated?
be aware of the effects of thermal receptor adaptation ( 884) & the rebound phenomenon (885)/ Various parts of the body differ in tolerance to heat & cold. The physiologic tolerance of individuals also varies. Heat applied to a localized body area (large area) may cause excessive peripheral vasodilatation (a drop in BP). A significant drop in BP can cause fainting. Client who has heart or pulmonary disease or circulatory disturbances (arteriosclerosis) are more prone to this effect than healthy people with extensive cold applied & vasoconstriction a clients BP can increase blood is shunted form the cutaneous circulation to the internal blood vessels. Specific conditions necessitate precautions in the use of hot or cold applications. (all on pg 884).