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205 Cards in this Set
- Front
- Back
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Layers of the skin
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Epidermis, Dermis, Subcutaneous Layer
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Epidermis
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top layer: outer layer of the skin
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Dermis
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Middle layer: lies between the epidermis and subcutaneous tissue. provides strength and elasticity to the skin, contains many blood vessels, sweat glands, sebaceous glands, collagen
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subcutaneous tissue
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deepest layer, composed of connective and adipose tissue, provides insulation, protection and a reserve of calories in the case of malnutrition
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factors that affect skin integrity
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age related variations, impaired mobility, nutrition and hydration, diminished sensation, impaired circulation, medications, moisture on the skin, fever, infection, lifestyle
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Age
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elderly less elastic, skin drier and takes longer to regenerate
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Mobility
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increased pressure leads to skin breakdown
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Nutrition/Hydration
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poor nutrition leads to less skin regeneration. dehydration=poor skin tugor
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Sensation
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diminished sensation leads to increased risk for pressure and breakdown
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Impaired Ciculation
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negatively affects tissue metabolism
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Medications
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side effects, itching, dryness
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Moisture
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leads to maceration (the process of softening a solid by steeping in fluid)
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Fever
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affects moisture on the skin and affects the metabolic rate (increases it)
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Infection
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impedes healing
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Lifestyle
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tanning, bathing, piercings
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wound
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a disruption in the normal integrity of the skin.
wounds can be: intentional (surgical wound) unintentional (cut or pressure ulcer) |
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types of wounds
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abrasion, abscess, contusion, crushing, incision, laceration, penetrating, puncture, tunnel
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Abrasion
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a scrape of the superficial layers of the skin; usually unintentional but may be performed intentionally for cosmetic purposes to smooth skin surfaces
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Abscess
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a localized collection of pus due to invasion from a pyogenic bacterium or other pathogen; must be opened and drained to heal
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Contusion
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a closed wound caused by blunt trauma. may be referred to as a bruise or ecchymotic area
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Crushing
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a wound caused by force leading to compression or disruption of tissues. often associated with fracture. usually there is minimal or no break in the skin
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Incision
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an open, intentional wound caused by a sharp instrument
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Laceration
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the skin or mucous membranes are torn open, resulting in a wound with jagged margins
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Penetrating
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an open wound in which the agent causing the wound lodges in body tissue (bullet or knife)
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Puncture
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an open wound caused by a sharp object. often there is collapse of tissue around the entry point, making this wound prone to infection.
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Tunnel
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a wound with an entrance and exit site
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Chronic Wounds
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pressure ulcers, arterial ulcers, venous stasis ulcers, diabetic ulcers
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Pressure Ulcers
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appearance depends upon the stage, usually located over bony prominences.
caused by pressure resulting in tissue ischemia and injury. |
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Arterial ulcers
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shiny, thin and dry. cool to touch. hair loss
caused by inadequate circulation of oxygenated blood to the tissue often there is loss of hair in the surrounding area. area has delayed capillary refill time, and patients may complain of pain that worsens with increased activity. |
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Venous stasis ulcers
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red or brown. normal skin temp and normal peripheral pulse. wounds are shallow, with irregular margin, contains exudate, hair loss surrounding ulcer.
caused by venous pooling, resulting in edema and blood stagnation |
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Diabetic ulcers
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caused by vascular changes and impaired sensation 2degree to neuropathy, shiny thin, dry and cool to touch.
may develop as a result of vascular changes associated with diabetes or impaired sensation secondary to neuropathy |
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Pressure
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caused by pressure resulting in tissue ischemia and injury
ischemia=a temporary deficiency of blood flow to an organ or tissue (either through an artery or throughout the circulation |
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wound healing process
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regenerative
primary intention (first) secondary intention tertiary intention |
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regenerative healing
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involves only the epidermis, no scar formation, cannot tell old skin from new regenerated skin
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primary/ first intention healing
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occurs when a wound involves minimal tissue loss and has edges that are well approximated with little scarring. ex)a clean surgical incision
approximated means closed |
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secondary healing
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takes place when a wound incurs extensive tissue loss which prevents the edges from approximating OR should NOT be closed; as in teh case of a wound infection.
when a wound is left open it will heal from the inner layer to the surface layer by filling in with red beefy granulation tissue. -disadvantages: -prone to infection -heal slowly -develop scar tissue |
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tertiary healing
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or delayed wound closure is a wound that heals because two layers of granulation tissue are brought together
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types of wound drainage
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serous exudate: straw colored
sanguineous: bloody serosanguineous: mix of blood and straw color drainage purulent: yellow and contains pus |
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3 stages of wound healing
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Phase 1: inflammatory phase
Phase 2: proliferative phase Phase 3: maturation phase |
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inflammatory phase
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phase 1 of wound healing
occurs day 1-5 distinguished as the "cleansing phase" identified by 2 processes: hemostasis and inflammation |
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proliferative phase
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phase 2 of wound healing
occurs day 5-21 distinguished as the "granulation phase" epithelial profliferation &migration full thickness wound repair (phase 1 and 2) |
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maturation phase
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phase 3 of wound healing
occurs days 14-21 and continues until completely healed distinguished as the "epithelialization phase" |
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cardinal signs of inflammation
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a general inflammatory response occurs whenever there is any invasion by bacteria, virus or some foreign body or substance. this is a basic concept that applies to ALL body invasion.
-redness, heat, swelling (edema), and pain |
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redness
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due to the dilation of blood vessels
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heat
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due to the vasodilation and increased blood flow
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edema
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due to intravascular fluids leaking into the surrounding tissues from the increased permeability of the blood vessels
-it predisposes a patient to pressure ulcer because there is an increased distance from the capillary blood supply to cells of the skin -the raised distance and pressure cause a decrease in blood flow |
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pain
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due to the pain receptors being stimulated by the swollen tissue and pH changes from all these chemicals excreted during the inflammatory response.
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inflammation process
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acute/chronic
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acute inflammation
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the intitial response of the body to harmful stimuli and is achieved by the increased movement of plasma and leukocytes from the blood into the injured tissues. a cascade of biochemical events propagates and matures the inflamatory response involving the local vascular system, the immune system, and various cells within the injured tissue
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chronic inflammation
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known as prolonged inflammation leads to a progressive shift in the type of cells are present at the site of inflammation and is characterized by simultaneous destruction and healing of the tissue from the inflammatory process.
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the complement system
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when activated, results in the increased removal of pathogens via opsonisation and phagocytosis
it is a biochemical cascade that helps clear pathogens from an organism |
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types of wound descriptors for documentation
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skin integrity
length of time for wound healing level of contamination depth of wound |
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skin integrity
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closed
open |
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closed
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no break in the skin (ex fractures)
contusions (bruises) are common with a fracture yet skin remains closed crushing: compression or disruption of tissues |
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open
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break in the skin (lacerations, abrasions, surgical incisions, and puncture wounds
incision laceration tunnel penetrating puncture |
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length of time for healing
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1.acute: short duration
2.chronic: long duration pressure, arterial, venous, and diabetic ulcers usually colonized with bacteria underlying disease process 3. level of contaimination 4. depth of wound (location, size, appearance, drainage) |
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Red wounds
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protect
pink to beefy red granulating tissue redness indicates healing requires a clean moist environment to protect the granulating tissue |
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wound care management: red wounds
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gently clean wound
apply dressing that keeps it moist and clean protect from friction |
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Yellow wounds
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cleanse
pale beige to shades of green and brown (result of moist devitalized tissue) drainage: large amount and usually purulent |
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wound care management: yellow wounds
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clean the wound to remove slough
wound irrigation wet-to-damp dressing/and or absorptive dressings debridement as needed |
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black wounds
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debride
brown to black shiny, leathery covering eschar indicative of necrotic tissue raised risk of infection from bacteria |
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wound care management black wounds
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debridement of necrotic tissue
exception: do not debride heel |
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complications of wound healing
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hemorrhage
infection dehiscence evisceration fistula |
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hemorrhage
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usually within 24-48 hours
capillary network is interrupted or a blood vessel is severed-bleeding occurs hemostasis: cessation of bleeding once hemostasis has occurred and bleeding occurs again-something is wrong possible causes: slipped suture, dislodged clot, infection |
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infection
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can be caused during an injury, during or after surgery
suspect if wound fails to heal swelling, redness, heat, pain and a fever more than 100.4 or foul smelling drainage, purulent drainage of a change in the color of the drainage |
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initiation of infectious symptoms
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with a traumatic injury usually within 2-3 days
surgical site:4-5 days |
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dehiscence
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separation of one or more layers
usually occur in the inflammatory phase of healing before large amounts of collagen have been deposited into the wound to strengthen it |
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causes of dehiscence
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poor nutritional status
inadequate closure of the muscles most often in obese people because fatty tissue does not heal readily and the large size increases strain on the suture line infection of the wound |
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pressure ulcers
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decubitus ulcer/pressure sore/bedsore
etiology: ischemia moisture friction shearing force reactive hyperemia is described as "nonblanching erythema" reactive hyperemia=body's defense mechanism |
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stages of pressure ulcer formation
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stage I
stage II stage III stage IV |
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Stage I
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non-blanching erythema: epidermis only
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stage II
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partial-thickness skin loss: epidermis and dermis
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stage III
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full-thickness skin loss with damage to dermis, epidermis, and subcutaneous tissue
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stage IV
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full-thickness skin loss with extensive tissue damage (all layers; dermis, epidermis, and subcutaneous tissue), including necrosis and damage to muscle or bone
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risk factors for wounds
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immobility
most notably the "pressure points" review next slide inadequate nutrition incontinence decreased mental status diminished sensation cva diabetic neuropathy excessive body heat advanced age |
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preventing pressure ulcers
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turning and positioning every 2hours
providing skin assessment and care inspect skin every 8-12 hours assess for erythema on pressure points, tenderness or edema prevention of infection: hand washing provide adequate nutrition therapeutic mattresses and cushions patient and family teaching |
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nutrition for wound healing
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protein
vitamin a vitamin c zinc |
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protein
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at least 2 to 3 servings per day
beef, fish, poultry, pork, veal, lamb, eggs, cheese, milk, yogurt, dried beans and peas, nuts, seeds |
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vitamin a
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at least 1 serving a day
dark green, leafy vegetables orange or yellow vegetables orange fruits fortified dairy products liver |
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vitamin c
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at least 1 serving a day
citrus fruits and juices strawberries, tomatoes peppers, potatoes, spinach some cruciferous vegetables (broccoli, cauliflower, brussel sprouts, cabbage -formation of collagen in the proliferative and maturational phases -collagen cements the capilalary wals |
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zinc
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fortified cereals
red meats and seafood (protein enriched diet for tissue building, essential for growth, maintenance, and repair of body cells & tissues) |
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high nutrient-dense foods
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beef vegetable soup, fruited jell-o, milk, milkshakes, ice cream floats sherbet ice cream
cottage cheese, cereals, cheesy entrees such as cheese ravioli and macaroni cheese, chicken or tuna salad, peanut butter fruit juices use a prepared liquid oral nutritional supplement (ensure) take a multivitamin (you will need a special multivitamin if the kidneys are impaired) |
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diabetes and wound healing
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if you have diabetes or high blood sugar
continue to monitor your blood sugar levels closely. having good control of blood sugar levels will help w/wound healing and may prevent infection. you may need to visit your doctor and a registered dietitian to help control blood sugar through diet and medication |
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types of debridement
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surgical
mechanical chemical autolytic normal saline is the debriding solution used |
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surgical debridement
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necrotic tissue is removed by scalpel or scissors
quick: only necrotic tissue is removed |
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mechanical debridement
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dressing pull dead tissue off of wound base
debride by using wet to dry dressings slow process non-selective (necrotic and healthy tissue removed) |
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chemical debridement
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application of enzymatic debriding to necrotic tissue
selective by slow |
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autolytic debridement
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natural process that occurs in a moist wound environment using the body's enzymes
slow and selective not indicated when risk of infection is high |
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guiding principles for cleaning wounds
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-medicate pain for 30 mins prior to wound care
-determine if the wound requires sterile or clean technique -cleanest to dirtiest -use normal saline for irrigation -frequency of dsg changes is r/t amount of exudates -saturated dressing=promotes contamination: use biohazard red bag -protect the newly granulated tissue-avoid over cleaning -pat the wound dry after irrigation (be gentle) -granulation is good (slightly moist wound bed is a good thing) |
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Dry gauze
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wicks drainage away from wound surface
stages III and IV |
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wet-to-damp gauze
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maintains moist wound environment, wicks drainage away from wound surface
stages III and IV |
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transparent barrier
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retains wound moisture, allows gas exchange, does not stick to wound surface
stages I and II |
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hydrocolloid
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occlusive, repels moisture and dirt, maintains moist wound environment
stage I |
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hydrogel
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maintains moist wound environment
stages II III IV |
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alginate
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maintains moist wound environment, absorbs exudate
stages III IV |
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hot and cold applications
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local effects of heat and cold rebound phenomenon
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muscle spasm
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heat: relaxes muscle and increases their contractility
cold: relaxes muscles and decreases contractility |
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inflammation
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heat: increases blood flow, softens exudates
cold: vasoconstriction decreases capillary permeability, decreases blood flow, slows cellular metabolism |
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pain
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heat: relieves pain, possibly by promoting muscle relaxation, increasing circulation, and promoting psychologic relaxation and a feeling of comfort, act as a counterirritant
cold: decreases pain by slowing nerve conduction rate and blocking nerve impulses; produces numbness, acts as a counterirritant, increases pain threshold |
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contracture
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heat: reduces contracture and increases joint range of motion by allowing greater distention of muscles and connective tissue
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joint stiffness
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heat: reduces joint stiffness by decreasing viscosity of synovial fluid and increasing tissue distensibility
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traumatic injury
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cold: decreases bleeding by constricting blood vessels, decreases edema by reducing capillary permeability.
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contraindications for the use of heat
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1.First 24 hours = heat increases bleeding and swelling
2.Hemorrhage = heat causes vasodilation and ↑ es bleeding 3.Edema = Heat increases capillary permeability 4.Skin disorders = heat can burn or cause further skin damage |
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contraindications for the use of cold
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1.Open wounds = cold will increase tissue damage by decreasing blood flow to the wound
2.Impaired circulation = cold will further impair nourishment of the tissues and cause more damage 3.Allergy = some people have an allergy to cold that manifests itself by an inflammatory response. |
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neurosensory impairment
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cannot perceive heat and therefore at risk for burns
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impaired mental status
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confused so require monitoring for safe therapy
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impaired circulation
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peripheral vascular disease, diabetes, CHR lack the normal ability to dissipate heat via the blood circulation and puts them at risk for damage r/t heat. cold increases risk r/t to decrease perfusion
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open wounds
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tissues around open wounds are more sensitive to heat and cold
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nursing process r/t skin integrity
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assessment
-braden and norden scale in addition to assessments nursing diagnosis:: -impaired skin (or tissue) integrity r/t immobility AEBredness of skin over coccyx -risk for infection r/t pressure ulcer aeb foul smelling, weeping decubitus planning implementation: -dressing a wound -supporting/immobilizing a wound -binders/badges -applying heat and cold |
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effects of immobility on various parts of the body
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-muscles and bones: muscle atrophy and contractures; disuse osteoporosis
-lungs: atelectasis and pneumonia -heart and vessels -raised workload of the heart by promoting venous stasis -leads to compression and injury of the small vessels of the legs -lower clearance clotting factors leads to dvt (deep vein thrombosis -orthostatic hypotension -metabolism -skin integrity: pressure ulcers -gi: constipation, slows peristalsis -gu: renal calculi (kidney stones), exercise decreases bone loss of calcium, urine then maintains acidity and therefore decreases risk for kidney stones -psychological: depression |
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orthostatic hypotension
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prolonged bedrest inactivates the baroreceptors involved with constriction and dilation of blood vessels. when changing position this results in the inability to maintain BP causing dizziness, lightheadedness, and an increased risk of falling
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general nursing care for patient's on prolonged bedrest
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-turning and positioning every 2 hours
-adequate nutrition -encourage coughing and deep breathing using an incentive spirometer -hydration -active and passive rom (range of motion) -adequate pain management |
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preventative measures associated with immobility or prolonged bedrest
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-dvt: anti embolitic stockings (teds), prevent venous distension
-atelectasis: incentive spirometry; turning and positioning every 2 hours to promote even lung expansion -orthostatic hypotension: access bp before sitting up and standing; assess for dizziness -footdrop: bed cradle, boots |
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incentive spirometer
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minimize lung collapse
-promotes expansion of chest and lungs to decrease risk of atelectasis and pneumonia -inhale slowly w/constant intake flow (like a straw) -raise max. amount of balls -hold for 2-3 seconds -exhale through pursed lips -encourage coughing; indicates using spirometer correctly -use 5-10/hour -fowler's position increases chest expansion |
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nursing interventions r/t complications associated with immobility or prolonged bedresst
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-increase fiber intake
-encourage adequate intake of fluids -maintain I&O -offer fluids often with special atten to specific "likes" -thicken fluids for stroke victims with bilateral weakness -may not be able to use a stra r/t inability to "suck in" bilaterally -sit in fowler's position for feeding (aspiration alert) -administer stool softener: colace (docusate sodium) one tablet po bid (weakend abdominal muscles, decreased peristalsis increases constipation, limited activity decreases appetite therefore decreasing nutritional intake of protein) |
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general concepts r/t hygiene
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-activities involved in personal grooming and cleanliness
-activities of daily living (ADLs): -bathing -showering -combing hair |
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maintenance of personal hygiene
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-promotes comfort
-improves self-image -decreases infection and disease |
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factors that influence personal hygiene
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-personal preferences
-body image -socioeconomic status -cultural beliefs -personal values -health beliefs -family customs |
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health status affects self care ability
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-pain
-limited mobility -sensory deficits: safety is a priority for any patient with sensory deficits -cognitive impairment -emotional disturbances |
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Nurse's role in hygeine
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-asses self-care abilities
-provide assistance with ADLs -promote self-care in ADLs -delegate approprate parts of hygiene care |
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types of hygiene care
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-morning care
-afternoon care -hs care |
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infectious agent
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infection: is successful invasion of the body by a pathogen
pathogen: organisms capable of causing disease |
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portal of entry
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normal body openings, such as the conjunctiva of the eye, the nares, mouth, urethra, vagina and anus are potential portals of entry, as are abnormal openings, such as cuts and scrapes.
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reservoir
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a source of infection: a place where pathogens survive and multiply
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carriers
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have no symptoms of disease, yet can pass the disease to others
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portal of exit
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through body fluids, including blood, mucus, saliva, breast milk, urine, feces, vomitus, semen, or other secretions
-nosocomial infections: puncture sites, drainage tubes, feeding tubes and intravenous lines commonly serve aas routes for pathogens to exit the body |
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mode of transportation
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direct or indirect (contact with fomite)
how the microorganism got someone infected shoes, eyeglasses, stethoscopes, and other items |
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susceptible host
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a person with adequate defenses against the invading pathogen
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3 factors that determine transmission of organism to host
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1.Virulence: the power to cause the disease
2.The number of organisms that is transmitted. The more organisms…. The sicker the patient! 3.The ability of the host to defend against the infection |
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Incubation
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From time of infection until manifestation of symptoms; can infect others
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Prodromal
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Appearance of vague symptoms; not all diseases have this stage
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illness
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Signs and symptoms present
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decline
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Number of pathogens decline
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convalescence
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Tissue repair, return to health
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primary infection
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the first infection that occurs in a patient
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secondary infection
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follows primary infection, especially in immunocompromised patients, may be one or more secondary infections
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nosocomial infections
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infection aquired in a healthcare facility
Leading cause of death Preventable with use of aseptic principles/ techniques |
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Exogenous Nosocomial Infection
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Pathogen acquired from health-care environment
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Endogenous Nosocomial Infection
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Normal flora multiply and cause infection as a result of treatment
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local infection
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infections that cause harm in a limited region of the body, such as the upper respiratory tract, the urethra, or a single bone or joint
-causes inflammatory response |
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systemic infection
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occur when pathogens invade the blood or lymph and spread throughout the body
-bactermia (clinical presence of bacteria in the blood) -septicemia (symptomatic systestmic infection spread via the blood) |
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inflammatory response
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-local, nonspecific defensive response to tissue injury or infection
Pain Swelling (edema) Redness Heat Loss of Function |
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acute infection
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Rapid onset of short duration
e.g., Common cold |
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chronic infection
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Slow development, long duration
e.g., Hypertension, diabetes mellitus, osteomyelitis |
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latent infection
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Infection present with no discernible symptoms
e.g., HIV/AIDS |
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primary defenses
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Anatomical features, limit pathogen entry
Intact skin Low pH of the skin Mucous membranes Cilia Tears Normal flora in GI tract Normal flora in urinary tract (Antibiotics eliminate an infection! It is NOT a defense! Inappropriate use of ABX destroys normal flora as well as bacteria Can predispose a patient to a secondary infection b/c defenses are down) |
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secondary defenses
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Biochemical processes activated by chemicals released by pathogens
Phagocytosis Complement cascade Inflammation Fever |
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inadequate secondary defenses
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Decreased hemoglobin
Less oxygen carrying capacity Suppression of WBC’s Drug or disease related Suppressed inflammatory response COX -2 inhibitors Leukopenia (decreased WBC count) |
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Tertiary Defenses
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-Humoral immunity
B-cell production of antibodies in response to an antigen -Cell-mediated immunity Direct destruction of infected cells by T cells |
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factors that increase the risk of infection
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Age
Breaks in the skin Urine back flow/ obstructed out flow Illness/injury, chronic disease Smoking, substance abuse Multiple sex partners Medications that inhibit/decrease immune response Nursing/medical procedures |
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factors that support host defenses
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Adequate nutrition
Protein, vitamins, minerals & water Balanced hygiene Sufficient to decrease skin bacterial count Rest/exercise Reducing stress Immunization |
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medical asepsis
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A state of cleanliness that decreases the potential for the spread of infections
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How do we promote medical asepsis
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Maintain clean hands
Maintain a clean environment Following Centers for Disease Control (CDC) guidelines |
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Hand-washing
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When you arrive in the unit
When you leave the unit Before and after restroom use Before and after patient contact Before and after contact with patient belongings Before gloving After glove removal Before and after touching your face Before and after eating After touching a contaminated article When you see visible dirt on your hands |
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Hand washing guidelines
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Wash for at least 15 seconds in nonsurgical setting; 2-6 minutes in surgical setting
Use warm water, not hot Apply soap to wet hands Use friction Clean beneath fingernails and jewelry Rinse soap Towel or hand dry |
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Maintaining a clean environment
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Clean spills and dirty surfaces promptly
Remove pathogens through chemical means (disinfect) Remove clutter Consider supplies brought to the client room as contaminated Consider items from the client’s home as contaminated |
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Common Nosocomial Infections
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Unsterile insertion of urinary catheter
Catheter & tubing become disconnected Improper specimen collection: i.e. blood cx w staph epi Improper hand hygiene Improper skin prep before procedure Use of contaminated equipment Improper disposal of soiled linen or secretions |
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cleaning and sterilizing
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Proper cleansing of skin, disinfection and sterilization of equipment or contaminated objects reduce and sometimes eliminate microorganisms.
Disinfection: eliminates many of the organisms Sterilization: eliminates ALL the organisms The decision to clean or sterilize is based on the purpose of the use of equipment! |
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Implementing CDC Guidelines
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Standard precautions (universal precautions)
Protects health-care workers from exposure Decreases transmission of pathogens Protects clients from pathogens carried by health-care workers |
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Contact Precautions
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Pathogen is spread by direct contact
Sources of infection - draining wounds, secretions, supplies Precautions include: Possible private room Clean gown and glove use Disposal of contaminated items in room Double-bag linen and mark |
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Droplet Precautions
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Pathogen is spread via moist droplets:
Coughing, sneezing, touching contaminated objects Precautions include: Same as those for contact Addition of mask and eye protection within 3 ft of client |
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Airborne Precautions
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Pathogen is spread via air currents
Transmission via ventilation systems, shaking sheets, sweeping Precautions include: Same as those for contact, with addition of special mask |
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Reverse” isolation
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Protects the patient from organisms (us)
Used with immune-compromised client population Precautions include: Private room likely Nurse not assigned to clients with active infection Mask, hand-washing, clean/sterile gown, gloves No reuse of gowns, gloves |
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Isolation Precautions
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Tier 1: Standard Precautions
Combines Universal Precautions with BSI Tier 2: Transmission-Based Precautions Airborne: tiny particles that remain in the air for long periods of time i.e. TB, measles, chickenpox Droplet: transmitted through close respiratory contact or mucous membranes secretions. Do not remain in the air for long periods of time Influenza, streptococcus, rhinovirus |
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respiratory tract
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common infectious organisms: parainfluenza virus, mycobacterium tuberculosis, staphylococcus aureus
portals of exit: nose or mouth through sneezing, coughing, breathing or talking |
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gastrointestinal tract
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common infectious organisms: hepatitis a virus, salmonella species
portals of exit: mouth through saliva, vomitus; anus through feces ostomies |
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urinary tract
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common infectious organisms: escherichia coli enterocci, pseudomonas aeruginosa
portals of ext: urethral meatus, and urinary diversion |
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reproductive tract
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common infectious organisms: neisseria gonorrheoae, treponema pallidum, herpes simplex virus type 2, hepatitis b (hbv)
portals of exit: vagina, vaginal discarche, urinary meatus, semen urine |
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blood
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common infectious organisms: hiv, staphylococcus auereus, staphyloccus epidermidis, hepatitis b virus
portal of exts: open wound, deedle puncture site, any disruption of intact skin or mucous membrane surfaces |
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tissue
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common infectious organisms: staphylococcus aureus, escherichia coli, proteus species, streptococcus beta hemolytic a or b
portals of exit: drainage from cut or wound |
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areas of hygiene care
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Skin: first line of defense!!!!
Oral cavity Buccal glands (secrete saliva) Mastication (action of chewing) Gingivitis (gum inflammation) Hands, feet, & nails Injury, deformity, growths Hair Indication of general health/wellbeing Eyes, ears & nose Hygiene provides opportunity for assessment |
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role of protection: epidermis first line of defense
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Prevents entrance of microorganisms
Weakened by scrapping or stripping Use of dry razors Tape removal Improper turning and positioning (shearing force) Chemical irritation (soap, deodorant) Cleansing of skin removes excess oil, sweat, dead skin; substances that can promote bacterial growth |
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other roles of the skin...
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Sensation
Sensory organs for touch, pain, heat, cold & pressure Temperature Regulation Temperature controlled by radiation, conduction, convection & evaporation Heat loss interferes w temp. control Excretion & Secretion Sweat promotes heat loss Perspiration & oil promotes growth of microorganisms Sebum lubricates skin & hair |
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guidelines for skin care
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Promote intact skin
All RN actions should prevent injury and irritation Shearing forces Promote healthy skin cells Poor nutrition/excess dryness increased susceptibility to injury Prevent excessive moisture Promotes bacterial growth & irritation At-risk populations: Infants, elderly, malnourished, obese |
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risks to skin integrity
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Any factor that interferes with hydration, circulation, and nutrition of the skin creates a risk to skin integrity!!!
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risk factors for skin impairment
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Dampness of the skin
Incontinence Fever and perspiration Moisture on the skin surface is a medium for bacterial growth Bacteria that remains on skin can soften the skin surface & lead to maceration. Dehydration Insufficient circulation Immobility Vascular disease Inadequate nutrition Immobilization Increases pressure on skin Decreases circulation 5. Reduced sensation Circulatory insufficiency Arterial blood supply to tissues is diminished Impaired venous return (pedal edema) Inadequate blood flow causes ischemia Nerve damage/loss of sensation called neuropathy Paralysis Impairs skin & wound healing Limited calorie & protein intake causes skin to loose elasticity, become thinner & loss of subcutaneous tissue 7. External devices Electrodes, tape, casts, bandages, restraints, dressings etc. |
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risk factors for hygiene problems...
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Oral Problems
Weakness, paralysis, restriction, NGT… Dehydration: NPO status Foot Problems Unable to bend over Visual acuity Eye Care Problems Reduced dexterity & hand coordination Skin Problems (already discussed) |
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baths
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Complete Bed Bath
Totally dependent/total hygiene Assisted Bed Bath Assist the patient as needed Partial Bed Bath Bathing body parts that would cause discomfort or an odor Bath in a Bag Shower Chair Watch DVD on Bathing |
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package bath
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A bath in a bag is a modification to the towel & washcloth bath.
Each part of the body is cleansed with a fresh cloth. They are remoistened and disposable. |
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principles of bathing
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Provide privacy
Obtain needed supplies Adjust the bed to working height Remove bedding and cover patient w/ a bath blanket Remove the patient’s gown but keep as much covered as possible Maintain modesty and prevent chills Don gloves (maintain standard precautions) Long strokes increase circulation Lift arm to provide ROM (range of motion) Wash anterior to posterior Wash or Wipe: from “clean to dirty” Wash extremities distal to proximal (hand to shoulder; foot to hip) to promote venous return Do not massage calves patient’s on bedrest are predisposed to DVT (deep vein thromobis). Massaging a calf can cause a release of the thrombus leading to an embolus Pat skin dry |
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principles of baithing
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Wash abdomen, legs and feet
Wash abdomen, umbilicus and pat dry Uncover one leg at a time and start w/ leg farthest from you Wash distal to proximal (foot to hip) with long gentle strokes to promote venous return Do NOT massage the calves (↑’es risk of releasing a clot causing an embolus) Wash back and buttocks Back first and then buttocks Pay attention to gluteal folds (observe for redness and dry thoroughly) Wash rectal area from front to back and remove any fecal matter Apply lotion if not contraindicated (do not do with any patient who has a musculoskeletal injury or cardiovascular disease) Stimulates circulation and maintains healthy skin Wash perineum from front to back to prevent contamination of vaginal area with stool |
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bathing with respect to elderly clients
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Skin is fragile
Bruises easily Less elastic, has less oil (avoid excessive soap) Soap very drying “Art” of bathing the dementia client Avoid HOT water Can cause burns (elderly have diminished senses to heat and cold Powder Inhaled = not good Cornstarch glucose/overgrowth of microorganisms |
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bathing the dementia patient
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Minimize the amount of time the patient is undressed
Keep room warm Use distractions & negotiation rather than “demands” Determine least distressing types of bathing (soak feet etc) Praise after completed |
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nail care
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Foot care for non-diabetic client only
Not done (by us, while at ECF) concerns: pain from feet from deformities, arthritis, weak structure, injuries & disease (diabetes), hammer toes, corns & calluses Diabetic foot care is performed by a Podiatrist due to increase risk of vascular deficiency and infection Fingernail care soak & file nails & push back cuticles You may offer this during clinical |
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oral care
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Overlooked in ECF population
Foam or glycerin swabs Lemon glycerin swabs used to promote mouth hygiene and prevent halitosis (bad breath) Use with CAUTION on any patient who has oral or mouth skin breakdown or cracks Will cause pain and burning Denture Care Safeguard them! (expensive) Assist with cleaning PRN Gloves worn (Standard Precautions) Fit top first and then bottom Can use Polident type of cleanser. |
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bed making
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Body mechanics
Be efficient Assess skin during procedure Delegate PRN Avoid plantar-flexion of toes Use foot board Bed cradle Avoid linen creases Know commonly used bed positions |
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client safety
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Safety bars in showers & toilets
Use of bed rails Use of bed alarms Locks on beds & WC’s Call lights within reach Canes, walkers Rubber soled shoes Keep hallways clear |
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client safety
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Keep important items within easy reach
Glasses, medications, tissues, hearing aids etc. Adequate lighting Use restraints (device to immobilize patient) sparingly Skin tears Falls (JACHO PSG) |
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eschar
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A thick coagulated crust or slough that develops following a burn, chemical or mechanical injury to the skin
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granulation
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The formation or growth of small blood vessels and connective tissue in a full-thickness wound.
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maceration
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Softening and breakdown of tissues from over exposure to moisture.
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slough
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Loose, stringy necrotic tissue.
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sinus tract
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A course or pathway which can extend in any direction from the wound surface; results in dead space with potential for abscess formation
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undermining
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Tissue destruction underlying intact skin along wound margins.
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wound bed base
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Uppermost viable layer of wound; may be covered with slough or eschar.
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wound margin
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Rim or border of a wound.
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erythema
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Redness of the skin surface produced by capillary dilation.
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exudate
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Accumulation of fluids in wound; may contain serum, cellular debris, bacteria, and leucocytes.
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epithiallization
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The regeneration of skin over a wound surface
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Excoriation
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Linear scratches on the skin
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Stage I Pressure Ulcer
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Stage I Pressure Ulcer- A defined area of non-blanchable redness in lightly pigmented skin, or persistent red, blue, or purple hues in darker skin tones.
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Stage II Pressure Ulcer
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Stage II Pressure Ulcer- Partial thickness skin loss involving epidermis and/or dermis. Presents clinically as an abrasion, blister, or shallow crater.
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Stage III Pressure Ulcer
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Stage III Pressure Ulcer- Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Presents clinically as a deep crater with or without undermining of adjacent tissue.
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Stage IV Pressure Ulcer
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Stage IV Pressure Ulcer- Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle bone, or supporting structures (e.g., tendon, joint capsule).
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Deep Tissue Injury (DTI)
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Deep Tissue Injury- A pressure-related injury to subcutaneous tissue under intact skin and initially has the appearance of a deep bruise. DTI’s may eventually develop into a Stage III or IV despite optimal treatment.
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