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185 Cards in this Set
- Front
- Back
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LEGAL ASPECTS OF DRUG ADMINISTRATION:
What defines and limits our functions in the legal aspect of drug administration? |
NPA
Nurse Practice Acts |
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LEGAL ASPECTS OF DRUG ADMINISTRATION:
As nurses we must be able to recognize the limits of our own knowledge and skill. Why is this? |
Because to function beyond the limits of nursing practice acts or our own ability is to endanger client's lives and leave oneself open to malpractice suits.
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Under law, who is responsible for the administration of a medication,whether or not their is a written order?
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The Nurse!
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If a physician writes an incorrect order (e.g., Demerol 500 mg instead of Demerol 50mg, who is responsible?
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A nurse who administers the written incorrect dosage is responsible as well as the physician.
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If an order seems unreasonable, what should the nurse do?
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Question the order!, and refuse to give the medication until the order is clarified.
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EFFECTS OF DRUGS
What is the primary effect intended, or why is a drug prescribed? |
The therapeutic effect.
Desired effect ex.) The therapeutic effect of morphine sulfate is analgesia, and the therapeutic effect of diazepam is relief of anxiety. |
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What is a side effect, or secondary effect?
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A effect that is unintended. Side effects are usually predictable and may be either harmless or potentially harmful.
For example, digitalis increases the strength of myocardial contractions (desired effect) but it can have the side effect of inducing nausea and vomiting; some side effects are tolerated for the drug's therapeutic effect. |
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More severe side effects are called what?
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adverse effects, or reactions; and may justify the discontinuation of a drug.
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Drug toxicity (deleterious effects of a drug on an organism or tissue) results from what?
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Overdose, ingestion of a drug intended for external use, and buildup of the drug in the blood because of impaired metabolism or excretion. (cumulative effect)
Some toxic effects are apparent immediately, some are not apparent for weeks or months. |
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EFFECTS OF DRUGS
What is a drug allergy? |
An immunological reaction to a drug. When a client is first exposed to a foreign substance (antigen), the body may react by producing antibodies. A client may react to a drug as to an antigen and thus develop symptoms of an allergic reaction.
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Allergic reactions can be mild or severe. What are the symptoms of a mild reaction?
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from skin rashes to diarrhea
Pruritus (Itching of the skin w/ or w/out rash) Angiodema (Edema) Rhinitis (watery discharge from the nose) Lacrimal tearing (excessive tearing) Nausea, vomiting Wheezing and dyspnea Diarrheas. |
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What are the symptoms of a severe reaction?
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BTW, an type of allergic reaction; mild or severe, can occur anywhere from a few minutes to 2 weeks after administration.
A severe allergic reaction usually occurs immediately after the drug is administered, and is called an anaphylactic reaction. This response may be fatal if the symptoms are not noticed immediately . Early symptoms are a subjective feeling of swelling in the mouth and tongue, acute shortness of breath, acute hypertension, and tachycardia. |
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Therapeutic Actions of Drugs
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Palliative-Relieves the symptoms of a disease but does not affect the disease itself.(Morphine, sulfate or aspirin for pain)
Curative-Cures a disease or condition. (Penicillin for infection) Supportive-Supports body function until other treatments or the body's response can take over.(Norepinephrine bitartrate for low blood pressure, aspirin for high body temperature) Substitutive-replaces body fluids or substances. (Thyroxine for hypothyroidisim, insulin for diabetes mellitus) Chemotherapeutic- destroys malignant cells. (Busulfan for leukemia) Restorative- Returns the body to health. (Vitamin, mineral supplements) |
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Drug tolerance
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exists in a person who has unusually low physiologic response to a drug and who requires increase in the dosage to maintain a given therapeutic effect.
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Drug interaction
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occurs when the administration of one drug before, at the same time as, or after another drug alters the effect of one or both drugs.
The effect of one or both drugs may be either increased (potentiating effect) or decreased (inhibiting effect). |
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Synergistic effect of drugs
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when two different drugs increase the action of one or another drug.
ex.) Probenecid, which blocks the the excretion of penicillin, can be given with penicillin to increase blood levels of the of the penicillin for longer periods. |
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Addictive effect of drugs
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aspirin and codeine can be given together to provide greater pain relief, decreasing the amount of narcotics needed.
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DRUG MISUSE
When using common medications improperly what can result? |
Drug misuse!
Both over the counter drugs and prescription drugs may be misused and can lead to acute and chronic toxicity. Laxatives, antacids, vitamins, headache remedies, and cough and cold medicines are often self-prescribed and overused. |
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What is drug abuse?
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inappropriate intake of a substance, either continually or periodically. By definition, drug use is abusive when society considers it abuse.
Drug abuse requires two main facts: Drug dependence and habituation |
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What is drug dependence and what are the two types?
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Drug dependence is a person's reliance on or need to take a drug or substance. Two types of dependence are:
Physiologic dependence= is due to biochemical changes in body tissues, especially the nervous system. The tissues come to require the substance for normal function. A dependent person who stops will experience withdrawal symptoms. Psychologic dependence: is emotional reliance on a drug to maintain a sense of well being, accompanied by feelings of need or cravings, for that drug. There are varying degrees from mild desire to craving and compulsive use of the drug. |
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Drug habituation is a mild form of what?
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psychologic dependence. The individual develops the habit of taking the substance and feels better after taking it. The habitual individual tends to continue the habit even though it may be injurious to health.
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What are illicit drugs?
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Street drugs, or drugs that normally require a prescription but are being obtained through illegal channels.
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What are the 3 checks when administering medication?
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MAR (medication administration record)
double check against dispense unit 2 forms of I.D against the EMAR, scanning, etc. |
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FACTORS AFFECTING MEDICATION ACTION:
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Developmental: During pregnancy drugs pose a risk throughout the pregnancy, but the highest risk is during the first trimester, due to the formation of vital organs and functions of the fetus during this time. Most drugs are contraindicated because of the possible adverse effects on the fetus.
Infants usually require small doses because of their body size and the immaturity of their liver and kidney's. In adolescence or adulthood, allergic reactions may occur to drugs formerly tolerated. Older adults have different responses due to physiologic changes, like decrease kidney and liver function. Plus, they could be on many drugs at once. |
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FACTORS AFFECTING MEDICATION ACTION:
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GENDER: men and women respond differently to drugs, chiefly due to the distribution of body fat and fluid and hormonal differences.
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FACTORS AFFECTING MEDICATION ACTION:
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Cultural, Ethnic, and genetic: herbal remedies may speed up or slow down the metabolism of prescribed meds.
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FACTORS AFFECTING MEDICATION ACTION:
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DIET: Nutrition can affect the action of a medication. Vitamin K found in green leafy vegetables can counteract the effect of warfarin.
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FACTORS AFFECTING MEDICATION ACTION:
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ENVIRONMENT:
the environment can affect the action of mood altering drugs, therefore these drugs should be considered carefully as well. |
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FACTORS AFFECTING MEDICATION ACTION:
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PSYCHOLOGIC:
A client's expectations about what a drug can do can affect the response to the medication. |
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FACTORS AFFECTING MEDICATION ACTION:
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ILLNESS AND DISEASE:
ex.) aspirin can reduce the body temp. of a feverish client but has no effect on the client without fever. |
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FACTORS AFFECTING MEDICATION ACTION:
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TIME OF ADMINISTRATION:
Oral meds are absorbed more quickly if the stomach is empty. P.S. If medication is given outside the 1hr. window of time it is considered a medication error. |
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What are the parts of a medication order? (MAR)
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-Full name of the client
-Date and time the order written -Name of drug to be administered -Dosage -Frequency of administration-make sure it is administered when scheduled) -Route of administration -Signature of person writing the order |
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What are we always looking for when administering medication?
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Therapeutic and Adverse Effects
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Always....
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monitor for medication errors
check vital signs before administering meds! |
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Types of Doses:
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STAT ORDER:given only once, immediately, don't wait!
SINGLE ORDER: ex. seconal 100mg hs before surgery (one time order) STANDING ORDER: Demerol 100 mg IM q4h X 5 days(May or may not have a termination date, could be indefinitely, ex. daily multi vitamins)_ PRN order: Amphojel 15mL prn. (EVERY PRN has to include the reason for administration. ex.) for nausea, for headaches, so that the nurse knows when she is to give it, or for what. |
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Antibiotics are "more" time sensitive, why?
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T.I.D or Q.I.D , B.I.D, can be given a little more outside of the "exact" time required for 12 hour time sensitive antibiotics.
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Full Physician Order should always have a:
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Start/Stop date
Seperate forms for PRN orders and MAR forms. |
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Once a day doses are usually given in the A.M. however, if a client is used to a P.M. of a certain med, what should we do?
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Notify physician, see if a change can be made.
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ADMINISTERING MEDICATIONS:
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1.) Identify the client!
2.) Inform the client 3.) Administer the drug 4.) Provide adjunctive interventions as indicated 5.) Record the drug administered 6.) Evaluate the client's response to the drug. |
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TEN RIGHT'S OF ACCURATE MEDICATION ADMINISTRATION:
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1.)Right medication
2.)Right dose 3.)Right time 4.) Right route 5.)Right client 6.)Right client education 7.)Right documentation 8.)Right to refuse 9.)Right assessment 10.)Right evaluation |
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SAFETY
3 checks: |
compare arm band to MAR
compare D/O/B to MAR! Inform them of the medication ex.) This is your medication to help you with your blood pressure! Never leave the medication in a room! Always stay with the patient until they have taken the medication. When using an inhalation device, check respiration sounds (breathing) to see if the treatment is helping. If you drop a pill throw it out, if you don't know what a pill is throw it out! |
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Nurses need to consider patient safety in many different environments:
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Hospital and the home
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If the client is at risk for injury then you would have what in their care plan?
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The goal of keeping them free from injury
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When assessing safety what is a primary nursing diagnosis?
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RISK FOR INJURY
Think about all the factors that can affect safety. How does age alter your assessment focus? ex.) People with knee (mobility) issues could be at risk for fall. How does environment alter your assessment focus? ex.) unsafe work environments, people in high crime neighborhoods, etc.) |
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NATIONAL PATIENT SAFETY GOALS:
Th joint commission for accreditation of Healthcare organizations developed safety goals: |
Use at least 2 patient identifiers
Prior to the start of any invasive procedure conduct a final verification process to confirm,the correct patient, procedure, site, and proper documents. Read back all verbal or telephone orders. Standardized abbreviations that are not to be used. All critical values from the lab are reported to a responsible caregiver within timeframes established by the lab. Hand-off communications Label all meds. |
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DIAGNOSING:
Risk for Injury has 7 subcategories that may be proffered when the nurse wants to describe injury more specific. |
Risk for Injury- a state at which the client is at risk for injury as a result of environmental conditions interacting with the individuals adaptive and defense resources.
Subcategories of Risk for Injury: Risk for Poisoning Risk for suffocation Risk for Trauma: accentuated risk of accidental tissue injury. ex.) wound, burn, or fracture. Risk for aspiration: At risk for the entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into tracheobronchial passages Risk for Disuse Syndrome: At risk for deterioration of body systems as the result for prescribed or unavoidable musculoskeletal inactivity. |
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FIRE PREVENTION:
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RACE
R= Rescue A= Alarm C= Contain E= Extinguish If a fire, close the door and sound the alarm......remove patients first. |
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Fire prevention:
In the hospital...... |
Know that fires exist
Know fire extinguishers: A= trash (paper wood upholstery, rubbish) B= flammable liquids and gas C= electrical fires |
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Fire prevention:
In the home: |
Safety with O2 use
**proper storage **No open flame Stop, Drop, and Roll Family exit plan....meeting place if separated. |
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Seizures:
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Sudden violent movements
High risk for Injury Nurse must implement seizure precautions: Gently lie them on the floor, with head turned to side, and loosen clothing. Don't restrain someone who is seizing! |
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What are the precautions necessary for seizure?
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Assess their seizure history.
Remember AIRWAY!!! 02 at bedside Suction equipment Ensure Safe environment -Pad side rails -Remove unnecessary objects IF seizure occurs- Clear area loose clothing Protect clients head |
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Safety Restraints:
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Physical: mechanical device that restricts movement
Chemical: medication to control behavior. |
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Can we use a restraint whenever we feel it is necessary?
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No!!! an order is required!
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What must be monitored when a patient is in restraints?
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Skin
Circulation Toileting |
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Where do the restraints get tied to?
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To the bed frame.
Always educate family, ongoing needs assessment, and pad the bony prominences. |
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What is important when it comes to equipment safety?
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Ensure regular inspection
Faulty equipment needs to be reported immediately and taken out of service Electrical equipment uses 3- pronged plug Unplug using the plug No overcrowded outlets |
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Diagnostic Testing:
What is the pretest phase of diagnostic testing? (TEACHING) |
Client preparation, which involves a thorough assessment and data collection. ex.) biologic, sociologic, cultural, and spiritual all aid in assisting the nurse in determining communication strategies.
Ex. Prior to radiologic studied it is important to ask female clients if pregnancy is possible. The nurse also needs to know what equipment and supplies are needed for the specific test. ex.) What type of sample will be needed and how will it be collected? Does the client need to stop oral intake for a certain number of hours before the teat? Does the test include administration of dye (contrast media), and if so, is it injected or swallowed? Are fluids restricted or forced? Is a consent form required? In teaching you will want to let the client know what to expect. ex.) a wave of heat during procedure. or don't take IBUPROFEN or aspiring 5 days before procedure. |
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Diagnostic Testing:
Intratest (CLIENT PREPARATION) |
This phase focuses on specimen collection and performing or assisting with certain diagnostic testing. The nurse uses standard precautions and sterile technique as appropriate. During the procedure the nurse provides physical and emotional support while monitoring the client. (ex. vital signs, pulse oximetry, ECK.) The nurse ensures correct labeling, storage, and transportation of the specimen to avoid invalid test results.
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Diagnostic Testing:
Post-Test (MONITORING) |
Focuses on client care and follow up activities and observations. As appropriate, the nurse compares the previous and current test results and modifies nursing interventions as needed. The nurse also reports the results to appropriate health team members.
Ex.) ASSESS VITAL SIGNS, or after a procedure your gag reflex has to return before you can go home. |
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What are diagnostic's?
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Diagnostic's open a window to a pateint's current health status. It is not just lab work, but MMRI's, echocardiograms, etc. Usually done in conjunction with a physical exam.
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What are some nursing diagnosis to consider with Diagnostic's?
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anxiety or fear:
Knowledge Deficit: Pain Impaired Mobility:some tests require the patient to remain immobile for a period of time. |
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What can help alleviate some of these fears?
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Teaching about the procedure:
It is necessary to teach about Pre and Post Test restrictions: Pre test- don't take Ibuprofen 5 days before test to prevent bleeding. Teach about: Test expectations Always allow for feedback and document teaching and patients response. |
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What are some of the common blood tests?
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Complete Blood Count (CBC)
Serum Electrolytes (chem panel) Serum Osmolality Serum Drug Monitoring Arterial Blood Gases (ABG's) Chemistry Panels Metabolic Screening Serum Glucose |
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What does a Complete blood count involve? (CBC)
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Venous blood are taken for a CBC, which includes:
Hemoglobin: carries oxygen and removes CO2 from red blood cells (IRON) Hematocrit: percentage of red blood cells in the total blood volume Normal values vary for both hemoglobin and hematocrit, with males having higher levels than females. M: 37-49% F: 36-46% |
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What happens to hemoglobin and hematocrit with dehydration? |
They increase as the blood becomes more concentrated.
ex.Salt in water |
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Hemoglobin and Hematocrit (H&H) are related to which blood count?
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The red blood cell count (RBC)
Which is the number of RBC's per cubic millimeter of whole blood. |
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What are low RBC counts indicative of?
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anemia
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What does a Complete blood count involve? (CBC)
What do the white blood cells consist of? (WBC's) |
The leukocyte or white blood cell (WBC) count determines the number of circulating WBC's rec cubic millimeter of whole blood.
Infection |
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In a bacterial infection what will you see?
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High WBC counts
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What will be seen in a viral infection?
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Low WBC counts
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What are normal ranges for WBC counts?
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4,500-11,000/mm
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What does a Complete blood count involve? (CBC)
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platelets (produced by bone marrow) Blood clotting
150,000-350,000 |
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What is a differential count?
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The proportion of each of the 5 types of WBC's in a sample of 100
WBC's. Neutrophils= 55-70% Lymphocytes= 20-40% Monocytes= 2-8% Eosinophils=1-4% Basohils= 0-2% |
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Types of WBC's
Neutrohils |
Stress and acute infection Viral diseases
55-70% |
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Types of WBC's
Lymphocytes |
20-40%
Viral infection, Mononucleosis Tuberculosis Chronic bacterial infections Lymphocytic leukemia |
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Types of WBC's
Monocytes |
2-8%
Chronic inflammatory disorders Tuberculosis Protozoan infection Rocky Mountain Spotted Fever |
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Types of WBC's
Eosinophils |
1-4%
Allergic reaction asthma, hayfever, hypersensitivity to a drug, etc |
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Basophils
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0-2%
Malignant tumors Polycythemia vera |
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Other types of blood tests:
Serum Electrolyte/Chemistries |
Routinely ordered for electrolyte and acid-base imbalances. ex.) clients who are being treated with a diuretic for hypertension or heart failure.
The most commonly ordered serum tests are for: Sodium (Na+) 135-145 Potassium (K+) 3.5-5.0 Chloride (Cl-) 95-105 Bicarbonate Ions Can be ordered as CHEM 7 or BMP Basal metabolic Panel |
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What are we looking at with Creatine and BUN levels?
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renal function, or kidneys
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What are we looking at when testing the Complete Metabolic Panel?
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Liver function
Albumim Total protein Liver Function Tests (LFT's) |
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What does the serum Osmolality blood test look for?
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It measures density.
The solute concentration of the blood. The particles included are sodium ions,glucose, and urea. (BUN) Used primarily to evaluate fluid balance. |
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An increase in serum osmolality indicates what?
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A fluid deficit
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A decreased in serum osmolality indicates what?
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a fluid volume excess
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If someone was in a car accident and bleeding what will show up in the lab work?
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Depleted hemoglobin values (IRON)
(LOW BLOOD VOLUME) |
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If someone is HYPOXIC what is one of the first symptoms that will appear?
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They will become very restless, because the heart is trying to compensate causing tachycardia, which can cause chest pain, and lead to heart attack.
(LOW BLOOD VOLUME) |
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Drug Monitoring
Often done when clients are taking a medication with a very narrow therapeutic range. This monitoring includes drawing blood sample for peak and trough levels to determine if the blood serum levels of a specific drug are at a therapeutic level and not a subtherapeutic level or toxic level. |
Peak level= Highest concentration of the drug in the blood serum
Trough- the lowest concentration |
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Another important diagnostic measurement is Arterial Blood Gases (ABG)
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Specialty nurses, medical technicians, and respiratory therapists normally take specimens from the radial, brachial, femoral, or groin arteries.
Because of the relatively great pressure of the blood in theses arteries it is important to prevent hemorrhaging by applying pressure to the puncture side for about 5 to 10 minutes after removing the needle. |
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What is the ABG blood test usually used for ?
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Respiratory functions
Measure exact oxygenation **Completed by respiratory therapy, arterial blood draw. (oxygenated blood) |
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What is the cardiac marker blood test?
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It measures Troponin levels : shows heart attack.
Creatine Kinase= muscle Myoglobing=cardiac muscle BNP= specifically measures heart failure. BNP= Brain Natriuretic Peptide |
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What specific test is done to measure heart failure?
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BNP
Brain Natriuretic Peptide |
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Cholesterol:
Which cholesterol is good? |
HDL (healthy)
should be above 35 |
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Cholesterol:
Which cholesterol is bad? |
LDL (Lousy)
should be below 100 |
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What do Triglycerides measure?
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animal fats in the body
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When type of blood glucose tests are there?
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Fasting=no food or coffee
-Random- less accurate because they can eat HGB A1C = most important test for diabetics. Accumulative average of blood sugar over last few moths. |
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What are the nursing responsibilities when it comes to blood tests?
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-Assess for need to be NPO prior
-Instruct on procedure -Assess site for bleeding -Report significant findings to the MD |
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Types of Specimen collection
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stool
urine sputnum throat |
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Stool specimens
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OCCULT (guaiac test)- testing for hidden blood, does not have to be seen with the gross eye. Bleeding can occur as a result of inflammatory disease or tumors.
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Stool specimens
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STEATORRHEA- tests for FAT
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Stool specimens
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O&P ova and parasites
BUGS |
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Stool specimens
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Culture:
Viruses or bacteria ex.)Clostridium difficile must use aseptic and sterile techniques. |
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When collecting stool specimens:
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-Verify order
-Instruct patient on the procedure: -use clean commode, hat, or bedpan -void before specimen collection -no TP -medical asepsis label container wear gloves seal the container tongue blades to transfer |
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URINE SPECIMEN
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Clean Voided= routine examination
Clean-catch UTI (sterile as possible- do not touch the container, clean the penis, front to back, etc. Go a little in the toilet first Timed= start at certain time, end at certain time.usually for renal (preserative) |
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URINE SPECIMEN
What is being tested in a urine sample? |
Specific gravity- measure of solutes= 1.010-1.025
PH acidity Glucose- Diabetes Ketones- breakdown of fatty acids Protein-glomerular damage Blood-trauma or glomerular damage |
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An increase in PH in a urine sample indicates what?
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Dehydration
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A decreased in PH in a urine sample indicates what?
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overhydration
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SPUTNUM specimens:
What are they? and can it be delegated? |
Mucous secretions and okay to delegate unless obtained from a tracheal device.
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SPUTNUM specimens:
What are we testing or collecting for? |
C&S culture and sensitivity
Cytology Acid-fast bacillus (AFB) Therapy effectiveness |
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SPUTNUM specimens:
Nursing Responsibilities: |
-Mouth care prior
-Instruct cleint to breathe deeply Wear gloves and possibly mask -Early morning is best time to collect specimen _Ensure that the patient does not "spit" into container -Label and transport immediately -Document |
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When a procedure is invasive ALWAYS.........
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get a consent form
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DIAGNOSTICS- Visualization procedures:
Gastrointestinal alterations (GI) |
Proctoscopy- viewing of the rectum
Proctosigmoidoscopy- viewing rectum and sigmoid colon Colonoscopy- viewing large Bowel (standard) All of these tests look for obstructions, tumors, ulcers, inflammatory disease, or hernias. If necessary can perform biopsy at the same time. All procedures are NPO Must get a consent! |
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Diagnositics- GI alterations
Nursing Responsibilities: |
Check vital signs every 15 minutes
If Barium enema is used clients will need to expel. Intruct clients to drink LOTS of water or Barium will harden like a rock and have to be surgically removed. Instruct client to expect clay colored stool Monitor for constipation Monitor for sedation complications ABC's ALWAYS FIRST!! |
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DIAGNOSTICS- Visualization procedures:
Urinary alterations |
-Kidney's, Ureters, Bladder (KUB) x-ray looks at stated structures
-Intavenous pyleography (IVP) Invasive -Injection of a contast medium allows greater visualization of urinary function usually done w/ kidney stones) -Ultrasound- Noninvasive similar to an X-Ray Cytoscopy- Repeated UTI's invasive (bladder) - |
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Nurses Responsibilities with Gastrointestinal Alterations:
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Assess Blood Gases
Vital Signs Constipation ABC's |
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Nurse's responsibilities with Urinary Alterations:
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Always Instruct on procedure
-If medium contrast is used assess for iodine or shellfish allergies. If medium contrast is used instruct patient to expect a flushing sensation when contrast is injected IVP and Cytoscopy assess for sedation complications and bleeding |
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Diagnostics visual procedures
Cardiopulmonary alterations: |
-Electrocardiography- EKG (non invasive) Monitors electrical functions for rhythm alterations, does not show blockage.
Angiography- assesses coronary blood flow Echocardiogram- Assesses cardiac muscle function Lung scan- blood clots invasive |
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Nurses Responsibilities for cardiac alterations:
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Instruct on procedure
-Consent required for invasive tests -Monitor for site complications with invasive test Monitor for sedation complications CHECK VITALS, RESPIRATIONS FIRST!! |
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Nurses Responsibilities for cardiac alterations:
Computerized Tomography (CT) Magnetic Resonance Imaging (MRI) |
CT:
Noninvasive Unlike regular X-ray, produces 3-D images MRI: Noninvasive Offers details of each structure |
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In an MRI a patient cannot wear, what?
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metal:
hip prosthetics pacemakers earrings |
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Nuclear Imaging (PET SCAN)
Physiology of an organ |
Physiologic vs. anatomic
Radioisotope is administered which can create colored images of bodily functions Invasive Nuclear Isotopin is used |
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Diagnostics:
What is the purpose of Paracentesis? |
To remove fluid from the abdomen
-Ascites- condition in which a large amount of fluid accumulates in the abdominal cavity Nurse assists the physician |
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Diagnostics:
What is the purpose of Thoracentesis? |
To remove fluid from the lung
Nurse assists the physician Can be done for diagnostic purposes or palliative end stage cancer. Can take up to 15ml off at one time. Makes the person more comfortable. |
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Diagnostics:
Biopsy Benign Malignant |
-Benign (non cancerous)
Malignant (cancerous) Always monitor airway and for bleeding at the site |
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What vital sign changes first when the body is bleeding?
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The pulse!
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Skin Integrity and Wound Care
What is the largest organ? |
Skin. A very important role in protection
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What are some of the reasons that increase the risk for impaired skin integrity?
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-Elderly
-Restricted Mobility -Illness -Trauma |
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What is a clean wound?
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uninfected wounds in which minimal inflammation is encountered and the respiratory, alimentary, genital, and urinary tracts are not entered. Primarily closed wounds.
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Clean contaminated wounds
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surgical wounds in which the respiratory, alimentry, genital, or urinary tract has been entered. Some contamination, but no infection.
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Contaminated wounds
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open, fresh, accidental and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Contaminated wounds show evidence of inflammation.
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Dirty wounds
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Large amount of debris/infectious
gunshot, stabbing |
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What is a pressure ulcer?
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any lesion caused by unrelieved pressure that results in damage to underlying tissue.
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Specifically, what causes a pressure ulcer?
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Pressure ulcers are due to ischemia, a deficiency in the blood supply to the tissue. The tissue is compressed between two surfaces, such as the bed and the bony skeleton. When blood cannot reach the tissue, the cells are deprived of oxygen and nutrients.
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Ulcers are secondary to what?
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Ischemia
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If the skin does not blanch, another words, go from red to white is it a pressure ulcer?
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Yes. no blanching = Stage 1 pressure ulcer
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What are the risk factors for pressure ulcers?
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Friction and Shearing: common with the Fowler's position, as the body tends to slide downward toward the foot of the bed. Can damage the sacrum.
Immobility: paralysis, extreme weakness, and pain can hinder a person's ability to move. Inadequate nutrition: Prolonged inadequate nutrition causes weight loss, muscle atrophy, and the loss of subcutaneous tissue, inadequate protein contributes to ulcer formation. (Hypoproteinemia is abnormally low protein in the blood) Fecal and urinary incontinence: promotes skin maceration (tissue softened by prolonged wetting or soaking, digestive enzymes in feces, and urea in unrine, as well as gastric tube drainage. Decreased mental status Diminished sensation Advanced age Illness Excessive Body Heat |
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How do we do a risk assessment for pressure ulcers?
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Braden scale assessment is most frequently used:
Assessing on a scale of 1-4 Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear. An adult below 18 points is considered at risk. |
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What can we accomplish by using the Braden scale assessment?
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Identify patients at increased risk for pressure ulcers.
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Another words for systematically identifying clients at high risk for pressure ulcers?
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Data Collection of:
Immobility Incontinence (Moisture) Nutrition Level of consciousness (Sensory Perception) |
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Pressure Ulcer Stages:
Stage 1 |
Non blanchable erythema (a redness associated with a variety of skin rashes.
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Pressure Ulcer Stages:
Stage 2 |
Partial thickness skin loss
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Pressure Ulcer Stages:
Stage 3 |
Full thickness skin loss
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Pressure Ulcer Stages:
Stage 4 |
Full thickness skin loss
Potentially to the bone |
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When do we begin to assess for pressure ulcers?
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Assessment begins on admission to the facility.
Areas are identified and interventions are implemented. Such as Relieve pressure, Appropriate wound care, may need to consult facility wound care nurse. |
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Wound Healing
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Primary Intention healing:
When the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring. ex.) a closed surgical incision, or the use of tissue adhesive or "glue" that can be used to seal clean lacerations or incisions which may result in better appearing scars. |
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Wound Healing
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Secondary Intention Healing:
Extensive wound that has considerable tissue loss, and in which the edges cannot or should not be approximated (closed) heals by secondary intention healing. ex.)pressure ulcer. Secondary differs from primary intention healing in three ways. a.) The repair time is longer. b.) the scarring is greater. c.) the susceptibility to infection is greater. These types of wounds are left open for 3 to 5 days to allow edema or infection to resolve or exudate the drain and are then closed with sutures, staples, or adhesive skin closures, and heal by TERTIARY intention. |
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Wound Healing:
Tertiary Intention Healing (Delayed Primary Intention) |
Initially left open
Edema, infection, or exudate resolves. Then closed |
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Phases of Wound Healing:
When is the inflammatory phase of wound healing initiated? |
Immediately after injury and lasts 3-6 days.
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What are the two major processes occurring during the inflammatory phase?
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Hemostasis (cessation of bleeding, fibrin formation, and clotting) and phagocytosis (clean up crew)
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What is the second phase in wound healing?
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Proliferative phase, the second phase in wound healing, extends from day 3 or 4 to about day 21 post injury. Collagen adds strength to the wound. Granulation begins.
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What is the third and final phase of wound healing?
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21 days-2years.
Would remodeling and contracting. Scars can develop. |
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What is exudate?
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Material such as fluid and cells that has escaped from blood vessels during the inflammatory process and is deposited on tissue.
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3 major types of exudate:
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SEROUS EXUDATE: consists chiefly of serum, very few if any cells. (the clear portion of blood)
ex.) fluid in a blister from a burn Normal healing process |
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3 major types of exudate:
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PURULENT EXUDATE:
thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria. Pinkish drainage can be yellow, it is infected, ugly, not healing well |
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3 major types of exudate:
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SANGUINEOUS (hemmorrhagic) exudate:
consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma. This type of exudate is frequently seen in open wounds. Clear and blood tinged drainage. or bright red Normal healing process |
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Mixed exudate
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Serosanguineous- clear and blood tinged drainage
Purosanguineous- pus and blood |
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Complications of wound healing:
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Hemorrhage: Some escape of blood from a wound is normal. Hemorrhage (massiave bleeding) however, is abnormal
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Complications of wound healing:
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Infection: Contamination of a wound surface with microorganisms is an inevitable result. But it can impair wound healing and lead to infection.
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Complications of wound healing:
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Dehiscence: partial or total rupturing of a sutured wound. Usually involves an abdominal wound in which the layers below the skin also separate. (limit walking must be treated.)
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Complications of wound healing:
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Evisceration: the protrusion of the internal viscera through an incision.
Down to organs. (medical emergency) |
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Factors affecting Wound Healing:
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-Age
-Nutritional status -Lifestyle- unhealthy? -Medications |
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Assessment Data for untreated wounds:
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-what is the location of the wound
-what is the extent of the tissue damage -what is the wound length, width, and depth -Is it bleeding -Does there appear to be any foreign bodies -Are there any associated injuries -When was the last tetanus shot? |
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Assessment data for treated wounds:
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-What is the appearance
-What is the size -Drainage (Document each drain separately because if one has less than 25mm. they will take it out. Is there any swelling present? -Pain? -Status of drains or tubes. |
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Assessment for pressure ulcers:
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-What is the location of the ulcer related to bony prominence
-Size of ulcer in centimeters including length (head to toe), width (side to side), and depth. -Presence of undermining( a wound looks like a dime but is much bigger on the inside) or sinus tracts -Color of the wound bed -Location of necrosis (yellow, dead tissue) or eschar ( black dead tissue) -Condition of the wound margins -Integrity of surrounding skin -Clinical signs of infection (heat, redness, swelling, pain) |
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Assessment of Pressure Sites:
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Inspect pressure area for discoloration and capillary refill or blanche response
Inspect pressure areas for abrasions and excoriations Palpate the surface temperature over the pressure area sites Palpate bony prominences and dependent body areas for the presences of edema |
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Nursing Diagnosis:
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Risk for Impaired Skin Integrity
Impaired skin integrity Risk for Infection Pain |
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Goals in planning client care:
Risk for impaired skin integrity: |
Maintain skin integrity
avoid or reduce risk factors |
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Goals in planning client care:
Impaired skin integrity: |
Progressive wound healing
Regain intact skin |
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Goals in planning client care:
Client and family education: |
assess and treat existing wound
prevention of pressure ulcers |
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What are some measures that we as nurses can take to prevent pressure ulcers?
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-provide nutrition
maintain skin hygiene avoid skin trauma provide support devices |
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How can we provide nutrition?
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Proper fluid intake
Enough protein, vitamins, and zinc. Dietary consultation Weight/Lab data monitoring |
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How do we maintain skin hygiene?
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Mild cleansing agents
Avoid hot water Moisturizing lotions/skin protection Reduce irritants |
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How doe we avoid skin trauma?
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Smooth, firm surfaces...no creases in bed no bunched up blankets underneath them in the wheelchair.
Semi-Fowler's position Frequent weight shift Q2hr. turns Exercise and ambulation Lifting devices Reposition q 2 hours Turning schedule |
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What are some of the supportive devices?
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Mattresses
Beds Wedges, pillows Miscellaneous devices |
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Do we ever use peroxide when treating?
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NO, it kills healthy tissues. Just saline treatment.
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How do we treat pressure ulcers?
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Minimize direct pressure
Schedule and record position changes Provide devices to reduce pressure areas Clean and dress the ulcer using surgical asepsis Never use alcohol or hydrogen peroxide Obtain C & S, if infected Teach the client Provide ROM exercise |
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What is the RYB Color Guide for wound care?
RED |
protect
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YELLOW
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cleanse
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BLACK
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debride
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RYB COLOR GUIDE FOR WOUND CARE:
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RED=late regeneration phase of tissue repair. (developing granulation tissue) They need to be protected to avoid disturbance to regenerating tissue. Gently cleanse, protect skin with alcohol-free barrier film.
Yellow-liquid to semi liquid slough, accompanied by purulent drainage or previous infection. Cleanse wound to remove nonviable tissue. Moist to moist normal saline dressing, and irrigating the wound. Black-Thick necrotic tissue, or eschar. Require debridement, or removal of nonviable tissue before healing can begin. We treat the most serious colors first. Black, then yellow, then red. |
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Types of wound dressing:
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Transparent: burn
Impregnated nonadherant: Hydrocolloids: water proof adhesive wafers. 3-7 days to be worn . Clear absorbent acrylic:Transparent absorbent wafer tp be worn 5-5 days. Hydrogel:Glycerin, water based jelly like sheets Alginate:Non adherent dressings |
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Types of Bandages: (Dressings)
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Gauze: protects the wound and the muscles around it. used to retain dressings on wounds. Used on hands and feet.
Elasticized: Provide pressure to an area. Improve venous circulation in legs. Binders: Support large areas of the body. Triangular arm sling; straight abdominal binder. |
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What are the physiological effects of heat?
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Vasodilation
Increases capillary permeability Increases cellular metabolism Increases inflammation Produces sedative effect |
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Indications for heat:
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-Muscle spasms
Inflammation Pain Contracture Joint Stiffness |
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Physiologic effects of cold...
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vasoconstriction
decreases capillary permeability decreases cellular metabolism slows bacterial growth decreases inflammation local anesthetic effect |
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Indications for cold:
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muscle spasms
inflammation pain traumatic injury |
