N15 Week 3

Front 1

Jackson-Pratt drain

Back 1

Are portable, self-contained suction units that connect to drainage tubes within the wound and provide constant low-pressure suction to remove and collect drainage without wall suction.
used when small amounts (100 to 200 mL) of drainage are anticipated.

Front 2

Hemovac drainage system

Back 2

Wound drainage.
Can be used for larger amounts (up to 500 mL) of drainage.

Front 3

Penrose drain

Back 3

Drainage devices, When drainage is expected within the wound. This soft rubber drain is a soft tube that can be "advanced" or pulled out in stages as the wound heals from the inside out. A safety pin is inserted through this drain to prevent the tubing from migrating into the wound.

Front 4

Types of Wound Drainage:
Serous

Back 4

Appearance: Clear, watery plasma

Front 5

Types of Wound Drainage:
Purulent

Back 5

Appearance:Thick, yellow, green, tan, or brown: indicates infection process

Front 6

Types of Wound Drainage:
Serosanguineous

Back 6

Appearance: Pale, red, watery: mixture of serous and sanguineous

Front 7

Types of Wound Drainage:
Sanguineous

Back 7

Appearance: Bright red: indicates active bleeding

Front 8

Purpose of Dressings

Back 8

•Protection from outside contaminants, further tissue injury, and spread of microorganisms
•Increased patient comfort
•Control of bleeding (hemostasis) and drainage
•Support or immobilize a body part
•Wound debridement (moist-to-dry dressings)

Front 9

Dressing changes allow the caregiver the opportunity to assess:

Back 9

•The wound
•The sutures or staples
•The drain sites (if used)
•The skin around the wound
•The patient's response to the wound

Front 10

•Acute wounds

Back 10

(caused by trauma or surgery) follow the normal healing process in an orderly and timely way.

Front 11

•Chronic wounds

Back 11

(peripheral vascular venous ulcers, lower extremity arterial ulcers, neuropathic ulcers, and pressure ulcers) heal slowly, repair does not occur, and return to normal function is slowed.

Front 12

primary intention

Back 12

A clean surgical incision is an example of a wound without tissue loss. The skin edges are approximated or closed, and the risk of infection is low because the wound is uncontaminated by microorganisms. Healing occurs quickly. Inflammation typically subsides in < 24 hours, the wound fills with epidermal cells, and resurfacing occurs between 4-7 days.

Front 13

secondary intention.

Back 13

Examples of tissue-loss wounds include burns, pressure ulcers, or severe lacerations, are wounds that heal by secondary intention. The wound remains open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention, and thus the chance of infection is greater. These wounds require ongoing wound care (a moist environment) to support wound healing.

Front 14

Moist dressings

Back 14

often used to help heal full-thickness deep wounds. Granulation tissue and new capillary networks must form to fill in the defect.

Moist-to-dry dressings are best used with necrotic, infected wounds requiring debridement.

Front 15

Normal Vital Signs:
Newborn

Back 15

Temp: 98.6-99.8 F/ 37-37.7 C
Pulse Rate: 120-160
Resp Rate: 30-80
BP: Systolic: 50-52
Diastolic: 25-30
Mean: 35-40

Front 16

Normal Vital Signs:
3 yr.

Back 16

Temp: 98.5-99.5 F/ 36.9-37.5 C
Pulse Rate: 80-125
Resp Rate: 20-30
BP Systolic: 78-114
Diastolic: 46-78

Front 17

Normal Vital Signs:
10 yr

Back 17

Temp: 97.5-98.6 F/36.3-37 C
Pulse Rate: 70-110
Resp Rate: 16-22
BP: Systolic: 90-132
Diastolic: 5-86

Front 18

Normal Vital Signs:
16 yr

Back 18

Temp: 97.6-98.8 F/36.4-37.1 C
Pulse Rate: 55-100
Resp Rate: 15-20
BP: Systolic: 104-108
Diastolic: 60-92

Front 19

Normal Vital Signs:
Adult

Back 19

Temp: 96.8-99.5 F/36-37.5 C
Pulse Rate: 60-100
Resp Rate: 12-20
BP: Sytstolic: <120
Diastolic: <80

Front 20

Normal Vital Signs:
Older Adult

Back 20

Temp: 96.5-97.5 F/35.9-36.3 C
Pulse Rate: 60-100
Resp Rate: 15-25
BP: Systolic: <120
Diastolic: <80

Front 21

The bladder

Back 21

normally holds up to600 mL of sterile urine. However, desire to urinate can be sensed w/urine amounts (150 to 200 mL in an adult and 50 to 100 mL in a child). Adult urinary output avgs 1200 to 1500 mL in 24 hrs. Min avg hourly output is 30 mL. Normal urine is clear, straw-colored, & slightly acidic.

Front 22

The bladder

Back 22

normally holds up to600 mL of sterile urine. However, desire to urinate can be sensed w/urine amounts (150 to 200 mL in an adult and 50 to 100 mL in a child). Adult urinary output avgs 1200 to 1500 mL in 24 hrs. Min avg hourly output is 30 mL. Normal urine is clear, straw-colored, & slightly acidic.

Front 23

Effects of age on urinary elimination

Back 23

•Infants and young children are unable to concentrate urine and reabsorb water effectively.
•Before 18 to 24 months, children are unable to control urination.
•Urine concentration declines and urination frequency increases with age.
•Because the bladder cannot contract as effectively, an older person often retains urine in the bladder after voiding (residual urine). This places the patient at increased risk for bacterial growth and development of urinary tract infections (UTIs).

Front 24

Effects of age on urinary elimination

Back 24

•Infants and young children are unable to concentrate urine and reabsorb water effectively.
•Before 18 to 24 months, children are unable to control urination.
•Urine concentration declines and urination frequency increases with age.
•Because the bladder cannot contract as effectively, an older person often retains urine in the bladder after voiding (residual urine). This places the patient at increased risk for bacterial growth and development of urinary tract infections (UTIs).

Front 25

Sociocultural effects on urinary elimination

Back 25

Culture and gender may affect degree of privacy desired by a person during urination.

Front 26

Sociocultural effects on urinary elimination

Back 26

Culture and gender may affect degree of privacy desired by a person during urination.

Front 27

Psychological effects on urinary elimination

Back 27

•Anxiety & stress may affect sense of urgency, frequency of urination, & completion of urination b/c of tense ab muscles.
•A pt uncomfortable phys or psych may be unable to relax the ext. urethral sphincter (voluntary m.) and therefore will be unable to void.
•Distraction measures, turning on a sink faucet so the patient can hear water running, may help pt void.
•You can promote comfort measures to relieve anxiety by: ◦Providing privacy
◦Offering the pt a warm bedpan
◦Assisting the pt into a normal voiding position (standing for a man, squatting for a woman)
◦Reducing pain by giving prescribed analgesic before helping pt walk to the bathroom

Front 28

Psychological effects on urinary elimination

Back 28

•Anxiety & stress may affect sense of urgency, frequency of urination, & completion of urination b/c of tense ab muscles.
•A pt uncomfortable phys or psych may be unable to relax the ext. urethral sphincter (voluntary m.) and therefore will be unable to void.
•Distraction measures, turning on a sink faucet so the patient can hear water running, may help pt void.
•You can promote comfort measures to relieve anxiety by: ◦Providing privacy
◦Offering the pt a warm bedpan
◦Assisting the pt into a normal voiding position (standing for a man, squatting for a woman)
◦Reducing pain by giving prescribed analgesic before helping pt walk to the bathroom

Front 29

Muscle tone effects on urinary elimination

Back 29

•Weak ab/pelvic floor muscles impair bladder contraction.
•Decreased muscle tone caused by immobility, childbirth, or trauma increases risk for urinary incontinence.
•Muscle tone may be lost because of cont. indwelling catheter drainage.
•can be taught exercises to strengthen these muscles and increase the ability of the bladder to contract and promote better control of the external urethral sphincter.

Front 30

Muscle tone effects on urinary elimination

Back 30

•Weak ab/pelvic floor muscles impair bladder contraction.
•Decreased muscle tone caused by immobility, childbirth, or trauma increases risk for urinary incontinence.
•Muscle tone may be lost because of cont. indwelling catheter drainage.
•can be taught exercises to strengthen these muscles and increase the ability of the bladder to contract and promote better control of the external urethral sphincter.

Front 31

Fluid intake effects on urinary elimination

Back 31

•If fluids, electrolytes, and solutes are bal.'d, ↑ fluid intake leads to↑ urine production.
•Alcohol halts the rel.of ADH, thus promoting urine production.
•Fluids cont. caffeine ↑ urination freq.
•High-fluid foods may ↑ urine production.
•Unless a pt is on restricted fluid intake, she should drink at least 1500 mL of fluids per day. If a pt is consuming less than 1500 mL per day, a care plan s/b devel. w/pt to ↑ fluid intake. Pts w/urinary problems may hesitate to take fluids for fear of incontinence and/or ↑ urinary freq. Educ. on the imp of fluid intake in maintaining urinary and overall health is vital.

Front 32

Disease condition effects on urinary elimination

Back 32

•Acute renal disease reduces urine volume.
•Chronic renal disease initially results in more dilute urine.
•Febrile conditions reduce the volume and increase the concentration of urine.
•Spinal cord injuries cause nerve injury, altering the ability to sense bladder fullness and control urination.
•Any condition that impairs mobility may affect the ability to sit on a toilet and void normally: ◦Rheumatoid arthritis
◦Degenerative joint disease
◦Parkinsonism

•Diabetes mellitus may result in voiding large amounts of urine.
•Multiple sclerosis may alter bladder function, leading to incontinence or urinary tract infections.

Front 33

Surgical effects on urinary elimination

Back 33

•Loss of body fluids during surgery results in reduced urinary output.
•Anesthetics and pain-killing drugs reduce urinary output.
•Local trauma during abdominal surgery may obstruct urine flow.

Front 34

Medication effects on urinary elimination

Back 34

•Diuretics prevent reabsorption of water and some electrolytes, which increases urination. Patients taking diuretic medications should receive them early in the morning so as to reduce the need to void during the night.
•Some drugs change urine color.

Front 35

Diagnostic effects on urinary elimination

Back 35

•Intravenous pyelograms may result in hypersensitive reactions and/or acute renal failure.
•Cystoscopy may cause edema of the urethral canal and/or bladder sphincter spasms, which may result in decreased ability to pass urine and/or the passing of red/pink urine.