248 Test 2
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What are the three layers of the skin?
- Stratum Corneum
What are three pressure related factors that contribute to the development of pressure ulcers?
- Pressure intensity
- Pressure duration
- Tissue Tolerance
What are risks for pressure ulcers?
- Impaired sensory perception
- Alterations in LOC
- Impaired mobility
What are differences in assessing pressure ulcers in darker skinned individuals?
- Use natural or halogen lighting
- color will be darker than the surrounding skin
- skin will feel warmer in beginning of sore formation, will get cooler as circulation is lost
- skin will feel softer or have edema
- skin will appear taught, shiny or scaly
What are the stages of pressure ulcers?
- I - intact skin with nonblanchable redness
- II - partial thickness skin loss involving epidermis, dermis or both
- III - full thickness tissue loss with visible fat
- IV - full thickness tissue loss with exposed bone, muscle or tendon
- Suspected deep tissue injury - depth unknown
- Unstagable - depth unknown
What are factors that increase the risk of pressure ulcers in older adults?
- Age related skin changes (reduced skin elasticity, decreased collagen and thinning of underlying muscles and tissues)
- co-morbidities and polypharmacy
- slow healing
- hypodermis thin
- nutritional deficiencies
What are the two scales for measuring pressure ulcers?
- Norton - score of 14 or less is at risk
- Braden - lower score means greater risk, 18 or less is at risk
What areas are measured on the Braden Scale?
- sensory perception
- friction and shear
What factors affect pressure ulcer healing?
- nutrition (need protein and calories)
- tissue perfusion
- psychosocial impact (affect of wound on body image, mobility)
What are primary, secondary and tertiary intention?
- Primary - Wound is closed. Example is surgical incision that has been sutured or stapled. heals by epithelialization and quickly with minimal scar formation
- Secondary - Wound edges are not approximated and healing occurs by granulation. Example is pressure ulcer, surgical wound with tissue loss.
- Tertiary - Wound left open for several days then edges are approximated. Example is wound that is contaminated (after trauma). Left open to clean and drain and closed later.
What is the inflammatory stage of wound healing?
Lasts 1-3 days, is the body's immediate reaction. In a clean wound this phase accomplishes control of bleeding and establishes a clean wound bed.
What is the proliferative stage of wound healing?
Occurs in days 3-24 after wound formation. Main activities are filling of wound with granulation tissue, contraction of wound and resurfacing by epithelialization. Fibroblasts synthesize collagen.
What is the remodeling stage of wound healing?
Takes place for up to a year after wound formation. Collagen fibers undergo remodeling or reorganization before assuming their normal appearance.
When is the highest risk of a surgical wound hemorrhaging?
24-48 hours after surgery
What needs to be checked in assessment of wounds?
- character of drainage
- drains, closures
What needs to be assessed with wound drainage?
- amount (# and weight of dressings)
- Descriptors - serous, serosanguinous, sanguinous, purulent
What needs to happen before a wound is cultured?
It must be cleaned with saline
What are complications related to wounds?
- Dehiscence - partial separation of edges
- Evisceration - total separation with organ protrusion
What are the purposes of dressings?
- Protection from microorganisms
- aid in hemostasis
- promotion of healing by absorbing drainage and debriding a wound
- supports wound site
- protects client from seeing wound
- thermal insulation for wound
- provides moist environment
What are 5 types of dressings?
- 1. Gauze - dry sterile
- 2. Gauze - wet sterile (wet to dry - a form of mechanical debridemant, wet to wet - topped with dry, to keep moist for healing
- 3. Hydrocolloid - protects wound from surface contamination
- 4. hydrogel - maintains a moist surface to support healing
- 5. Wound VAC - uses negative pressure to support healing
What are the benefits of hydrocolloid dressings?
- The dressing part forms a gel that keeps the wound moist and supports healing in clean, granulating wounds. They protect the wound from contamination and autolytically debride necrotic wounds.
- Most useful in shallow to moderately deep dermal ulcers.
What are the benefits of hydrogel dressings?
- They are soothing and reduce pain, provide a moist environment, debride the wound by softening necrotic tissue and are easy to remove.
- They are used in partial-thickness to full thickness wounds, deep wounds with some exudate, necrotic wounds, burns and radiation damaged skin.
What is the benefit of VAC?
- it applies negative pressure to draw edges of wound together, evacuates wound fluids, stimulates granulation, reduces bacteria and maintains moist environment.
- It is used for acute and chronic wounds.
What are the principles of wound cleaning?
- start in the middle and work out
- never go back to middle with same swab
- usually dome 3 times
- may irrigate to flush debris
- assess for tunnelling
What are methods of debridement?
- chemical - enzymes, Dakins
- mechanical - wet to dry, don't do on clean, granulating wounds
- autolytic - use of a synthetic dressing with enzymes (hydrocolloid)
- Surgical - use of a scalpel or scissors
What is the normal bladder capacity and when is the need to urinate sensed?
Normal capacity is 600ml, sensed at 150-200ml
What are factors influencing urinary patterns?
- disease conditions - diabetes, prostate etc
- sociocultural norms - need for provacy
- psychological factors - anxiety, emotions
- fluid balance - between retention and excretion
- surgical procedures - stress response --> increased ADH
- medications - diuretics
What is urinary retention?
An accumulation of urine due to the inability of the bladder to empty. Normal amount voided is about 150ml, their amount is 50ml. Overflow can occur. Concern is infections, common in post surgery patients or hypertrophy of prostate
What are concerns with urinary tract infection?
May occur from catheterization, accounts for 40% of HAI's. May lead to sepsis. More common in womenthan men
What is a nephrostomy?
It is a urinary diversion where a tube is placed into the renal pelvis.
What is an ileal loop?
a part of the patient's ileum is taken and the ureters are implanted into it. It can either be made into a continent diversion (needing intermittent catheterization) or an incontinent diversion (with an external pouch)
What is a suprapubic catheter?
A catheter left in place above the pubic bone that comes to a bag
What are parts of physical assessment for urinary concerns?
- skin and mucosal membranes
- urethral meatus - check for discharge
- urine and urine testing
- I and O
What are reasons for inserting a catheter?
- if unable to control micturation
- urinary obstruction or retention
- relieve distention
- assess urine output in unstable patients
- skin conditions or wounds irritated by urine contact
What are primary considerations with catheterization?
- maintain closed system
- hang bag on bed-frame, not side rail, not floor
- never raise bag above level of bladder
- empty bag at spigot
- obtain urine specimen at specific port in catheter using sterile technique
- check tubing for kinks, bends etc.
- maintain good perineal and catheter hygiene
What are general nursing goals related to bowel elimination?
- to help promote lifelong health habits that facilitate regular bowel elimination
- alleviate symptoms and prevent complications due to bowel elimination problems
What are factors that affect bowel elimination?
- Age - elderly are at increased risk of incontinence and constipation
- Diet and fluid intake - fiber!
- Physical activity - activity promotes peristalsis
- Psychological factors - stress increases peristalsis, depression reduces
- Personal habits - privacy
- Position - immobilization, laying supine makes it impossible to contract muscles needed
- Pregnancy - constipation and hemorrhoids
- Surgery and anesthesia leading to paralytic ileus
- diagnostic tests
What are common bowel problems?
- fecal impaction
- diarrhea - c.difficile
What is a stoma, colostomy and ileostomy?
- Stoma - artificial opening in the abdominal wall
- Colostomy - colon is brought through the abdominal wall
- Ileostomy - ileum is brought through the the abdominal wall.
What is a loop colostomy?
A temporary colostomy - usually done in emergency - done in the transverse colon. Two openings - one for stool and one for mucus.
What is an end colostomy?
Proximal end forms stoma and distal end is either removed or forms "Hartman's pouch" (useless). Often a result of colorectal cancer or diverticulitus.
What is a double barrel colostomy?
The bowel is surgically cut and both ends are brought through the abdomen. The proximal end is for stool, distal is nonfunctioning.
What are assessment parts related to bowel elimination?
- lab data
- diagnostic examinations
- stool characteristics
What are common nursing diagnoses related to bowel elimination?
- bowel incontinence
- constipation (or risk of)
- toileting self care deficit
What are areas for potential interventions in chronic constipation of older adults?
- evaluate medications
- increase activity
- assess hydration
- increase fiber to 20gm/day
- caution with stimulant laxatives
What are the steps for administering an enema?
- put on clean gloves and provide privacy, gather materials
- assess for abdominal distention and bowel sounds
- place client on left side in sims position
- insert lubricated tip 3-4 inches
- open clamp and allow to flow, raise to appropriate height.
Wat should be done with an impaction?
digital removal may be performed if enemas fail. May cause vagal nerve stimulation so monitor heart rate, need provider order
What are physiological factors affecting oxygenation?
- decreased oxygen carrying capacity - anemia and inhalation of toxic substances (CO)
- decreased inspired oxygen - airway obstruction, decreased environmental O2, decreased inspiration (drugs)
- hypovolemia - decreased circulating blood (shock, severe dehydration)
- increased metabolic rate - pregnancy, wound healing, fever, exercise
What are conditions affecting chest wall movement?
- musculoskeletal abnormalities
- neuromuscular diseases - myansthenia gravis, guillain-Barre, polio
- CNS alterations - medulla or spinal cord affected
- chronic disease
What are three respiratory alterations?
- hypoxia - inadequate tissue O2 at cellular level
What are oxygenation changes in older adults?
- TB tests are frequently false positive because of changes in immune system
- mental status changes are the first sign of respiratory distress
- Older adults may not complain of dyspnea until it affects ADLs
- changes in cough lead to retention of secretions, airway plugging and atelectasis. Caution should be used with cough suppressants.
What are early and late signs of hypoxia?
- early - tachycardia, changes in mental status or LOC, restlessness
- late - hypotension, bradycardia, cyanosis, shock
What factors should be included in an assessment of oxygenation?
- respiratory infections
- health risks
What are diagnostic tests related to oxygenation?
- chest x ray
- tb testing
- thoracentesis - perforation of chest wall and pleural space and gathering of plural fluid
- pulmonary function tests
- diagnostic blood tests
- bronchoscopy - looking at bronchi with a fiberoptic scope, specimen is obtained
- ventilation scan
- sputum specimen
What are nursing diagnosis related to oxygenation?
- activity intolerance
- impaired gas exchange
- ineffective airway clearance
- ineffective breathing pattern
When does suctioning need to be done?
When patient is unable to clear airway or cough effectively
What is the procedure for airway suctioning?
- sterile procedure
- suction set at 100-150mmHg
- insert catheter, suction intermittantly for 10-15 seconds, rotate slowly and withdraw
- monitor patient for hypoxia, hypotension, arrythmias, trauma, irritation
What is vagal stimulation?
- potentially hazardous complication from suctioning, can lead to bradycardia
- (Vagus nerve is 10th cranial, has sensory motor functions and a wide distribution)
What are three types of artificial airways and when are they used?
- used for patients with decreased consciousness or airway obstruction
- Oral airway - displaces tongue
- endotrachial airway - placed for a short term airway to assist with ventalation
- tracheostomy - surgical incision providing a longterm airway
What are two ways to maintain and promote lung expansion?
- Positioning (every 2 hours) - semi-fowlers or Fowlers optimal
- Incentive spirometry
What are purposes of chest tubes?
- to remove air and fluid
- to prevent air or fluid from reentering the pleural space
- to reestablish normal pulmonary pressures
What are nursing interventions for chest tuber?
- maintain secure, airtight seal
- maintain underwater seal
- monitor and secure all connections
- observe for bubbling
- monitor tubing
- record output
- monitor patient
- dressing changes per policy
What are O2 levels of room air, nasal cannula, simple mask, venturi mask and nonrebreather?
- room air - 21%
- nasal cannula - 1-6lpm, 24-44% o2
- simple mask - 5-8lpm, 40-60% O2 (estimated)
- Venturi mask - 4-12 lpm, 24-60% O2 (more precise)
- Nonrebreather 6-10 lpm, 60-95% O2
What are restorative care techniques for oxygenation?
- hydration - thin secretions
- coughing - cascade and huff
- respiratory muscle training
- breathing exercises - pursed lip, diaphragmatic
What are objective lab results for nutrition?
- Plasma proteins - pre-albumin, albumin, transferrin, iron binding capacity
- Other indicators - urinalysis, stool, h&h, blood glucose, BUN, creatinine, electrolytes
What are aspiration precautions for a patient with dysphagia?
- promote safety, dignity and independence
- speech and swallow consult
- patient in upright position, tuck chin, food in correct side of mouth
- food must be correct consistency
- feed slowly with small bites
- provide rest periods
What is the dietary progression for a patient with dysphagia?
- clear liquids
- full liquids
- mechanical soft
- soft/low residue
What is the difference between enteral nutrition ad total parenteral nutrition?
- EN - provides nutrition to the GI tract via tubes
- TPN - provides nutrition requirements IV (IV if under 10% dextrose or central line if over)
What are the three types of enteral feedings?
- Polymeric - Whole nutrient formulas (blenderized or Ensure)
- Modular - single nutrient, not complete (protein, glucose)
- Elemental - predigested - illness specific
How do you start enteral feedings?
Full strength, slow rate. Increase every 8-12 hours and assess for intolerance/complications
What are complications of tube feedings?
- pulmonary aspiration
- bacterial contamination
- tube occlusion
- delayed gastric emptying
What are ways to check tube placement?
- x-ray (best)
- ph of gastric aspirate under 4
- aspirate color
- NOT auscultation
What is the procedure for administering TPN via central line?
- 24 hour infusion with contents double checked by 2 RNs
- IV bag and tubing changed every 24 hours
- Tubing and ports used for TPN and lipids NOT accessed for any reason
- Dedicated and labeled port
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