NU 226: INTRODUCTION TO NURSING THEORY AND PRACTICE Exam III Study Guide Chapter Chapter 44 Chapter 48 Chapter 41 Chapter

41 Chapter 43 Topic Nutrition Skin Integrity and Wound Care Fluid, electrolytes, acid and base IV Therapy and Blood transfusions Pain management Medication calculations Total APPROXIMATE number of questions 8 10 10 8 10 4 50

General Reminders: There is a lot of information in the skills boxes. Unless otherwise stated, review these for the critical decision points, and at the end of each you should be familiar with the Unexpected Outcomes and Interventions.

Chapter 41: Fluid, Electrolytes, Acid-Base balance and IV therapies

Distribution of body fluids

Movement of body fluids

Type of Movement Osmosis Definition/Example Movement of a solvent across a semi-permeable membrane from an area of lesser to one of greater concentration. Random movement of a solute through a semi-permeable membrane from higher to lower concentration. Example oxygen & carbon dioxide Movement of water and diffusable substances across a membrane together, under pressure, from higher to lower pressure Movement of ions against osmotic pressure to an area of higher pressure. Takes energy.

Diffusion

Filtration Active transport

 Regulation of body fluids, electrolytes and acid-base balance

Normal range and function for each electrolyte (table 41-1) Specifically, potassium, sodium and magnesium

Electrolyte imbalances o Focus the sodium (Na) (hyper/hyponatremia) and potassium (K) (hyper/hypokalemia). (table 41-3)

Lab values and treatments of Hypokalemia, hyperkalemia, hyponatremia and hypernatremia

o Hypokalemia Lab Values o Decrease in K+ in blood/extra-cellular fluid, Lab: K below 3.5 mEq/L Treatments o Replacement of K+: Oral or IV Hyperkalemia Lab Values o Lab: K Above 5mEq/L (increase of K+ in serum: extra cellular fluid.) Treatments o IV /parenteral therapy to shift K+ into cells (Nabicarb, insulin, hypertonic dextrose), o Kayexalate: oral or enema that eliminates excess K+ Hyponatremia Lab Values o Lab: Serum Na+ below 135 mEq/L (Less than normal concentration of sodium in the blood - ECF). Treatments o Goal: restore normal sodium levels Excess fluid with decrease Na+=restricting fluids Sodium replacement through diet Normal fluid balance with decreased Na+= isotonic saline (0.9% NaCl) or lactated ringers solution. Hypernatremia Lab Values o Lab: Serum Na+ greater than 145mEq/L Treatments o Fluid replacement therapy with isotonic solution (0.9%NaCl) or hypotonic solution (0.45% NaCl) o Sodium restricted diet Prevent More Sodium o P=processed foods ( canned, frozen) o M= moo (milk, cheeses, butter, ice cream) o S=sodium ( salty: nuts, chips, ham, bacon)

Clinical manifestations to know for each of the following:

o o o o Hypokalemia muscle weakness, cardiac dysrhythmias Hyperkalemia hyperkalemia, nausea, vomiting and cardiac dysrhythmias Hyponatremia abdominal cramps, nausea, vomiting, diarrhea, tachycardia and postural hypotension Hypernatremia Thirst, dry mucous membranes, fever, postural hypotension

Safety considerations when administering intravenous potassium

o Safety measures!!! Never give IV PUSH Always dilute as directed Be sure KCL mixes thoroughly Do not add to a hanging container Monitor clients ECG

Regulation of Acid Base balance - pH, Buffers o Normal values of ABG (arterial blood gas) - specifically, the pH, CO2 and HCO3 levels

o Be able to identify types of imbalances (pp. 977) Respiratory Acidosis o PaCO2, excess carbonic acid, H+ pH 7.35 o Results from HYPOventilation o Neuro changes o Hypoxemia due to respiratory depression o Hyperkalemia and hypercalcemia o Kidneys compensate by conserving bicarb and releasing H+ in urine o Process may take up to 24 hrs Respitatory Alkalosis o PaCO2 and pH above 7.45 o Results from HYPERventilation o Anxiety, asthma, salicylate overdose o pH may return to normal before kidneys can respond o Kidneys will compensate increase excretion of bicarb Metabolic Acidosis o Results from high acid content in blood (pH7.35), causes loss of bicarb (bicarb deficit) o Related to: severe diarrhea, renal disease, starvation, diabetic ketoacidosis, drug use o Calculating the anion gap helps identify cause (see Table 41-6) o Respiratory compensation: CO2 excretion by resp rate/depth Metabolic Alkalosis o Result of heavy loss of acid or bicarb levels o Related to: vomiting and gastric suctioning, overcorrection of met acidosis, K+ deficiency, thiazide therapy, excess aldosterone o Respiratory compensation: resp rate, renal loss of bicarb (if no renal disease)

Review imbalances (table 41-5) broad categories of each type of imbalances. (You will not be tested on physical exam findings of these imbalances or anion gaps)

Assessment risk factors (summary on slides)

o o o o o o o Pathologies that affect homeostatic regulators of fluid balance Diabetes, congestive heart failure, renal failure Abnormal losses of body fluids Prolonged vomiting, diarrhea, draining wounds, Burns , trauma Therapies that disrupt fluid, electrolyte balance Meds, (diuretics, steroids), IVs, blood transfusions.

Assessment - prior medical history (p. 979-980) Specifically, be familiar with the following general condition and how it may affect fluid and electrolytes o Cardiovascular Cardiovascular disease may result in a diminished cardiac output, which reduces kidney perfusion, causing the client to experience a decrease in urinary output. The client will retain sodium and water, resulting in circulatory overload, and run the risk of developing pulmonary edema. Renal Kidney disease alters fluid and electrolyte balance by causing an abnormal retention of sodium, chloride, potassium, and water in the extracellular compartment. The plasma levels of metabolic waste products such as blood urea nitrogen (BUN) and creatinine are elevated because the kidneys are unable to filter and excrete the waste products of cellular metabolism. Metabolic acidosis results when hydrogen ions are retained due to decreased renal function. Because of impaired renal function, the usual renal compensatory mechanisms such as bicarbonate reabsorption are not available, so the body loses ability to restore normal acid-base balance. Respiratory Many alterations in respiratory function predispose the client to respiratory acidosis, for example, changes involved in pneumonia and sedative overdose interfere with the elimination of carbon dioxide. Pneumonia causes pulmonary congestion,which leads to CO retention fromhypoventilation. Cardon dioxide is retained during hypoventilation. As the cardon dioxide continues to build up in the bloodstream, the bodys compensatory mechanisms can no longer adapt and the pH decreases. Similarily, hyperventilation that occurs with conditions such as fever or anxiety causes the client to experience respiratory alkalosis by blowing off too much carbon dioxide with the increased respiratory rate. Environment factors extreme temp excessive exercise

Assessment - environmental factors information on the slides

o

Assessment - medications (Box 41-2) Specifically, be familiar with the effects of the following medications:
o o o Diuretics (Lasix/furosemide) Respiratory depressants (opiods) Antibiotics Nephrotoxicty of Vancomycin

Assessment - physical examination

o Daily weights; Same time & scale, after client voids, calibrate scale, same amt clothes or sheets on bed scale Intake and output: Hourly/24 hour, when important, all sources Laboratory studies: provide obj data.

o o

Daily weights, intake/output and Box 41-3

Fluid disturbances: FVD and FVE (Table 41-8) know the definition, possible causes and clinical manifestations of each of these disturbances. On table 41-8, pay particular attention to the cardiovascular system, respiratory system and renal systems.

Implementation - enteral replacement , restricting fluids, parenteral fluids, TPN, IV therapy o Oral replacement may be contraindicated o Feeding tubes: gastrostomy, jejunostomy, nasogastric o Restriction of fluids: FVE, types of fluids (jello, ice chips, popsicles), divide over 24 hours, frequent mouth care o Parenteral replacement of fluids/electrolytes: o Total parenteral nutrition: Nutritionally adequate hypertonic solution via central IV catheter Fluid restriction (from class and slides) o As a nurse what do you need to plan? Document strict I & O Patient and family teaching Communication at shift report, sign on door thirsty all the time - use ice chips, swabs, oral care, lip moisturizer Planning schedule of fluids (meals & meds) Work with Dietician o Fluid Restrictions: Key Considerations Patient and family education Allot amounts throughout the day the total during 7AM 3 PM Frequent mouth care When are medications given?

Intravenous Therapy
Types of IV therapy (table 41-9) and handout posted on BB

Summary points of Intravenous (IV) solutions

HYPOTONIC SOLUTIONS replace fluid in intracellular spaces Used when there is a fluid loss in the intracellular space Include NS (0.45% sodium chloride) and 0.33% sodium chloride (1/3 NS) Normal Saline = NS

HYPERTONIC SOLUTIONS replace fluid from the intracellular space Used if there is a fluid excess in intracellular space Need to use cautiously because the fluid is drawn from the intracellular space to the intravascular space and can cause circulatory overload Include 3-5% NS, D5NS (D50.9% Sodium chloride)or D5NS (D50.45% Sodium chloride)

ISOTONIC SOLUTIONS used to replace intravascular (ECF) volume Includes NS (0.9% sodium chloride), Lactated Ringers and D5W (5% Dextrose in water)

TO DETERMINE WHAT KIND OF ACID-BASE IMBALANCE, please follow the following steps. The first three steps are essential. You do NOT need to know the fourth in terms of specific blood gases (ABGs arterial blood gases). I do want you to know there are 2 compensatory mechanisms (respiratory and renal) that respond to imbalances that Is covered on the other slides.

Four Key Steps

1. Look at the pH: Is it acidic, normal or alkalotic? 2. Is the PCO2 normal or abnormal?
1. This will help you to determine if the condition is respiratory acidosis or alkalosis

3. Is the HC0- 3 is normal or abnormal;

1. This will help you determine if the condition is metabolic alkalosis or metabolic acidosis

4. Determine whether compensation is occurring

Initiating intravenous therapy (skill 41-1) Assessment and maintenance of IV

Procedure for discontinuing an IV

Infiltration vs. phlebitis and appropriate nursing interventions

Regulating and maintain IV (skill 41-2 & 41-3)

o IV flow is regulated via gravity, control/regulator pumps, and electronic infusion device (pumps). Regardless of the method used, nurses are responsible for monitoring fluid flow to prevent over or underinfusion. o The system is maintained by replacing IV bags, tubing, dressings, and connections via hospital policy and protocol. Three things are of utmost importance: 1. Keeping the system sterile 2. Changing solutions, bags, and site dressing 3. Assisting client with self-care so as to not disrupt the integrity/sterility of the system. When to use an IV pump prioritizing their use (safety alert, p. 992) o SAFETY ALERT: Use intravenous pumps or volume controlled devices with children, with clients with renal or cardiac failure, with medications that require precise rates, or with critically ill clients to ensure prescribed infusion rate and to prevent uncontrolled fluid administration. Complications (and treatments) of IVs o Complications include swelling at site, pallor, and coolness at the site. Phlebitis is an inflammation of the vein. Flood volume excess occurs when the fluid is administered too rapidly. (See above: Infiltration vs. phlebitis and appropriate nursing interventions)

Blood Transfusion
Purpose of transfusions o The purposes of blood replacement are to: Increase circulating volume after surgery, trauma, or hemorrhage Increase the number of RBCs and maintain hemoglobin levels Provide replacement therapy of clotting factors, platelets, or albumin. Autologous transfusions o Collection and reinfusion of persons own blood o Obtained up to 5 weeks before surgery o Safer option Transfusion process o PRE-TRANSFUSION Signed informed consent Patent IV site with large gauge cannula (i.e. 18/19 gauge) Must use special tubing with in-line filter Prime tubing with 0.9% NS to prevent hemolysis Asessment: hx, procedure, sx, baseline vital signs. Checking blood order, patient identification & blood component: 2 nurses (agency policy) o INITATING & MONITORING TRANSFUSION Start with slow infusion Stay with patient for first 15 minutes Assess vital signs and signs of transfusion reaction Continue frequent vital signs and checks throughout the transfusion Components of a transfusion order o Physician order must specify: Blood component Date and rate specified o Unit transfused over 2 hrs, lengthened to 4 hrs if client at risk for FVE (beyond 4 hours risk of contamination o IV push Furosemide may be prescribed before or between PRBCs to prevent fluid overload

Blood Reactions: know clinical manifestations and management from slides and Table 41-12 including circulatory overload o Transfusion Reactions Systemic response by the body to incompatible blood o Acute Hemolytic: Febrile Mild allergic Anaphylactic STOP TRANSFUSION IMMEDIATELY o Intervention: Transfusion Reaction Stop transfusion Keep IV line open, infuse 0.9% NS directly into IV line (not through y connector on blood adm set as some blood will remain) Notify physician Remain with client, vital signs every 5 mins Prepare to adm emergency drugs, CPR Obtain urine spec Save blood container, tubing, labels

Chapter 43: Pain Management

Nature of Pain o A form of suffering o Pain is highly personal experience o Can interfere with all aspects of an individuals life & overall well being Perception of Pain o Definition of Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage (IASP) International Association for the Study of Pain Pain is Whatever the experiencing person says it is (McCaffrery) Author of Nursing the Patient in Pain. Defined from clients perspective Responses to pain (table 43-1)

Types of Pain differentiate between acute, persistent (chronic), chronic episodic and cancer pain Type Acute Persistent Chronic, episodic Cancer Patholog-ical Idiopathic Description Protective, identifiable cause; Short duration, limited tissue and emotional damage Serves no purpose; last longer than anticipated, no identifiable cause; leads to great personal suffering Sporadic pain over an extended time (e.g. migraine headaches) Usually related to tumor progression, pathology; or treatment; 90% can be managed; Nociceptive (muscular skeletal); visceral (internal organs); neuropathic Chronic pain with no identifiable source

Factors influencing pain

Myths and misconceptions about pain (Box 43-2 & Table 43-4)

Acute and cancer care pain guidelines including quality indicators

Assessment
Clients expressions, characteristics (e.g. responses to pain)

Attitudes and assumptions about pain including cultural

Pain characteristics & appropriate pain scales be familiar with all those on the slides in terms of which type (e.g. numeric, visual, observational) and when itd be appropriate to use.

Cultural effects of pain assessment and management o Stoicism vs. Expressivity o Decisions about managing pain o Language and interpretation problems o Nonverbal communication problems o Culturally inappropriate assessment tools o Under-reporting of pain o Reluctance to use pain medications o Access to pain medications o Providers fears of drug abuse o Prejudice and discrimination o o Culturally sensitive pain assessment include tools that have been translated and validated in many languages Explanatory Model Interview* with items such as: What do you think is causing your pain? When did it start? What do you fear most about the pain? What problems has it caused for you? What have you used to help? Who else have you consulted?

Be able to distinguish between acute pain, persistent pain and cancer pain Acute Pain vs. Persistent Pain o Acute A transient state, usually linked to tissue pathology. Usually with well focused sensory characteristics; lasts or is expected to last no more than 6 months o Persistent Lasts or expected to last longer than 6 months because it is related to a chronic illness or condition (Also see above table on Types of Pain)

Interventions:
Non-pharmacological nursing interventions o Distraction o Humor o Music o Guided imagery & Relaxation response o Cutaneous stimulation Massage, TENS units, cold/heat application o Acupuncture o Hypnosis

Environment (Box 43-12)

Acute Care - Pharmacological Pain Relief o Non-Opoid Analgesics

Analgesics know the information on the slides (non-opiods and opiods medications). Alos know which medications are used to manage neuropathic pain

Nursing principles (Box 43-13)

Comparative potencies & range orders Patient-controlled analgesics

Topical analgesics & local and regional anesthetics

Nursing implications

Cancer pain management

Know common side effects of opiods o Constipation o Sedation o Respiratory Depression or Sedation Respiratory rate less than 8/min, SpO2 less than 90% Naloxone (Narcan) cautious administration (while providing resp support and supplemental O2), will cause opioid reversal/pain o Nausea and Vomiting Know name of reversal agent for opiods o Naloxone (Narcan) will cause opioid reversal/pain

Barriers to effective pain relief (box 43-16) and slides

Definitions related to Opiod Pain Treatment (Box 43-17)

Treating pain associated with Cancer WHO ladder

Evaluation strategies

I will also post the Pain Case studies we discussed in class with some notes that may help you.

Chapter 44: Nutrition

Anatomy and Physiology of Digestive system

Dietary guidelines Food pyramid (p. 1091) & Box 44-2

Anorexia and bulimia (Box 44-3)

Considerations for older adults (p. 1094 and box 44-4)

Drug nutrient interactions (see slide) and remember our conversation about Coumadin, and being aware of whether or not a medication should be given with food.

Assessment:
Mini Nutritional Assessment tool recognize this as one of the better nutrition-specific assessment tools. Theres a figure in the book.

Physical signs (Table 44-4)

Dysphagia and aspiration precautions o Dysphagia Topic Definition Causes Signs Complications Screening More Details Difficulty when swallowing Myogenic, neurogenic, obstructive and other (see Box 44-7 for examples) A cough while eating, change in voice tone or quality after swallowing Aspiration pneumonia, dehydration, impaired nutrition, weight loss Assess holding, leakage, coughing, choking, breathlessness and quality of voice. Speech therapist should be consulted!

Causes Box 44-7 (p. 1101)

Nutrition and older adults (slides) that is, why is it more of a concern with this population? o Access to Foods Homebound individuals have higher nutritional risks o Economic Concerns, fixed income difficult choices o Meat (source of protein $$) Alternatives Cheese, Eggs, Peanut Butter o Chronic Illness (diabetes, renal disease, cancer) impacting nutritional intake. o Cognitive Impairments (delirium, dementia, depression) o Readmission to hospital often are related to poor oral intake especially with the elderly population

Implementation:
Aspiration precautions (Skill 44-1) Acute Care - Advancing diets (Box 44-10, p. 1111), specifically clear and full liquid, soft mechanical and low sodium Acute Care Promote appetite and assist with oral feeding Promote Appetite o Keep free of odors o Provide oral hygiene o Maintain client comfort o Minimize medication side effects o Promote socialization during meals o Appropriate use of appetite stimulants o Appropriate proportions (not too much!) Assisting With Oral Feeding o Protect clients safety, dignity and independence o Assess risk for aspiration o Client with dysphagia 30 min rest period before eating Upright position (high fowlers) Flex head to chin down position If unilateral weakness place food on stronger side of mouth Determine the viscosity that client can tolerate; thicker liquids usually easier Liquid types: thin, nectar-like, honey-like and spoon-thick o Dysphagia Slowly, smaller size bites Freq chewing/swallowing assessments Match feeding speed to client readiness Include clients food preferences, requests and order of eating o Visually impaired: orient to plate as if food were on a clock o Adaptive equipment Acute Care - Enteral tube feedings know the different types of tubes (anatomically) and any special considerations. o Enteral Nurtrition Providing nourishment by means of a tube in the GI tract Client is unable to ingest food but can digest and absorb nutrients Receive formula via nasogastric, gastric or jejunal (when risk of aspiration) tubes Indications for enteral and parenteral nutrition know the major categories/reasons

o Enteral Tube Feeding Nasogastric Nasointestinal Gastrostomy Jejunostomy PEG PEJ o Nasogastric Tube

o Gastrostomy Tube

o Jejunostomy Tube

General indications for enteral or parenteral nutrition (Box 44-11, p.1112) Testing gastrointestinal pH (Box 44-12, p. 1117).

Administering enteral feeding (Skill 44-3) and preventing complications (Table 44-7). On Table 44-7, focus on pulmonary aspiration, diarrhea, constipation, tube occulusion, tube displacement. o Administering Enteral Feeding Administering feeding can be delegated to CNA (after tube placement verification) with proper instruction Elevate HOB at least 30 degrees or sitting up in chair Check order for formula, rate, route and frequency (formula at room temperature) Verify tube placement whats the procedure? o Testing pH Check for residual/ return aspirate unless over 200 ml (or agency policy) Hold feeding if residual > 200 ml, maintain upright, recheck in 1 hour Infuse slowly, increase amount and rate

Parenteral nutrition - initiating & preventing complications o Parentral Nutrition Administered to clients who are unable to digest or absorb enteral nutrition (sepsis, head injury, burns) Nutrients provided intravenously through: o Peripheral (short-term) o Central line Requires close clinical & lab monitoring by team Goal to discontinue and use GI tract (enteral or oral)

o Initiating Parentral Nurtition (PN) Initiating PN: check policy/procedures, needs dedicated line Verify order, inspect solution (do not confuse with enteral formula) Must use an infusion pump, initially 40-60 ml/hr, gradually increased Lipid emulsions administered through separate peripheral line or Y connector tubing o Preventing Complications PN Air embolism during catheter insertion or tubing change Have patient bear down in a left lateral position to prevent air embolism Catheter occlusion Temporarily stop infusion & flush per agency policy Catheter sepsis Change tubing every 24 hours. PN not to hang beyond 24 hours; use sterile technique dressing change Metabolic complications Monitor electrolytes, blood sugar

Chapter 48: Skin Integrity and Wound Care

Understand skin structure

Skin associated changes with aging (Box 48-1)

Pressure ulcers (Figure 48-2), pathophysiology, pathogenesis, risk factors, shear (figure 48-5) and classification of pressure ulcers (including when unstageable). Be able to distinguish between the different stages. o Definition: Localized areas of cellular necrosis of the skin and subcutaneous tissues as a result of unrelieved pressure in combination with shear and/or friction Other terms: pressure sores, bedsores or decubitis ulcers o Pressure ulcers (Figure 48-2) Pressure ulcer with tissue necrosis.

Pathophysiology Unrelieved pressure on the skin interrupts normal circulation by occluding cutaneous and subcutaneous blood vessels. This leads to tissue ischemia, and necrosis (tissue death) Pathogenesis Three elements contribute to development of pressure ulcers o Intensity of the pressure and capillary closing pressure o Duration and maintenance of pressure o Tissue tolerance Risk Factors Immobility: Patients who are unable to change position Age: Thinning of the skin, decreased turgor impaired sensory or motor function Impaired cognition/sensory impairment: Someone who has a dementia or a delirium who is unable to understand, follow, or make position changes. EX: a paraplegic who cannot feel sensation, pain, or discomfort of pressure Moisture: Excessive moisture of the skin increases the susceptibility to damage when force is exerted Decreased nutritional state: patients with low albumin are at great risk for poor wound healing, anemia reduces oxygen to tissues Friction: the mechanical force exerted when skin is dragged across a coarse surface such as bed linens..affects the epidermis. Two surfaces rubbing together Lying on wrinkled sheets Shearing: pressure exerted against the skin in a direction parallel to the bodys surface o Occurs when one layer of tissue slides over another layer o Can occur while moving a patient in bed, or when a patient slips down in the bed. Skin and subcutaneous layers adhere to the surface of the bed, and the layers of muscle slide in the direction of body movement o Occurs when patients are pulled rather than lifted Shear (Figure 48-5) As you elevate the head of the bed, the skeleton slides down while the skin stays fixed, resulting in shearing

Classification of Pressure Ulcers (including when unstageable). Be able to distinguish between the different stages.

An unstageable ulcer is a full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and /or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore the stage cannot be determined. (pg. 1282)

Characteristics of dark skin at risk (Box 48-2)

Wound classifications (table 48-1 & figure 48-7)

Fig 48-7 Wounds classified by color assessment. A, Black wound. B, Yellow wound. C, Red wound. D, Mixed-color wound.

Process of wound healing and (figure 48-8)

Figure 48-8 A,Wound healing by primary intention such as a surgical incision. Wound healing edges are pulled together and approximated with sutures or staples, and healing occurs by connective tissue deposition. B, Wound healing by secondary intention. Wound edges are not approximated, and healing occurs by granulation tissue formation and contraction of the wound edges.

Wound repair Wound Healing o Healing is the tissues response to injury and the process is the same for all wounds o Two types of wounds: Those with loss of tissue and those without A surgical incision has little tissue loss Heals by primary intention where the skin edges come together and risk of infection is low. o Wounds with tissue loss (such as a pressure ulcer, arterial or venous ulceration, a burn, or severe laceration) heal by secondary intention o Takes longer, as wound edges do not approximate and the wound is left open until it is filled with scar tissue. Chances of infection are greater. Terminology and characteristics of (a) slough, (b) eschar and (c) granulation tissue and understand how you would cleanse each a) Slough- Soft yellow or white tissue (stringy substance attached to wound bed), you will need to remove this before wound is able to heal. b) Eschar- Black or brown necrotic tissue, which you will also need to remove before healing can proceed. c) Granulation tissue- red moist tissue composed of new blood vessels, the presence of which indicated progression toward healing. (New tissue that forms the foundation for scar tissue development. Highly vascular, red and bleeds easily.)

Complications of wound healing pay particular attention to WHEN these complications are most likely to occur o Bleeding: Normal after original trauma, buts stops within minutes. Bleeding that occurs later can be due to a slipped suture, a clot, infection, or erosion of a blood vessel. Look for distension or swelling or the change in the amount and type of drainage o Hematoma localized collection of blood underneath the tissues o Surgical incisions are at greatest risk for bleeding within the first 24-48 hrs after surgery o Dehiscence: When a wound fails to heal and the layers of skin and tissue separate. Patients with abdominal wounds who may be straining to cough, moving around in bed, vomiting Partial or total disruption of wound layers Patients will say that they feel something give Evisceration: total separation of wound layers where the organs protrude Medical emergency Cover extruding tissue with sterile towel soaked in saline Fistula: Abnormal tract between 2 organs or between an organ and the outside of the body Chronic drainage, risk of infection Name of fistula designates the site of the tract Infection: When purulent material drains from it even if culture is negative or not taken. All wounds contain bacteria but infected wounds have a higher colony count: greater than 100,000 org/ml Inhibits wound healing Surgical wounds may show signs of infection on post op days 4 or 5.. Signs and symptoms: fever, pain, tenderness, and elevated white blood cell count Drainage may be yellow, green, brown, and be odorous Types of wound drainage (Table 48-2)

Risk assessment, specifically the Braden scale and how it is scored (Table 48-4) Not the Norton scale

Prevention of pressure ulcers o Pressure Ulcer: Prevention 1st Question: What are risk factors? Immobility: Turn patients, reduce shear and friction, provide pressure relief surface, provide assistive devices to increase activity Incontinence: Keep patient clean and dry, toileting schedules Malnutrition: Provide adequate hydration and nutrition, nutritionist referral Impaired skin integrity: Lubricate skin, avoid pressure, do not massage reddened areas, educate patient/family o Pressure Ulcer: Three Prevention Strategies 1. Excellent skin hygiene 2. Mechanical loading & support 3. Education o Prevention: Topical Skin Care Avoid soaps and hot water Use nonionic solutions Completely dry skin & moisturize Contain/manage incontinence Use absorbent pads only if they wick away the moisture Use moisture barriers o Prevention: Mechanical Loading Proper positioning to reduce pressure and shear forces o Schedule at least every 90 minutes 2 hours o Recommend using 30 degree positioning o Use transfer devices to reduce friction Support surfaces specialized device o Mattresses o Specialty beds o Prevention: Education Shift weight every 15 minutes Use foam/gel pads to redistribute weight Do NOT use donut shaped cushions or rigid pads Reason for interventions Never massage the area General understanding of nutrients, sources and role not specific dose recommendations, (Table 48-5)

Factors influencing pressure ulcer formation and wound healing (See above Wound Repair and Risk Factors) Pressure ulcers (pp. 1293-1294) and Skill 48-1 o Because pressure ulcers have multiple etiological factors, assessment for pressure ulcer risk (Skill 48-1) includes several important factors. These include using an appropriate predictive measure and assessing the clients mobility, nutrition, presence of body fluids, and comfort level. (pg . 1293) Sites of pressure points (Figure 48-12)

Figure 48-12 A, Body prominences most frequently underlying pressure ulcer. B, Pressure ulcer sites. Wound types, appearance and character of drainage and wound assessment

Wound Classifications o Intentional: surgical incision, IV site o Unintentional: trauma, fall, accident Increased risk of infection o Open: skin surface is broken o Closed: skin is not broken, but there is tissue damage/internal bleeding or injury o Acute: heal within days to weeks o Chronic: does not progress, delayed healing Wound Assessment Nursing Assessment of Wounds o Types of emergency wounds o Describe appearance Abrasions vs. lacerations vs. puncture Are edges closed? o Size & location of wound Are edges inflamed? o Wound appearance (e.g. closed) Is there any bruising? o Wound drainage Is the surrounding skin macerated or irritated Serous, serosanguineous, sanguineous Measure and record length/width o Removal of dressing o Drainage Careful of healing tissue or drains Note amount, color odor, consistency(serous, purulent, Premedicate 30 minutes ahead of change seosanguineous, sanguineous, see p 1287) o Drains check placement & drainage Look at removed dressing o Wound closures Strong odor=possible infection Staples (stronger, less irritation) or sutures First 2-3 days, suture/staple line is edematous If becomes too tight risk for dehiscence Nursing Process: Assessing Wounds o Palpation of wound o Inspection: sight and smell o Wound culture Appearance: color, wound edges, signs of dehiscence, Clean wound first with normal saline evisceration, drainage (amount/color/odor), wound Gold standard is tissue biopsy bed, periwound surface o o o Wound cultures; How to obtain (Box 48-7) Palpation: edema, skin temp, tenderness, induration Pain: Increased/constant . Associated with increased drainage, etc. Lab data: increased WBC, wound culture

Quick guide for pressure ulcer prevention (Table 48-7)

Positioning, Safety alert (p 1304) and support surfaces Safety Alert Incorrect positioning of an immobile client will possibly create a shearing injury. When repositioning the client, place a transfer sliding board under the clients body. Obtain assistance for repositioning, and with at least one other caregiver, use the board to slide the client up and toward the new position. Dragging the client on bed sheets will place the client at high risk for shearing and friction injuries. o Support Surfaces (Therapeutic Beds and Mattresses) A support surface is a specialized device for pressure redistribution designed for management of tissue loads, microclimate, and/or other therapeutic functions (i.e., mattresses, integrated bed system, mattress replacement, overlay or seat cushions, or seat cushion overlay). There are a variety of support surfaces, including specialty beds and mattresses that reduce the hazards of immobility to the skin and musculoskeletal system.

Acute Care - management of pressure ulcers. Wound Care o Goal: to promote tissue repair and regeneration o Draining wounds, infected wounds and open wounds. o General principles: Aseptic technique cleansing the wound usually with normal saline(0.9% sodium chloride) Dressing application Record findings Wound Management o Great diversity in practice regarding wound healing and types of dressings. o Certified wound specialists and enterostomal therapist who have develop guidelines for evidence-based practice. o Some facilities have specific protocols regarding wound care. Acute Care - treatment of pressure ulcers (skill 48-2) know the different types of dressings (i.e enzymes, hydrogel, calcium alginate) and their specific purposes. o Assess and document: Location Size Stage Exudate Surrounding skin condition Reassess & evaluate treatment of acute wounds every 8 hours or every dressing change

Dressings for pressure ulcers (table 48-9)

Acute care - Wound management o Goal = maintain physiological local environment to promote healing o Key components: Prevent and manage infection Cleanse wound Remove non-viable tissue Manage exudate Maintain the wound in moist environment Protect the wound (cover & stabilize) o o o Great diversity in practice regarding wound healing and types of dressings. Certified wound specialists and enterostomal therapist who have develop guidelines for evidence-based practice. Some facilities have specific protocols regarding wound care.

Debridement: know the different types Wound Debridement Definition: removal of necrotic tissue Three types: Mechanical wet to dry dressings o Not used as often because removes viable tissue Autolytic synthetic dressings (dsg) o Wound base dry use dsg to add moisture o Wound base wet use dsg to absorb moisture Surgical debridement o May be done by trained advance nurses check state practice act o Quickest method Reminder: wound will not heal unless contributory factors addressed Purposes of dressings o Protection o Aids hemostasis o Promotes healing o Supports or splints the site o Visual protection o Thermal insulation o Provides moist environment Wound dressing orders and remember our class discussion about post-operative dressings (the first one is usually changed by the surgeon). o Sterile vs. clean technique o Health provider order is needed: Frequency Type Solution o Surgical dressing reinforce prn o Administer analgesic o Describe procedure to patient

Phases of wound healing (slides) o Inflammatory phase Starts at time of injury and prepares wound for healing Exudate is created from plasma and blood components that leak into the area White blood cells arrive to ingest bacteria and cellular debris: macrophages Generalized body response, mildly elevated temp, leukocytosis, and malaise. o Proliferative phase Begins 2-3 days after the injury New tissue starts to fill in the wound space, capillaries grow across the wound, and Blood flow is reinstituted New tissue is called granulation tissue forms the foundation for scar tissue development. o Highly vascular, red and bleeds easily. o Remodeling or maturation phase Begins about three weeks after the injury Collagen continues to be deposited and gain strength Wounds that heal by secondary intention take longer to remodel and form scar tissue Healed wound does not recover tensile strength of tissue it replaces. Factors affecting wound healing o Age: children and healthy adults heal more rapidly. o Tissue perfusion/oxygenation: delivery of nutrients/removal of toxins o Nutritional status: proteins and vitamins help with the healing process o Wound condition: large, contaminated, etc. o Health status: chronic illness, medications Complications of wound healing and pay particular attention to WHEN these complications are most likely to occur (See Above Slides) WOCN Recommendations (Box 48-12)

Applying dry and moist dressings (skill 48-3) Changing dressings, packing wounds and securing dressings

Vacuum assisted closures

Basic skin cleansing (p 1324) Basic Skin Cleansing. Cleanse surgical or traumatic wounds by applying noncytotoxic solutions with sterile gauze or by irrigation. The following three principles are important when cleansing an incision or the area surrounding a drain: 1. Cleanse in a direction from the least contaminated area, such as from the wound incision to the surrounding skin or from an isolated drain site to the surrounding skin. 2. Use gentile friction when applying solutions locally to the skin. 3. When irrigating, allow the solutions to flow from the least to most contaminated area. (Skill 48-5) Wound Cleansing o Use non-cytotoxic cleansers Normal saline Commercial cleansers o Do NOT use cytotoxic cleansers in clean, granulating wounds Dakins solution Betadine (povidone-iodine) o Be careful of pressure with irrigation o Use 19 gauge needle & 35 mL syringe

Performing wound irrigations (skill 48-5)

Heat and cold therapy Focus on the slides

Risk and safety of heat/cold therapy ( Table 48-10 & Box 48-15)

As reminder (and based on questions Ive received), you need to be familiar with sterile vs. clean dressing changes. As you may remember, we talked about this in class. Clean dressing technique can be used in the home setting and sterile dressings are done in acute care settings.

Medication Calculations: There will be four questions that include oral medications, IV rates via pump or gravity and parenteral injections (subcutaneous and/or intramuscular).