NU 226 IN1kCDUC1ICN 1C NUkSING 1nLCk AND kAC1ICL

Lxam III Study Gu|de

Chapter 1op|c AkCkIMA1L number of quest|ons
ChapLer 44 nuLrlLlon 8
ChapLer 48 Skln lnLegrlLy and Wound Care 10
ChapLer 41 lluld elecLrolyLes acld and base 10
ChapLer 41 lv 1herapy and 8lood Lransfuslons 8
ChapLer 43 aln managemenL 10
MedlcaLlon calculaLlons 4
1ota| S0
Genera| kem|nders
1here ls a loL of lnformaLlon ln Lhe skllls boxes unless oLherwlse sLaLed revlew Lhese for Lhe crlLlcal declslon polnLs and
aL Lhe end of each you should be famlllar wlLh Lhe unexpecLed CuLcomes and lnLervenLlons

Chapter 41 I|u|d L|ectro|ytes Ac|d8ase ba|ance and IV therap|es
O lsLrlbuLlon of body flulds






O MovemenL of body flulds
















1ype of Movement Def|n|t|on]Lxamp|e
Csmosls
MovemenL of a solvenL across a semlpermeable membrane from an
area of lesser Lo one of greaLer concenLraLlon
lffuslon
8andom movemenL of a soluLe Lhrough a semlpermeable membrane
from hlgher Lo lower concenLraLlon
Lxample oxygen carbon dloxlde
lllLraLlon
MovemenL of waLer and dlffusable subsLances across a membrane
LogeLher under pressure from hlgher Lo lower pressure
AcLlve LransporL
MovemenL of lons agalnsL osmoLlc pressure Lo an area of hlgher
pressure 1akes energy

8egulaLlon of body flulds elecLrolyLes and acldbase balance






































O normal range and funcLlon for each elecLrolyLe (Lable 411)
Spec|f|ca||y potass|um sod|um and magnes|um












O LlecLrolyLe lmbalances
4 locus Lhe sodlum (Na) (hyper/hyponaLremla) and poLasslum (k) (hyper/hypokalemla) (Lable 413)




















































O ab values and LreaLmenLs of Pypokalemla hyperkalemla hyponaLremla and hypernaLremla

4 nypoka|em|a
O lob voloes
4 ecrease ln k+ ln blood/exLracellular fluld
ab k below 33 mLq/
O @eotmeots
4 8eplacemenL of k+ Cral or lv

4 nyperka|em|a
O lob voloes
4 ab k Above 3mLq/ (lncrease of k+ ln serum exLra cellular fluld)
O @eotmeots
4 lv /parenLeral Lherapy Lo shlfL k+ lnLo cells (nablcarb lnsulln hyperLonlc dexLrose)
4 kayexalaLe oral or enema LhaL ellmlnaLes excess k+

4 nyponatrem|a
O lob voloes
4 ab Serum na+ below 133 mLq/ (ess Lhan normal concenLraLlon of sodlum ln Lhe blood LCl)
O @eotmeots
4 oal resLore normal sodlum levels
O Lxcess fluld wlLh decrease na+resLrlcLlng flulds
O Sodlum replacemenL Lhrough dleL
O normal fluld balance wlLh decreased na+ lsoLonlc sallne (09 naCl) or lacLaLed rlngers
soluLlon

4 nypernatrem|a
O lob voloes
4 ab Serum na+ greaLer Lhan 143mLq/
O @eotmeots
4 lluld replacemenL Lherapy wlLh lsoLonlc soluLlon (09naCl) or hypoLonlc soluLlon (043 naCl)
4 Sodlum resLrlcLed dleL
O revenL More Sodlum
4 processed foods ( canned frozen)
4 M moo (mllk cheeses buLLer lce cream)
4 Ssodlum ( salLy nuLs chlps ham bacon)
O Cllnlcal manlfesLaLlons Lo know for each of Lhe followlng
4 nypoka|em|a muscle weakness cardlac dysrhyLhmlas
4 nyperka|em|a hyperkalemla nausea vomlLlng and cardlac dysrhyLhmlas
4 nyponatrem|a abdomlnal cramps nausea vomlLlng dlarrhea Lachycardla and posLural hypoLenslon
4 nypernatrem|a 1hlrsL dry mucous membranes fever posLural hypoLenslon

O SafeLy conslderaLlons when admlnlsLerlng lnLravenous poLasslum
4 Safety measures!!!
O Never g|ve IV USn
O Always dlluLe as dlrecLed
O 8e sure kC mlxes Lhoroughly
O Do not add to a hang|ng conta|ner
O MonlLor cllenL's LC





O 8egulaLlon of Acld 8ase balance pP 8uffers
4 normal values of A8 (arLerlal blood gas) speclflcally Lhe pP CC2 and PCC3 levels










4 8e able Lo ldenLlfy Lypes of lmbalances (pp 977)

O kesp|ratory Ac|dos|s
4 aCC2 excess carbonlc acld P
+
pP 733
4 8esulLs from P?CvenLllaLlon
4 neuro changes
4 Pypoxemla due Lo resplraLory depresslon
4 Pyperkalemla and hypercalcemla
4 kldneys nmpeosote by conservlng blcarb and releaslng P+ ln urlne
4 rocess may Lake up Lo 24 hrs

O kesp|tatory A|ka|os|s
4 aCC2 and pP above 743
4 8esulLs from P?L8venLllaLlon
4 AnxleLy asLhma sallcylaLe overdose
4 pP may reLurn Lo normal before kldneys can respond
4 kldneys wlll nmpeosote lncrease excreLlon of blcarb

O Metabo||c Ac|dos|s
4 8esulLs from hlgh acld conLenL ln blood (pP733) causes loss of blcarb (blcarb deflclL)
4 8elaLed Lo severe dlarrhea renal dlsease sLarvaLlon dlabeLlc keLoacldosls drug use
4 CalculaLlng Lhe anlon gap helps ldenLlfy cause (see 1able 416)
4 8esplraLory nmpeosotlo CC2 excreLlon by resp raLe/depLh

O Metabo||c A|ka|os|s
4 8esulL of heavy loss of acld or blcarb levels
4 8elaLed Lo vomlLlng and gasLrlc sucLlonlng overcorrecLlon of meL acldosls k+ deflclency
Lhlazlde Lherapy excess aldosLerone
4 8esplraLory nmpeosotlo resp raLe renal loss of blcarb (lf no renal dlsease)










4 8evlew lmbalances (Lable 413) broad caLegorles of each Lype of lmbalances
(?ou wlll noL be LesLed on physlcal exam flndlngs of Lhese lmbalances or anlon gaps)





















































O AssessmenL rlsk facLors (summary on slldes)
4 aLhologles LhaL affecL homeosLaLlc regulaLors of fluld balance
4 labeLes congesLlve hearL fallure renal fallure
4 Abnormal losses of body flulds
4 rolonged vomlLlng dlarrhea dralnlng wounds
4 8urns Lrauma
4 1heraples LhaL dlsrupL fluld elecLrolyLe balance
4 Meds (dlureLlcs sLerolds) lvs blood Lransfuslons

O AssessmenL prlor medlcal hlsLory (p 979980) Speclflcally be famlllar wlLh Lhe followlng general condlLlon and
how lL may affecL fluld and elecLrolyLes

4 Cardlovascular
O Cardlovascular dlsease may resulL ln a dlmlnlshed cardlac ouLpuL whlch reduces kldney perfuslon
causlng Lhe cllenL Lo experlence a decrease ln urlnary ouLpuL 1he cllenL wlll reLaln sodlum and waLer
resulLlng ln clrculaLory overload and run Lhe rlsk of developlng pulmonary edema
4 8enal
O kldney dlsease alLers fluld and elecLrolyLe balance by causlng an abnormal reLenLlon of sodlum chlorlde
poLasslum and waLer ln Lhe exLracellular comparLmenL 1he plasma levels of meLabollc wasLe producLs
such as blood urea nlLrogen (8un) and creaLlnlne are elevaLed because Lhe kldneys are unable Lo fllLer
and excreLe Lhe wasLe producLs of cellular meLabollsm MeLabollc acldosls resulLs when hydrogen lons
are reLalned due Lo decreased renal funcLlon 8ecause of lmpalred renal funcLlon Lhe usual renal
compensaLory mechanlsms such as blcarbonaLe reabsorpLlon are noL avallable so Lhe body loses ablllLy
Lo resLore normal acldbase balance
4 8esplraLory
O Many alLeraLlons ln resplraLory funcLlon predlspose Lhe cllenL Lo resplraLory acldosls for example
changes lnvolved ln pneumonla and sedaLlve overdose lnLerfere wlLh Lhe ellmlnaLlon of carbon dloxlde
neumonla causes pulmonary congesLlonwhlch leads Lo CC& reLenLlon fromhypovenLllaLlon Cardon
dloxlde ls reLalned durlng hypovenLllaLlon As Lhe cardon dloxlde conLlnues Lo bulld up ln Lhe
bloodsLream Lhe body's compensaLory mechanlsms can no longer adapL and Lhe pP decreases
Slmllarlly hypervenLllaLlon LhaL occurs wlLh condlLlons such as fever or anxleLy causes Lhe cllenL Lo
experlence resplraLory alkalosls by blowlng off Loo much carbon dloxlde wlLh Lhe lncreased resplraLory
raLe

O AssessmenL envlronmenLal facLors lnformaLlon on Lhe slldes
4 LnvlronmenL facLors
O exLreme Lemp
O excesslve exerclse

O AssessmenL medlcaLlons (8ox 412)
Speclflcally be famlllar wlLh Lhe effecLs of Lhe
followlng medlcaLlons
4 D|uret|cs (aslx/furosemlde)
4 kesp|ratory depressants (oplods)
4 Ant|b|ot|cs
O nephroLoxlcLy of vancomycln

O AssessmenL physlcal examlnaLlon
4 ally welghLs
O Same Llme scale afLer cllenL volds callbraLe
scale same amL cloLhes or sheeLs on bed scale
4 lnLake and ouLpuL
O Pourly/24 hour when lmporLanL all sources
4 aboraLory sLudles provlde ob[ daLa


O ally welghLs lnLake/ouLpuL and 8ox 413















O lluld dlsLurbances lv and lvL (1able 418) know Lhe deflnlLlon posslble causes and cllnlcal
manlfesLaLlons of each of Lhese dlsLurbances Cn Lable 418 pay parLlcular aLLenLlon Lo Lhe cardlovascular
sysLem resplraLory sysLem and renal sysLems



































O lmplemenLaLlon enLeral replacemenL resLrlcLlng flulds parenLeral flulds 1n lv Lherapy
4 Cral replacemenL may be conLralndlcaLed
4 leedlng Lubes gasLrosLomy [e[unosLomy nasogasLrlc
4 8esLrlcLlon of flulds lvL Lypes of flulds ([ello lce chlps popslcles) d|v|de over 24 hours frequenL
mouLh care
4 arenLeral replacemenL of flulds/elecLrolyLes
4 1oLal parenLeral nuLrlLlon
O nuLrlLlonally adequaLe hyperLonlc soluLlon vla centra| IV caLheLer

O lluld resLrlcLlon (from class and slldes)
4 As a nurse whaL do you need Lo plan?
O ocumenL sLrlcL l C
O aLlenL and famlly Leachlng
O CommunlcaLlon aL shlfL reporL slgn on door
O #LhlrsLy all Lhe Llme" use lce chlps swabs oral care llp molsLurlzer
O lannlng schedule of flulds (meals meds)
O Work wlLh leLlclan
4 lluld 8esLrlcLlons key ConslderaLlons
O aLlenL and famlly educaLlon
O AlloL amounLs LhroughouL Lhe day
O * Lhe LoLal durlng 7AM 3 M
O lrequenL mouLh care
O When are medlcaLlons glven?

Intravenous 1herapy

O 1ypes of lv Lherapy (Lable 419) and handouL posLed on 88






















Summary polnLs of lnLravenous (lv) soluLlons
nC1CNIC SCLU1ICNS replace fluld ln lnLracellular spaces
O used when Lhere ls a fluld loss ln Lhe lnLracellular space
O lnclude * nS (043 sodlum chlorlde) and 033 sodlum chlorlde (1/3 nS)
O normal Sallne nS
nLk1CNIC SCLU1ICNS replace fluld m Lhe lnLracellular space
O used lf Lhere ls a fluld excess ln lnLracellular space
O need Lo use cauLlously because Lhe fluld ls drawn from Lhe lnLracellular space Lo Lhe lnLravascular
space and can cause clrculaLory overload
O lnclude 33 nS
3
nS (
3
09 Sodlum chlorlde)or
3
*nS (
3
043 Sodlum chlorlde)
ISC1CNIC SCLU1ICNS used Lo replace lnLravascular (LCl) volume
O lncludes nS (09 sodlum chlorlde) acLaLed 8lngers and
3
W (3 exLrose ln waLer)
1C DL1LkMINL WnA1 kIND CI ACID8ASL IM8ALANCL please follow Lhe followlng sLeps 1he flrsL Lhree sLeps are
essenLlal ?ou do nC1 need Lo know Lhe fourLh ln Lerms of speclflc blood gases (A8s arLerlal blood gases)
l do wanL you Lo know Lhere are 2 compensaLory mechanlsms (resplraLory and renal) LhaL respond Lo
lmbalances LhaL ls covered on Lhe oLher slldes
Four Key Steps
1. Look at the pH: !s it acidic, normal or alkalotic?
2. !s the PCO
2
normal or abnormal?
1. This will help you to determine if the condition is
respiratory acidosis or alkalosis
3. !s 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






O lnlLlaLlng lnLravenous Lherapy (sklll 411)

O AssessmenL and malnLenance of lv













O rocedure for dlsconLlnulng an lv











O lnfllLraLlon vs phleblLls and approprlaLe nurslng lnLervenLlons






















O 8egulaLlng and malnLaln lv (sklll 412 413)











4 lv flow ls regulaLed vla gravlLy conLrol/regulaLor pumps and elecLronlc lnfuslon devlce (pumps)
8egardless of Lhe meLhod used nurses are responslble for monlLorlng fluld flow Lo prevenL over or
underlnfuslon
4 1he sysLem ls malnLalned by replaclng lv bags Lublng dresslngs and connecLlons vla hosplLal pollcy
and proLocol 1hree Lhlngs are of uLmosL lmporLance
1 keeplng Lhe sysLem sLerlle
2 Changlng soluLlons bags and slLe dresslng
3 AsslsLlng cllenL wlLh selfcare so as Lo noL dlsrupL Lhe lnLegrlLy/sLerlllLy of Lhe sysLem

O When Lo use an lv pump prlorlLlzlng Lhelr use (safeLy alerL p 992)
4 SAlL1? AL81 use lnLravenous pumps or volume conLrolled devlces wlLh chlldren wlLh cllenLs wlLh
renal or cardlac fallure wlLh medlcaLlons LhaL requlre preclse raLes or wlLh crlLlcally lll cllenLs Lo
ensure prescrlbed lnfuslon raLe and Lo prevenL unconLrolled fluld admlnlsLraLlon

O CompllcaLlons (and LreaLmenLs) of lvs
4 CompllcaLlons lnclude swelllng aL slLe pallor and coolness aL Lhe slLe hleblLls ls an lnflammaLlon of
Lhe veln llood volume excess occurs when Lhe fluld ls admlnlsLered Loo rapldly
%ee obe lolltotlo s pblebltls ooJ oppplote oosloq loteeotlos)




















8|ood 1ransfus|on

O urpose of Lransfuslons
4 1he purposes of blood replacemenL are Lo
O lncrease clrculaLlng volume afLer surgery Lrauma or hemorrhage
O lncrease Lhe number of 88Cs and malnLaln hemoglobln levels
O rovlde replacemenL Lherapy of cloLLlng facLors plaLeleLs or albumln

O AuLologous Lransfuslons
4 CollecLlon and relnfuslon of person's own blood
4 CbLalned up Lo 3 weeks before surgery
4 Safer opLlon

O 1ransfuslon process
4 8L18AnSluSlCn
O Slgned lnformed consenL
O aLenL lv slLe wlLh large gauge cannula (le 18/19 gauge)
O MusL use speclal Lublng wlLh lnllne fllLer
O rlme Lublng wlLh 09 nS Lo prevenL hemolysls
O AsessmenL hx procedure sx basellne vlLal slgns
O Checklng blood order paLlenL ldenLlflcaLlon blood componenL 2 nurses (agency pollcy)
4 lnl1A1ln MCnl1C8ln 18AnSluSlCn
O SLarL wlLh slow lnfuslon
O SLay wlLh paLlenL for flrsL 13 mlnuLes
O Assess vlLal slgns and slgns of Lransfuslon reacLlon
O ConLlnue frequenL vlLal slgns and checks LhroughouL Lhe Lransfuslon

O ComponenLs of a Lransfuslon order
4 hyslclan order musL speclfy
O 8lood componenL
O aLe and raLe speclfled
4 unlL Lransfused over 2 hrs lengLhened Lo 4 hrs lf cllenL aL rlsk for lvL (beyond 4 hours rlsk of
conLamlnaLlon
4 lv push lurosemlde may be prescrlbed before or beLween 88Cs Lo prevenL fluld overload















O 8lood 8eacLlons know cllnlcal manlfesLaLlons and managemenL from slldes and 1able 4112 lncludlng
clrculaLory overload

4 1ransfuslon 8eacLlons
O SysLemlc response by Lhe body Lo lncompaLlble blood
4 AcuLe PemolyLlc
O lebrlle
O Mlld allerglc
O AnaphylacLlc
S1C 1kANSIUSICN IMMLDIA1LL

4 lnLervenLlon 1ransfuslon 8eacLlon
O SLop Lransfuslon
O keep lv llne open lnfuse 09 nS dlrecLly lnLo lv llne (noL Lhrough y connecLor on blood adm seL
as some blood wlll remaln)
O noLlfy physlclan
O 8emaln wlLh cllenL vlLal slgns every 3 mlns
O repare Lo adm emergency drugs C8
O CbLaln urlne spec
O Save blood conLalner Lublng labels































Chapter 43 a|n Management
O naLure of aln
4 A form of sufferlng
4 aln ls hlghly personal experlence
4 Can lnLerfere wlLh all aspecLs of an lndlvlduals llfe overall well belng

O ercepLlon of aln
4 eflnlLlon of aln
O #An unpleasanL sensory and emoLlonal experlence assoclaLed wlLh acLual or poLenLlal Llssue damage"
(lAS) lnLernaLlonal AssoclaLlon for Lhe SLudy of aln
O aln ls #Jbotee tbe expeleonloq peso soys lt ls (McCaffrery) AuLhor of nurslng Lhe aLlenL ln aln

Def|ned from c||ent's perspect|ve

O 8esponses Lo paln (Lable 431)


















O 1ypes of aln dlfferenLlaLe beLween acuLe perslsLenL (chronlc) chronlc eplsodlc and cancer paln
1ype Descr|pt|on
4cute roLecLlve ldenLlflable cause ShorL duraLlon llmlLed Llssue and emoLlonal damage
9ersistent Serves no purpose lasL longer Lhan anLlclpaLed no ldenLlflable cause leads Lo greaL personal
sufferlng
chronic
episodic
Sporadlc paln over an exLended Llme (eg mlgralne headaches)
concer usually relaLed Lo Lumor progresslon paLhology or LreaLmenL 90 can be managed
aLhologlcal noclcepLlve (muscular skeleLal) vlsceral (lnLernal organs) neuropaLhlc
ldlopaLhlc Chronlc paln wlLh no ldenLlflable source







O lacLors lnfluenclng paln














O MyLhs and mlsconcepLlons abouL paln
(8ox 432 1able 434)






































O AcuLe and cancer care paln guldellnes lncludlng quallLy lndlcaLors













Assessment
O CllenL's expresslons characLerlsLlcs (eg responses Lo paln)









O ALLlLudes and assumpLlons abouL paln lncludlng culLural



























O aln characLerlsLlcs approprlaLe paln scales be famlllar wlLh all Lhose on Lhe slldes ln Lerms of whlch Lype (eg
numerlc vlsual observaLlonal) and when lL'd be approprlaLe Lo use



















































O CulLural effecLs of paln assessmenL and managemenL
4 SLolclsm vs LxpresslvlLy
4 eclslons abouL managlng paln
4 anguage and lnLerpreLaLlon problems
4 nonverbal communlcaLlon problems
4 CulLurally lnapproprlaLe assessmenL Lools
4 underreporLlng of paln
4 8elucLance Lo use paln medlcaLlons
4 Access Lo paln medlcaLlons
4 rovlders fears of drug abuse
4 re[udlce and dlscrlmlnaLlon

4 CulLurally senslLlve paln assessmenL lnclude Lools LhaL have been LranslaLed and valldaLed ln many
languages
4 LxplanaLory Model lnLervlew* wlLh lLems such as
O WhaL do you Lhlnk ls causlng your paln?
O When dld lL sLarL?
O WhaL do you fear mosL abouL Lhe paln?
O WhaL problems has lL caused for you?
O WhaL have you used Lo help?
O Who else have you consulLed?

O 8e able Lo dlsLlngulsh beLween acuLe paln perslsLenL paln and cancer paln
AcuLe aln vs erslsLenL aln
4 AcuLe
O A LranslenL sLaLe usually llnked Lo Llssue paLhology usually wlLh well focused sensory characLerlsLlcs
lasLs or ls expecLed Lo lasL no more Lhan 6 monLhs
4 erslsLenL
O asLs or expecLed Lo lasL longer Lhan 6 monLhs because lL ls relaLed Lo a chronlc lllness or condlLlon

%ls see obe toble o @ypes lolo)

Intervent|ons
O nonpharmacologlcal nurslng lnLervenLlons
4 lsLracLlon
4 Pumor
4 Muslc
4 ulded lmagery 8elaxaLlon response
4 CuLaneous sLlmulaLlon
O Massage 1LnS unlLs
cold/heaL appllcaLlon
4 AcupuncLure
4 Pypnosls


O LnvlronmenL (8ox 4312)






O AcuLe Care harmacologlcal aln 8ellef
4 nonCpold Analgeslcs



O Analgeslcs know Lhe lnformaLlon on Lhe slldes (nonoplods and oplods medlcaLlons) Alos know whlch
medlcaLlons are used Lo manage neuropaLhlc paln











































O nurslng prlnclples (8ox 4313)





















ComparaLlve poLencles range orders
O aLlenLconLrolled analgeslcs











O 1oplcal analgeslcs local and reglonal anesLheLlcs














O nurslng lmpllcaLlons















O Cancer paln managemenL












O know common slde effecLs of oplods
4 ConsLlpaLlon
4 SedaLlon
4 8esplraLory epresslon or SedaLlon
O 8esplraLory raLe less Lhan 8/mln SpC2 less Lhan 90
O naloxone (narcan) cauLlous admlnlsLraLlon (whlle provldlng resp supporL and supplemenLal
C2) wlll cause oplold reversal/paln
4 nausea and vomlLlng

O know name of reversal agenL for oplods
4 naloxone (narcan) wlll cause oplold reversal/paln










O eflnlLlons relaLed Lo Cplod aln 1reaLmenL
(8ox 4317)

O 8arrlers Lo effecLlve paln rellef (box 4316) and slldes


































O 1reaLlng paln assoclaLed wlLh Cancer WPC ladder


















O LvaluaLlon sLraLegles
















l wlll also posL Lhe aln Case sLudles we dlscussed ln class wlLh some noLes LhaL may help you




































Chapter 44 Nutr|t|on
O AnaLomy and hyslology of lgesLlve sysLem

























O leLary guldellnes lood pyramld (p 1091) 8ox 442























O Anorexla and bullmla (8ox 443)


O ConslderaLlons for older adulLs (p 1094 and box 444)

























O rug nuLrlenL lnLeracLlons (see sllde) and remember our conversaLlon abouL Coumadln and belng aware
of wheLher or noL a medlcaLlon should be glven wlLh food

















Assessment
O Mlnl nuLrlLlonal AssessmenL Lool recognlze Lhls as one of Lhe beLLer nuLrlLlonspeclflc assessmenL Lools
1here's a flgure ln Lhe book















































hyslcal slgns (1able 444)

















































O ysphagla and asplraLlon precauLlons
4 ysphagla

O Causes 8ox 447 (p 1101)











O nuLrlLlon and older adulLs (slldes) LhaL ls why ls lL more of a concern wlLh Lhls populaLlon?
4 Access Lo loods
O Pomebound lndlvlduals have hlgher nuLrlLlonal rlsks
4 Lconomlc Concerns flxed lncome dlfflculL cholces
4 MeaL (source of proLeln $$)
O AlLernaLlves Cheese Lggs eanuL 8uLLer
4 Chronlc lllness (dlabeLes renal dlsease cancer) lmpacLlng nuLrlLlonal lnLake
4 CognlLlve lmpalrmenLs (dellrlum demenLla depresslon)
4 8eadmlsslon Lo hosplLal ofLen are relaLed Lo poor oral lnLake especlally wlLh Lhe elderly populaLlon













1op|c More Deta||s
eflnlLlon lfflculLy when swallowlng
Causes Myogenlc neurogenlc obsLrucLlve and oLher
(see 8ox 447 for examples)
Slgns A cough whlle eaLlng change ln volce Lone or quallLy afLer swallowlng
CompllcaLlons AsplraLlon pneumonla dehydraLlon lmpalred nuLrlLlon welghL loss
Screenlng Assess holdlng leakage coughlng choklng breaLhlessness and quallLy of volce
Speech LheraplsL should be consulLed!

Imp|ementat|on
O AsplraLlon precauLlons (Sklll 441)

O AcuLe Care Advanclng dleLs (8ox 4410 p 1111)
speclflcally clear and full llquld
sofL mechanlcal and low sodlum

O AcuLe Care
romoLe appeLlLe and asslsL wlLh oral feedlng

romoLe AppeLlLe
4 keep free of odors
4 rovlde oral hyglene
4 MalnLaln cllenL comforL
4 Mlnlmlze medlcaLlon slde effecLs
4 romoLe soclallzaLlon durlng meals
4 ApproprlaLe use of appeLlLe sLlmulanLs
4 ApproprlaLe proporLlons (noL Loo much!)

AsslsLlng WlLh Cral leedlng
4 roLecL cllenL's safeLy dlgnlLy and lndependence
4 Assess rlsk for asplraLlon
4 CllenL wlLh dysphagla
O 30 mln resL perlod before eaLlng
O uprlghL poslLlon (hlgh fowler's)
O llex head Lo chln down poslLlon
O lf unllaLeral weakness place food on
sLronger slde of mouLh
O eLermlne Lhe vlscoslLy LhaL cllenL can LoleraLe
Lhlcker llqulds usually easler
O lquld Lypes Lhln necLarllke honeyllke and spoonLhlck
4 ysphagla
O Slowly smaller slze blLes
O lreq chewlng/swallowlng assessmenLs
O MaLch feedlng speed Lo cllenL readlness
O lnclude cllenL's food preferences requesLs and order of eaLlng
4 vlsually lmpalred orlenL Lo plaLe as lf food were on a clock
4 AdapLlve equlpmenL

O AcuLe Care LnLeral Lube feedlngs know Lhe dlfferenL Lypes of Lubes (anaLomlcally) and any speclal
conslderaLlons

4 LnLeral nurLrlLlon
O rovldlng nourlshmenL by means of a Lube ln Lhe l LracL
O CllenL ls unable Lo lngesL food buL can dlgesL and absorb nuLrlenLs
O 8ecelve formula vla nasogasLrlc gasLrlc or [e[unal (when rlsk of asplraLlon) Lubes
O lndlcaLlons for enLeral and parenLeral nuLrlLlon know Lhe ma[or caLegorles/reasons


4 LnLeral 1ube leedlng
O nasogasLrlc
O nasolnLesLlnal
O asLrosLomy
O e[unosLomy
O L
O L

4 Nasogastr|c 1ube













4 Gastrostomy 1ube












4 e[unostomy 1ube














O 1esLlng gasLrolnLesLlnal pP (8ox 4412 p 1117)

O eneral lndlcaLlons for enLeral or parenLeral nuLrlLlon (8ox 4411 p1112)



'





























O AdmlnlsLerlng enLeral feedlng (Sklll 443) and prevenLlng compllcaLlons (1able 447) Cn 1able 447 focus
on pulmonary asplraLlon dlarrhea consLlpaLlon Lube occuluslon Lube dlsplacemenL

4 AdmlnlsLerlng LnLeral leedlng
O AdmlnlsLerlng feedlng can be delegaLed Lo CnA (ote Lube placemenL verlflcaLlon) wlLh proper
lnsLrucLlon
O LlevaLe PC8 aL leasL 30 degrees or slLLlng up ln chalr
O Check order for formula raLe rouLe and frequency (formula aL room LemperaLure)
O verlfy Lube placemenL hat's the procedure?
4 1est|ng pn
O Check for resldual/ reLurn asplraLe unless over 200 ml (or agency pollcy)
O Pold feedlng lf resldual 200 ml malnLaln uprlghL recheck ln 1 hour
O lnfuse slowly lncrease amounL and raLe







































O arenLeral nuLrlLlon lnlLlaLlng prevenLlng compllcaLlons
4 arenLral nuLrlLlon
O AdmlnlsLered Lo cllenLs who are unable Lo dlgesL or absorb enLeral nuLrlLlon
(sepsls head ln[ury burns)
O nuLrlenLs provlded lnLravenously Lhrough
4 erlpheral (shorLLerm)
4 CenLral llne
O 8equlres close cllnlcal lab monlLorlng by Leam
O oal Lo dlsconLlnue and use l LracL (enLeral or oral)





4 lnlLlaLlng arenLral nurLlLlon (n)
O lnlLlaLlng n check pollcy/procedures needs ded|cated llne
O verlfy order lnspecL soluLlon (do noL confuse wlLh enLeral formula)
O MusL use an lnfuslon pump lnlLlally 4060 ml/hr gradually lncreased
O lpld emulslons admlnlsLered Lhrough separaLe perlpheral llne or ? connecLor Lublng
4 revenLlng CompllcaLlons n
O Alr embollsm durlng caLheLer lnserLlon or Lublng change
O Pave paLlenL #bear down" ln a lefL laLeral poslLlon Lo prevenL alr embollsm
O CaLheLer occluslon
O 1emporarlly sLop lnfuslon flush per agency pollcy
O CaLheLer sepsls
O Change Lublng every 24 hours n noL Lo hang beyond 24 hours use sLerlle Lechnlque dresslng
change
O MeLabollc compllcaLlons
O MonlLor elecLrolyLes blood sugar

Chapter 48 Sk|n Integr|ty and Wound Care
O undersLand skln sLrucLure











O Skln assoclaLed changes wlLh aglng (8ox 481)





















O ressure ulcers (llgure 482) paLhophyslology paLhogenesls rlsk facLors shear (flgure 483) and classlflcaLlon of
pressure ulcers (lncludlng when unsLageable) 8e able Lo dlsLlngulsh beLween Lhe dlfferenL sLages
4 Def|n|t|on ocallzed areas of cellular necrosls of Lhe skln and subcuLaneous Llssues as a resulL of unrelleved
pressure ln comblnaLlon wlLh shear and/or frlcLlon
O Cther terms pressure sores bedsores or decublLls ulcers
4 ressure ulcers (llgure 482)
O ressure ulcer wlLh Llssue necrosls







4 aLhophyslology
O unrelleved pressure on Lhe skln lnLerrupLs normal clrculaLlon by occludlng cuLaneous and subcuLaneous
blood vessels 1hls leads Lo Llssue lschemla and necrosls (Llssue deaLh)
4 aLhogenesls
O 1hree elemenLs conLrlbuLe Lo developmenL of pressure ulcers
4 lnLenslLy of Lhe pressure and caplllary closlng pressure
4 uraLlon and malnLenance of pressure
4 1lssue Lolerance
4 8lsk lacLors
O Immob|||ty aLlenLs who are unable Lo change poslLlon
O Age 1hlnnlng of Lhe skln decreased Lurgor lmpalred sensory or moLor funcLlon
O Impa|red cogn|t|on]sensory |mpa|rment Someone who has a demenLla or a dellrlum who ls unable Lo
undersLand follow or make poslLlon changes Lx a parapleglc who cannoL feel sensaLlon paln or
dlscomforL of pressure
O Mo|sture Lxcess|ve molsLure of Lhe skln lncreases Lhe suscepLlblllLy Lo damage when force ls exerLed
O Decreased nutr|t|ona| state paLlenLs wlLh low albumln are aL greaL rlsk for poor wound heallng anemla
reduces oxygen Lo Llssues
O Ir|ct|on Lhe mechanlcal force exerLed when skln ls dragged across a coarse surface such as bed
llnensaffecLs Lhe epldermls @o surfoces rubbinq toqether
O ylng on wrlnkled sheeLs
O Shear|ng pressure exerLed agalnsL Lhe skln ln a dlrecLlon parallel Lo Lhe body's surface
4 ccurs hen one /oyer of tissue s/ides over onother /oyer
4 Can occur whlle movlng a paLlenL ln bed or when a paLlenL sllps down ln Lhe bed Skln and
subcuLaneous layers adhere Lo Lhe surface of Lhe bed and Lhe layers of muscle sllde ln Lhe dlrecLlon of
body movemenL
4 Cccurs when paLlenLs are pulled raLher Lhan llfLed
4 Shear (llgure 483)
O As you elevaLe Lhe head of Lhe bed Lhe skeleLon slldes down whlle Lhe skln sLays flxed resulLlng ln shearlng











O ClasslflcaLlon of ressure ulcers (lncludlng when unsLageable) 8e able Lo dlsLlngulsh beLween Lhe dlfferenL sLages















































4 An unstageab|e u|cer ls a fullLhlckness Llssue loss ln whlch Lhe base of Lhe ulcer ls covered by slough (yellow
Lan gray green or brown) and /or eschar (Lan brown or black) ln Lhe wound bed unLll enough slough and/or
eschar ls removed Lo expose Lhe base of Lhe wound Lhe Lrue depLh and Lherefore Lhe sLage cannoL be
deLermlned (pg 1282)



O CharacLerlsLlcs of dark skln aL rlsk (8ox 482)
















O Wound classlflcaLlons (Lable 481 flgure 487)


































4 I|g 487 Wounds classlfled by color assessmenL
A 8lack wound 8 ?ellow wound C 8ed wound D Mlxedcolor wound

O rocess of wound heallng and (flgure 488)





















O Wound repalr
Wound nea||ng
4 Peallng ls Lhe Llssues response Lo ln[ury and Lhe process ls Lhe same for all wounds
4 1wo Lypes of wounds 1hose wlLh loss of Llssue and Lhose wlLhouL
O A surglcal lnclslon has llLLle Llssue loss
O Peals by primory intention where Lhe skln edges come LogeLher and rlsk of lnfecLlon ls low
4 Wounds wlLh Llssue loss (such as a pressure ulcer arLerlal or venous ulceraLlon a burn or severe laceraLlon)
heal by secondory intention
4 1akes longer as wound edges do noL approxlmaLe and Lhe wound ls lefL open unLll lL ls fllled wlLh scar Llssue
Chances of lnfecLlon are greaLer

O 1ermlnology and characLerlsLlcs of (a) slough (b) eschar and (c) granulaLlon Llssue and undersLand how you would
cleanse each
a) S|ough SofL yellow or whlLe Llssue (sLrlngy subsLance aLLached Lo wound bed) you wlll need Lo remove Lhls
before wound ls able Lo heal
b) Lschar 8lack or brown necroLlc Llssue whlch you wlll also need Lo remove before heallng can proceed
c) Granu|at|on t|ssue red molsL Llssue composed of new blood vessels Lhe presence of whlch lndlcaLed
progresslon Loward heallng (new Llssue LhaL forms Lhe foundaLlon for scar Llssue developmenL Plghly
vascular red and bleeds easlly)












I|gure 488 AWound heallng by prlmary lnLenLlon
such as a surglcal lnclslon Wound heallng edges are
pulled LogeLher and approxlmaLed wlLh suLures or
sLaples and heallng occurs by connecLlve Llssue
deposlLlon 8 Wound heallng by secondary
lnLenLlon Wound edges are noL approxlmaLed and
heallng occurs by granulaLlon Llssue formaLlon and
conLracLlon of Lhe wound edges

O 8lsk assessmenL speclflcally Lhe 8raden scale and how lL ls scored
(1able 484) -ot Lhe norLon scale
O CompllcaLlons of wound heallng poy potlnolo otteotlo t J- tbese nmpllnotlos oe mst llkely t nno
4 8|eed|ng normal afLer orlglnal Lrauma buLs sLops wlLhln mlnuLes 8leedlng LhaL occurs laLer can be due Lo a
sllpped suLure a cloL lnfecLlon or eroslon of a blood vessel ook for dlsLenslon or swelllng or Lhe change ln Lhe
amounL and Lype of dralnage
4 nematoma locallzed collecLlon of blood underneaLh Lhe Llssues
4 Surglcal lnclslons are aL greatest r|sk for bleedlng wlLhln Lhe flrsL 2448 hrs afLer surgery

4 Deh|scence When a wound falls Lo heal and Lhe layers of skln and Llssue separaLe aLlenLs
wlLh abdomlnal wounds who may be sLralnlng Lo cough movlng around ln bed vomlLlng
O arLlal or LoLal dlsrupLlon of wound layers
O aLlenLs wlll say LhaL Lhey feel someLhlng #glve"

4 Lv|scerat|on LoLal separaLlon of wound layers where Lhe organs proLrude
O Medlcal emergency
O Cover exLrudlng Llssue wlLh sLerlle Lowel soaked ln sallne

4 I|stu|a Abnormal LracL beLween 2 organs or beLween an organ
and Lhe ouLslde of Lhe body
O Chronlc dralnage rlsk of lnfecLlon
O name of flsLula deslgnaLes Lhe slLe of Lhe LracL

4 Infect|on When purulenL maLerlal dralns from lL even lf culLure ls negaLlve or noL Laken All wounds conLaln
bacLerla buL lnfecLed wounds have a hlgher colony counL greaLer Lhan 100000 org/ml
O lnhlblLs wound heallng
O Surglcal wounds may show slgns of lnfecLlon on posL op days 4 or 3
O S|gns and symptoms fever paln Lenderness and elevaLed whlLe blood cell counL
O Dra|nage may be yellow green brown and be odorous
4 1ypes of wound dralnage (1able 482)





























O revenLlon of pressure ulcers
4 ressure ulcer revenLlon
1
st
uest|on What are r|sk factors?
O Immob|||ty 1urn paLlenLs reduce shear and frlcLlon provlde pressure rellef surface provlde asslsLlve
devlces Lo lncrease acLlvlLy
O Incont|nence keep paLlenL clean and dry LolleLlng schedules
O Ma|nutr|t|on rovlde adequaLe hydraLlon and nuLrlLlon nuLrlLlonlsL referral
O Impa|red sk|n |ntegr|ty ubrlcaLe skln avold pressure do noL massage reddened areas educaLe
paLlenL/famlly
4 ressure ulcer @bee leeotlo toteqles
1 LxcellenL skln hyglene
2 Mechanlcal loadlng supporL
3 LducaLlon
4 revenLlon @opico/ 5kin core
O Avold soaps and hoL waLer
O use nonlonlc soluLlons
O CompleLely dry skln molsLurlze
O ConLaln/manage lnconLlnence
O use absorbenL pads on/y lf Lhey wlck away Lhe molsLure
O use molsLure barrlers
4 revenLlon ,echonico/ Loodinq
O roper poslLlonlng Lo reduce pressure and shear forces
4 Schedule ot /eost every 90 mlnuLes 2 hours
4 8ecommend uslng 30 degree poslLlonlng
4 use Lransfer devlces Lo reduce frlcLlon
O SupporL surfaces speclallzed devlce
4 MaLLresses
4 SpeclalLy beds
4 revenLlon ducotion
O ShlfL welghL every 13 mlnuLes
O use foam/gel pads Lo
redlsLrlbuLe welghL
O o nC1 use #donuL shaped"
cushlons or rlgld pads
O 8eason for lnLervenLlons
O Never massage Lhe area
O eoeol ooJestooJloq of nuLrlenLs
sources and role not speclflc dose
recommendaLlons (1able 483)














O lacLors lnfluenclng pressure ulcer formaLlon and wound heallng
%ee obe JooJ kepol ooJ klsk lonts)

O ressure ulcers (pp 12931294) and Sklll 481
4 8ecause pressure ulcers have mulLlple eLlologlcal facLors assessmenL for pressure ulcer rlsk (Sklll 481) lncludes
several lmporLanL facLors 1hese lnclude uslng an approprlaLe peJlntle meosoe and ossessloq Lhe cllenL's
mblllty ootltlo peseone bJy lolJs and nmt leel (pg 1293)

O SlLes of pressure polnLs (llgure 4812)
























O Wound Lypes appearance and characLer of dralnage and wound assessmenL



















I|gure 4812
A 8ody promlnences mosL frequenLly underlylng pressure ulcer
8 ressure ulcer slLes

Nurs|ng Assessment of Wounds
4 escrlbe appearance
O Are edges closed?
O Are edges lnflamed?
O ls Lhere any brulslng?
O ls Lhe surroundlng skln maceraLed or lrrlLaLed
O Measure and record lengLh/wldLh
4 ralnage
O noLe amounL color odor conslsLency(serous purulenL
seosangulneous sangulneous see p 1287)
O ook aL removed dresslng
O Strong odorposs|b|e |nfect|on

Nurs|ng rocess Assess|ng Wounds
4 Inspect|on slghL and smell
O Appearance color wound edges slgns of dehlscence
evlsceraLlon dralnage (amounL/color/odor) wound
bed perlwound surface
4 a|pat|on edema skln Lemp Lenderness lnduraLlon
4 a|n lncreased/consLanL AssoclaLed wlLh lncreased
dralnage eLc
4 Lab data lncreased W8C wound culLure

Wound C|ass|f|cat|ons
4 Intent|ona| surglcal lnclslon lv slLe
4 Un|ntent|ona| Lrauma fall accldenL lncreased rlsk of lnfecLlon
4 Cpen skln surface ls broken
4 C|osed skln ls noL broken buL Lhere ls Llssue damage/lnLernal bleedlng or ln[ury
4 Acute heal wlLhln days Lo weeks
4 Chron|c does noL progress delayed heallng

Wound Assessment
4 1ypes of emergency wounds
O Abraslons vs laceraLlons vs puncLure
4 Slze locaLlon of wound
4 Wound appearance (eg closed)
4 Wound dralnage
O Serous serosangulneous sangulneous
4 8emoval of dresslng
O Careful of heallng Llssue or dralns
O remedlcaLe 30 mlnuLes ahead of change
4 ralns check placemenL dralnage
4 Wound closures
O SLaples (sLronger less lrrlLaLlon) or suLures
O llrsL 23 days suLure/sLaple llne ls edemaLous
O lf becomes Loo LlghL rlsk for dehlscence
4 alpaLlon of wound
4 Wound culLure
O Clean wound flrsL wlLh normal sallne
O old sLandard ls Llssue blopsy





O Wound culLures Pow Lo obLaln (8ox 487)






















O ;ulck gulde for pressure ulcer prevenLlon (1able 487)











O oslLlonlng SafeLy alerL (p 1304) and supporL surfaces





4 Support Surfaces (1herapeut|c 8eds and Mattresses) A supporL surface ls a speclallzed devlce for pressure
redlsLrlbuLlon deslgned for managemenL of Llssue loads mlcrocllmaLe and/or oLher LherapeuLlc funcLlons (le
maLLresses lnLegraLed bed sysLem maLLress replacemenL overlay or seaL cushlons or seaL cushlon overlay)
1here are a varleLy of supporL surfaces lncludlng speclalLy beds and maLLresses LhaL reduce Lhe hazards of
lmmoblllLy Lo Lhe skln and musculoskeleLal sysLem

O AcuLe Care managemenL of pressure ulcers
Wound Care
4 oal Lo promoLe Llssue repalr and regeneraLlon
4 ralnlng wounds lnfecLed wounds and open wounds
4 eneral prlnclples
O AsepLlc Lechnlque
O cleanslng Lhe wound usually wlLh normal sallne(09 sodlum chlorlde)
O resslng appllcaLlon
O 8ecord flndlngs
Wound Management
4 reaL dlverslLy ln pracLlce regardlng wound heallng and Lypes of dresslngs
4 CerLlfled wound speclallsLs and enLerosLomal LheraplsL who have develop guldellnes for evldencebased
pracLlce
4 Some faclllLles have speclflc proLocols regardlng wound care

O AcuLe Care LreaLmenL of pressure ulcers (sklll 482)
know Lhe dlfferenL Lypes of dresslngs (le enzymes
hydrogel calclum alglnaLe) and Lhelr speclflc purposes

4 Assess and documenL
O ocaLlon
O Slze
O SLage
O LxudaLe
O Surroundlng skln condlLlon
4 8eassess evaluaLe LreaLmenL of acuLe wounds
every 8 hours or every dresslng change



Safety A|ert lncorrecL poslLlonlng of an lmmoblle cllenL wlll posslbly creaLe a shearlng ln[ury When
reposlLlonlng Lhe cllenL place a Lransfer slldlng board under Lhe cllenL's body CbLaln asslsLance for
reposlLlonlng and wlLh aL leasL one oLher careglver use Lhe board Lo sllde Lhe cllenL up and Loward Lhe new
poslLlon ragglng Lhe cllenL on bed sheeLs wlll place Lhe cllenL aL hlgh rlsk for shearlng and frlcLlon ln[urles

O resslngs for pressure ulcers (Lable 489)






















































O AcuLe care Wound managemenL
4 oal malnLaln physlologlcal local envlronmenL Lo promoLe heallng
4 key componenLs
O revenL and manage lnfecLlon
O Cleanse wound
O 8emove nonvlable Llssue
O Manage exudaLe
O MalnLaln Lhe wound ln molsL envlronmenL
O roLecL Lhe wound (cover sLablllze)

4 reaL dlverslLy ln pracLlce regardlng wound heallng and Lypes of dresslngs
4 CerLlfled wound speclallsLs and enLerosLomal LheraplsL who have develop guldellnes for evldencebased
pracLlce
4 Some faclllLles have speclflc proLocols regardlng wound care

O ebrldemenL know Lhe dlfferenL Lypes
Wound Debr|dement
eflnlLlon removal of necroLlc Llssue
1hree types
O ,echonico/ weL Lo dry dresslngs
4 noL used as ofLen because removes vlable Llssue
O 4uto/ytic synLheLlc dresslngs (dsg)
4 Wound base dry use dsg Lo add molsLure
4 Wound base weL use dsg Lo absorb molsLure
O 5urqico/ debridement
4 May be done by Lralned advance nurses check sLaLe pracLlce acL
4 ;ulckesL meLhod
kem|nder ound ||| not hea| un|ess contr|butory factors addressed

O urposes of dresslngs
4 roLecLlon
4 Alds hemosLasls
4 romoLes heallng
4 SupporLs or spllnLs Lhe slLe
4 vlsual proLecLlon
4 1hermal lnsulaLlon
4 rovldes molsL envlronmenL

O Wound dresslng orders and remember our class dlscusslon abouL posLoperaLlve dresslngs (Lhe flrsL one ls usually
changed by Lhe surgeon)
4 SLerlle vs clean Lechnlque
4 PealLh provlder order ls needed
O lrequency
O 1ype
O SoluLlon
4 Surglcal dresslng #relnforce prn"
4 AdmlnlsLer analgeslc
4 escrlbe procedure Lo paLlenL







O hases of wound heallng (slldes)
4 nf/ommotory phose
O SLarLs aL Llme of ln[ury and prepares wound for heallng
O LxudaLe ls creaLed from plasma and blood componenLs LhaL leak lnLo Lhe area
O WhlLe blood cells arrlve Lo lngesL bacLerla and cellular debrls macrophages
O enerallzed body response mlldly elevaLed Lemp leukocyLosls and malalse
4 9ro/iferotive phose
O 8eglns 23 days afLer Lhe ln[ury
O new Llssue sLarLs Lo flll ln Lhe wound space caplllarles grow across Lhe wound and
O 8lood flow ls relnsLlLuLed
O new Llssue ls called granu|at|on t|ssue forms Lhe foundaLlon for scar Llssue developmenL
4 Plghly vascular red and bleeds easlly
4 emode/inq or moturotion phose
O 8eglns abouL Lhree weeks afLer Lhe ln[ury
O Collagen conLlnues Lo be deposlLed and galn sLrengLh
O Wounds LhaL heal by secondary lnLenLlon Lake longer Lo remodel and form scar Llssue
O Pealed wound does noL recover Lenslle sLrengLh of Llssue lL replaces

O lacLors affecLlng wound heallng
4 Age chlldren and healLhy adulLs heal more rapldly
4 1|ssue perfus|on]oxygenat|on dellvery of nuLrlenLs/removal of Loxlns
4 Nutr|t|ona| status proLelns and vlLamlns help wlLh Lhe heallng process
4 Wound cond|t|on large conLamlnaLed eLc
4 nea|th status chronlc lllness medlcaLlons

O CompllcaLlons of wound heallng and pay parLlcular aLLenLlon Lo WPLn Lhese compllcaLlons are mosL llkely Lo occur
%ee be llJes)

O WCCn 8ecommendaLlons (8ox 4812)

























O Applylng dry and molsL dresslngs (sklll 483)

O Changlng dresslngs packlng wounds and securlng dresslngs














O vacuum asslsLed closures











O 8aslc skln cleanslng (p 1324)

8as|c Sk|n C|eans|ng Cleanse surglcal or LraumaLlc wounds by applylng noncyLoLoxlc soluLlons wlLh sLerlle gauze or
by lrrlgaLlon 1he followlng Lhree prlnclples are lmporLanL when cleanslng an lnclslon or Lhe area surroundlng a
draln
1 Cleanse ln a dlrecLlon from Lhe leasL conLamlnaLed area such as from Lhe wound lnclslon Lo Lhe
surroundlng skln or from an lsolaLed draln slLe Lo Lhe surroundlng skln
2 use genLlle frlcLlon when applylng soluLlons locally Lo Lhe skln
3 When lrrlgaLlng allow Lhe soluLlons Lo flow from Lhe leasL Lo mosL conLamlnaLed area (Sklll 483)

Wound C|eans|ng
4 use noncyLoLoxlc cleansers
O normal sallne
O Commerclal cleansers
4 o NC1 use cyLoLoxlc cleansers ln clean granulaLlng wounds
O aklns soluLlon
O 8eLadlne (povldonelodlne)
4 8e careful of pressure wlLh lrrlgaLlon
4 use 19 gauge needle 33 m syrlnge

O erformlng wound lrrlgaLlons %sklll 485)





O PeaL and cold Lherapy locus on Lhe slldes






















































O 8lsk and safeLy of heaL/cold Lherapy ( 1able 4810 8ox 4813)



































As remlnder (and based on quesLlons l've recelved) you need Lo be famlllar wlLh sLerlle vs clean dresslng changes
As you may remember we Lalked abouL Lhls ln class Clean dresslng Lechnlque can be used ln Lhe home seLLlng and
sLerlle dresslngs are done ln acuLe care seLLlngs
















Med|cat|on Ca|cu|at|ons 1here wlll be four quesLlons LhaL lnclude oral medlcaLlons lv raLes vla pump or gravlLy
and parenLeral ln[ecLlons (subcuLaneous and/or lnLramuscular)