Flashcards in Inflammation, Wounds, and Pressure Ulcers part 7 Deck (25)
What is the assessment for pressure injuries?
-past med history
-functional health patterns
-assessment findings: integumentary and diagnostic findings
Acute care pressure injuries care
-do not turn patient onto unblanchable skin
-do not massage
-lift versus sliding when repositioning
What area of the body do you not debride?
Explain nursing care of pressure injuries
keep wound bed moist
-do not disrupt new granulation tissue
-avoid cytotoxic cleaning
What labs would make a pt nutritionally at risk?
Hgb-A1c > 6.5%
How do you document a wound?
location - specifically
-size: length (head to toe), width (hip to hip), depth (deepest point)
-measure in cm
-tunneling: measure using a clock
-edges: approximation (edges meet), rolled, jagged, undermining
-wound base: granulation, epithelialization, necrotic tissue (slough, eschar, adherence)
-drainage: serous, sanguineous, sero-sangineous, purulent, odor, amount
Who performs the first dressing change 24-48 hours after surgery?
What are the types of debridement?
-autolytic: dressing (clear) and bodys own mechanisms
-enzymatic: commercially prepared enzymes
-mechanical: physical force (dry and wet dressing to remove
-surgical/sharp: using an instrument
What are the 3 basic tyes of dressings?
-keep wound tissue moist and surrounding skin dry
remain for 4-7 days
-use for stage 1 pressure injuries
-facilitate autolytic debridement
-use for stage 2 and 3
-use for high riskfriction areas
-wounds with necrosis or slough
-not for infected wounds
hydrocolloid EX duoderm
-use for 3-5 days
-use for stage 2-4
-absorb light to heavy
Foams EX: Mepilex
Removes excess fluid
Promotes moist wound environment
Stage 3 of 4 PI
Arterial, venous, and diabetic ulcers
Dehisced surgical wounds
Infected wounds, skin graft sites
Full thickness burns
negative pressure wound vac
What vitamins are good for nutrition therapy for wound healing?
C and B
increases amount of oxygen dissolved in plasma
Promotes cell proliferation and healing,
Increases wound metabolism,
Promotes an increased response to growth factors, stimulates development of blood vessels,
antibacterial and antioxidant effects, improve immune function
What are some nursing interventions for the immobile older adult?
increase protein, calcium, and D
reduce risk of falls
What does immobility do to the cardiovascular system?
-increases workload of the heart
-increases risk of orthostatic hypotension
-increases risk for venous thrombosis
What does immobility do to the respiratory system?
-decreases depth of resp
-decreases rate of resp
-pooling of secretions
-impaired gas exchange
What does immobility do to the GI system?
-disturbance in appetite
-altered protein metabolism
-altered digestion and utilization of nutrients
What does immobility do to the urinary system?
-increased urinary stasis
-increases risk of renal calculi (stones)
-decreases bladder muscle tone
What does immobility do to the musculoskeletal system?
-decreases muscle size, tone, strength
-decreases joint mobility and flexability
-decreased endurance and stability
-increased risk for contracture formation
What does immobility do to the metabolic system?
-increased risk for electrolyte imbalance
-altered exchange of nutrients and gases
What does immobility do to the integumentary system?
increases risk for skin breakdown and formation of pressure injuries