Flashcards in NSG 1101 Unit i & II Deck (20):
Factors that would influence performance of an intervention
■culture - understanding other cultures
■religion - can place restrictions on care
■health beliefs - what is the patient's definition of wellness and/or health
■developmental stage - from infancy to geriatrics
■Maslow - physiologic, safety, love and belonging, self esteem, self actualization
■resources - ■client - insurance
■facility - PET scanner
critical thinking & solve problem by
■assessment - identify assessment data and where can the data be found
■analysis - clusters and interprets all the data collected
■planning - defining outcomes acceptable to the family and patient
■interventions - specific strategies developed to achieve positive patient outcomes
■evaluation - compare to the outcomes. Plan of care can be revised at this time.
Three layers of skin
The outer layer of the skin which is thin but tough. Most epidermis is 4 layers but on the soles of the hands and feet it is 5 layers.
The second layer of the skin is the inner supportive layer consisting of connective tissue, the nerves, sensory receptors, blood vessels, hair follicles, sebaceous glands, and sweat glands are embedded in the dermis.
This layer is composed of adipose tissue and connects the skin to underlying structures. This layer stores fat for energy, provides insulation for temperature control, and helps with protection of underlying structures because of its cushioning effect.
Functions of the skin
1.The skin is the first line of defense against microbes. It protects the body as a physical barrier.
2.The skin assists in regulating body temperature by production of perspiration which evaporates and carries off heat from the body surface and lowers body temperature.
3.The skin is a sensory organ that responds to heat, cold, touch, pain, and pressure.
4.The skin aids with Vitamin D synthesis.
Increased body temperature
Warmth at the site
The reduced blood flow causes the skin to blanch (pale color), as if the blood has been squeezed out of it. When the pressure is relieved the skin turns bright red due to the blood flow returning to the tissues.If the pressure is not relieved then the skin becomes cyanotic.
Decubitus Ulcers –Pressure Sores
These localized areas of skin breakdown occur due to unrelieved pressure that leads to the damage of underlying tissue. Pressure ulcers are located over bony prominences or any area of prolonged and unrelieved pressure.
stage of pressure ulcers
Stage 1 - Non blanching erythema of intact skin. This condition signals potential ulcer formation.
Stage 2- Partial thickness skin loss that involves the epidermis, dermis or both.This ulcer is superficial and resembles an abrasion or blister.
Stage 3 - Full thickness skin loss that involves the subcutaneous.
This stage resembles a deep crater with or without undermining of the surrounding tissue.
Stage 4 - Full thickness skin loss with extensive destruction of tissue involving damage to muscle, bone, tendons and ligaments.Tissue necrosis is also present. Sinus tracts or undermining (tunneling) of tissue may also be present.
Factors that contribute to dehiscence and evisceration are
The term asepsis is the absence of disease producing organisms. Aseptic techniques refers to practices that keep a patient as free from microbes as possible.
2 Types of asepsis technique
1) medical asepsis- clean technique
2) surgical technique - sterile technique
Medical asepsis - clean technique
Includes procedures to reduce and prevent the transmission of microoganisms.
Examples are: Handwashing, using clean gloves, cleaning the environment routinely and isolation.
Nurses follow the principles and procedures to prevent infection and control it spread.
Surgical technique - sterile technique
Includes produces to eliminate all microbes, from an object or area.
In surgical asepsis an object is considered contaminated if touched by an object that is not sterile.
The nurse uses surgical asepsis at the patient's bedside performing procedures such as: inserting an IV or urinary catheter, suctioning, and reapplying sterile dressings.
Principles of Sterile Technique
1)Sterile touching clean becomes contaminated
2) Touch only the 1 inch edge of a sterile package or a sterile field
3) Avoid passing over the sterile field with unsterile items
4) Keep sterile gloves and sterile equipment above the waist level and in the line of vision at all times
5) Moisture from an unsterile surface that comes in contact with a sterile object or sterile field causes contamination
6) Open sterile wrapped packages from distal to proximal
7) Date and time sterile solutions when opening
8) Consciousnesses, alertness, and honesty are essential qualities in maintaining sterile technique
Common types of drains
PENROSE-Open Drainage System
JACKSON-PRATT-Closed Drainage Systems
HEMOVAC-Closed Drainage Systems