test #2 Flashcards
Bathing
- intact skin is 1st line of defense against infection
- regular bathing: increases circulation, maintains muscle and joint mobility, promotes relaxation, provides and sense of wellbeing and comfort, time for assessment and interaction
- wash from clean to dirty
- maintain privacy and dignity
- incorporate patient preferences and values
- distal to proximal increases venous return
- basin bath is associated with increase in infection rates
- turn unconscious patient to side for oral care
Oral Care
- increases saliva, taste, and comfort
- prevents pneumonia
Foot care
- important for diabetic patients and peripheral vascular disease
- do not soak feet: dryness, cracking, skin breakdown, increases infection risk
- assess for temperature, circulation, sensation, wounds
Feeding
- dysphagie, difficulty swallowing
- supervise
- assistive devices
- separate flavors
Toileting
- provide privacy
- provide hand hygeine for patient
- assess need for assistance with peri-care
critical evaluation of bathing
- check for self-care deficits
- lack of knowlege
- lack of resources
- mental disability
- cultural issues
- use this in your care plan
Self Care Deficit
Nursing Diagnosis
- bathing r/t confusion, fatigue: AEB unwashed hair, body odor, incontinent episode
- Feeding r/t unilateral wekaness, difficulty AEB right sided weakness, inabikity to feed self, weight loss of 1 lb in 5 days
Planning/Goal/Outcome
- overall goals are increased independence and safety
- pt will participate in hygiene routine this morning
- pt will demonstrate ability to feed himself using assistive decives within 24 hours
Implemmentation
- assess functional abilities/deficits
- assess resources available: education, referrals, encouragement, available aids
Evaluation
- was the goal met?
- if yes, move to higher level goal with more independence
- if not, reassess needs, methods, ongoing goals
- > 75% of all meals today using assistive utensils, continue with plan; OT to assess food preparation needs/abilities prior to discharge in 48 hours
Pressure Ulcer Staging
*Braden Scale is uses for predictiing pressure ulcers. higher score = worse
stage 1: intact skin with nonblanchable redness of localized area, usually over bony prominence. Area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. May be difficult to detect in darker skin tones
stage 2: partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister
stage 3: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. may include undermining or tunneling.
stage 4: full-thickness tissue loss with exposed bone, tendon, or muscle. slough or eschar may be present on some parts of the wound bed. often includes undermining and tunneling. can extend into muscle or fascia, tendon, joint capsules. Osteomyelitis is possible
Unstagable: full-thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed. true depth cannot be determinied until slough is removed
Risks for pressure ulcers
- immobility: unable to move independently
- impaired perception: unable to sense pain/pressure
- altered LOC: confused, unable to communicate pain, coma
Shearing
- skin moves one way, muscles slides another way
- can occure when raising head of bed, transferring patient by sliding, stretching of skin, tears capillaries, necrosis leads to underminig of tissues
Friction
- top layers of skin
- sliding across coarse linens, seats
Wound Healing
Primary Intention
- surgical wound
- clean edges, approximated (closed)
- low risk of infection
- quick healing, fine scar
Secondary Intention
- trauma, ulcer, dehisced wound
- open, filled with scar tissues, deep scar
- slow healing, increased risk of inection
Wound Dressings
- Purpose of Dressings: provide right environment to enhance and promote wound healing, moist healing environment stimulates cell proliferation and encourages epithelial cells to migrate, provide barrier against bacteria, decrease or eliminate pain
- Gauze: draiing wounds, necrotic wounds, wounds requiring debridgement or packing, wounds with tunnels, surgical incisions, dermal ulcers, pressure ulcers
- impregnated with antimicrobial: Iv sites, trach, drains, full-thickness wounds
- transparent films: let oxygen pass through the wound and moisture vapor exit, partial thickness wounds, stage 1 and 2 ulcers, superficial burns, donor sites
- tegederm: IV, central lines, skin protection dressing
- Foam: nonadherent and nonocclusive, stage 2 and 4 ulcers, partial and full-thickness wounds with minima to heavy drainage. surgical wounds, dermal ulcers, under compression wraps
- non-adhesive foam dressing: leave for a few days and sucks out infection
- composite dressings: cmobination of two or more different products in one, bacterial barrier, absorptive layer, foam, hydrogel,
- heat therapy: increase blood flow, limit time, evenutally vasoconstriction occurs. 1st vasodilate, then vasoconstrics
- cold therapy: decreases swelling and pain, first vasoconstricts then vasodilates
Dehiscence
- wound opened up
- ## most likely day 4-5 post op
Pressure Ulcer Nursing Plan
Nursing Diagnosis
- impaired skin integrity related to unrelieved, prolonged pressure AEB full thickness pressure ulcer on L heel
- risk of infection
- imbalanced nutrition
- pain, chronic or acute
- impaired mobility
- impaired skin integrity
- ineffective tissue perfusion
- alteration of body image
Plan
- on-going skin assessment
- nutritional assessment
- pressure relief for affected areas
- preventative care for intact skin
- restoritive care for wounds
Goals
- pressure ulcer will not increase in size this shift/during hospitalization
- pt will be free of symptoms of infetion in pressure ulcer this shift
- pt will eat a balanced, high protein diet today, while in facility
- pt and family will develop a plan for preventing further skin breakdown within two days
Interventions
- RN to assess skin every shift, document including size and appearance of wounds
- RN will provide wound care per policy every shift as needed
Outcome Evaluation
- goal not met: by discharge date, patient had developed stage 1 ulcer on rt hip — revise and update plan for ulcer prevention
- goal met: pt afebrile, wound culture negative, continue with plan
- goal met: patient has gained 3lbs this month and serium proteins have increased
Types of Interventions
- Nurse Initiated: independent
- Physician Initiated: Dependent
- collaborative: interdependent
key points
- pressure ulcers: painful, decrease mobility, increase cost and length of stay, they are preventable
- braden scale and staging
- assess all pts for risks to skin integrity
- wound assessment and documentation
- control bleeding, clean , protect
- wound care: least to most contaminated
- increase protein, vitamin c, calories for healing
Integumentary system consists of
skin, protection
hair, cosmetic
nails, cosmetic
skin assessment: - largest organ of body - protection: regulates body temp maintains fluid and electrolyte balance can repel microoraganisms (keratin) can alarm the body that something is wrong many sense receptors to allow the use of touch
epidermis
- outer layer of skin
- doesn’t have its own blood supply
- keratin makes the o uter layer waterproof
- vitamin d is activated by uv light then distributed to intestines and promotes updtake of calcium
- melanocytes give color to skin
- darker tones have bigger melanocytes
Hair
- hair located in dermis, but extend into epidermis
- growth occurs in cycles
- hair color is genetically determined by person’s melanin production
- premanent baldness is genetic
nails
- useful for grasping and scraping
- clubbing of nails shows lack of oxygen
- brittle nails shows lack of nutrients
- assess for: color, shape, thickness, texture and lesions
- color depends on: nail thickness, # of RBCs, arterial blood flow and pigment deposits
- aging increases nail thickness
- blanch nail beds less than 3 seconds
skin assessment
- 1st take history: OTCs, herbal meds, allergies, nutriton, hydration status, edema, lesions, cleanliness, pruritis, zerosis (dry skin), lichenification (exsima).
- edema: skin is shiny, tight, decreased elasticity, check for pitting, petechiae, bruises, skin tears
Hair Assessment
- Assess for: cleanliness, quantity, quality, itchy (lice, nits), check pubic hair, scaling, redness, open areas, crusting, tender spots, sudden patches of hair loss, hirsutism
skin infections
Bacterial Infections
- folliculitis: isolated pustules, may have hair growing from it
- furuncle: pus filled
- cellulitis: red or darker in dakr skiinned
Viral Infections
- Herpes Simplex: patches, vesicles evolve to pustules, which rupture and week and crust
- herpes zoster: similar to simplex but present in a line, along cranial or spinal nerves
Fungal Infections
- candidiasis: skin folds, reddened, macular, oral, whitish plaques
Wound healting
First intention
- can be easily “put back”
- straight line
- closing wound immediately helps connective tissue repair
Second intention
- Deeper injuries with tissue loss (pressure ucler) have cavity open wound that has to heal from fradula filling up the wound with connective tissue
Third Intention
Delaying closing the wound, waiting for infetion or erythema to decrease and then closing it by primary intention (surgical wound where trauma happened under nonsterile conditions). clear out the wound then put it back together as best you can
Pressure Ulcers
- tissue compresion from pressure
- restriced blood flow and o2 to tissue
- cells die
- reposition every hours in a chair and every 2 hours in a bed
