248 Test 2

• Stratum Corneum
• Epidermis
• Dermis

• Pressure intensity
• Pressure duration
• Tissue Tolerance

• Impaired sensory perception
• Alterations in LOC
• Impaired mobility
• shear
• friction
• moisture

• Use natural or halogen lighting
• color will be darker than the surrounding skin
• skin will feel warmer in beginning of sore formation, will get cooler as circulation is lost
• skin will feel softer or have edema
• skin will appear taught, shiny or scaly

• I - intact skin with nonblanchable redness
• II - partial thickness skin loss involving epidermis, dermis or both
• III - full thickness tissue loss with visible fat
• IV - full thickness tissue loss with exposed bone, muscle or tendon

• Suspected deep tissue injury - depth unknown
• Unstagable - depth unknown

• Age related skin changes (reduced skin elasticity, decreased collagen and thinning of underlying muscles and tissues)
• co-morbidities and polypharmacy
• slow healing
• hypodermis thin
• nutritional deficiencies

• Norton - score of 14 or less is at risk
• Braden - lower score means greater risk, 18 or less is at risk

• sensory perception
• moisture
• activity
• mobility
• nutrition
• friction and shear

• nutrition (need protein and calories)
• tissue perfusion
• infection
• age
• psychosocial impact (affect of wound on body image, mobility)

• Primary - Wound is closed. Example is surgical incision that has been sutured or stapled. heals by epithelialization and quickly with minimal scar formation
• Secondary - Wound edges are not approximated and healing occurs by granulation. Example is pressure ulcer, surgical wound with tissue loss.
• Tertiary - Wound left open for several days then edges are approximated. Example is wound that is contaminated (after trauma). Left open to clean and drain and closed later.

Lasts 1-3 days, is the body's immediate reaction. In a clean wound this phase accomplishes control of bleeding and establishes a clean wound bed.

Occurs in days 3-24 after wound formation. Main activities are filling of wound with granulation tissue, contraction of wound and resurfacing by epithelialization. Fibroblasts synthesize collagen.

Takes place for up to a year after wound formation. Collagen fibers undergo remodeling or reorganization before assuming their normal appearance.

24-48 hours after surgery

• appearance
• character of drainage
• drains, closures
• palpation
• cultures

• color
• amount (# and weight of dressings)
• odor
• consistency
• Descriptors - serous, serosanguinous, sanguinous, purulent

It must be cleaned with saline

• Hemorrhage
• Infection
• Dehiscence - partial separation of edges
• Evisceration - total separation with organ protrusion
• Fistula

• Protection from microorganisms
• aid in hemostasis
• promotion of healing by absorbing drainage and debriding a wound
• supports wound site
• protects client from seeing wound
• thermal insulation for wound
• provides moist environment

• 1. Gauze - dry sterile
• 2. Gauze - wet sterile (wet to dry - a form of mechanical debridemant, wet to wet - topped with dry, to keep moist for healing
• 3. Hydrocolloid - protects wound from surface contamination
• 4. hydrogel - maintains a moist surface to support healing
• 5. Wound VAC - uses negative pressure to support healing

• The dressing part forms a gel that keeps the wound moist and supports healing in clean, granulating wounds. They protect the wound from contamination and autolytically debride necrotic wounds.
• Most useful in shallow to moderately deep dermal ulcers.

• They are soothing and reduce pain, provide a moist environment, debride the wound by softening necrotic tissue and are easy to remove.
• They are used in partial-thickness to full thickness wounds, deep wounds with some exudate, necrotic wounds, burns and radiation damaged skin.

• it applies negative pressure to draw edges of wound together, evacuates wound fluids, stimulates granulation, reduces bacteria and maintains moist environment.
• It is used for acute and chronic wounds.

• start in the middle and work out
• never go back to middle with same swab
• usually dome 3 times
• may irrigate to flush debris
• assess for tunnelling

• chemical - enzymes, Dakins
• mechanical - wet to dry, don't do on clean, granulating wounds
• autolytic - use of a synthetic dressing with enzymes (hydrocolloid)
• Surgical - use of a scalpel or scissors

Normal capacity is 600ml, sensed at 150-200ml

• disease conditions - diabetes, prostate etc
• sociocultural norms - need for provacy
• psychological factors - anxiety, emotions
• fluid balance - between retention and excretion
• surgical procedures - stress response --> increased ADH
• medications - diuretics
• diagnostics

An accumulation of urine due to the inability of the bladder to empty. Normal amount voided is about 150ml, their amount is 50ml. Overflow can occur. Concern is infections, common in post surgery patients or hypertrophy of prostate

May occur from catheterization, accounts for 40% of HAI's. May lead to sepsis. More common in womenthan men

It is a urinary diversion where a tube is placed into the renal pelvis.

a part of the patient's ileum is taken and the ureters are implanted into it. It can either be made into a continent diversion (needing intermittent catheterization) or an incontinent diversion (with an external pouch)

A catheter left in place above the pubic bone that comes to a bag

• skin and mucosal membranes
• kidneys
• bladder
• urethral meatus - check for discharge
• urine and urine testing
• I and O

• if unable to control micturation
• urinary obstruction or retention
• relieve distention
• assess urine output in unstable patients
• skin conditions or wounds irritated by urine contact

• maintain closed system
• hang bag on bed-frame, not side rail, not floor
• never raise bag above level of bladder
• empty bag at spigot
• obtain urine specimen at specific port in catheter using sterile technique
• check tubing for kinks, bends etc.
• maintain good perineal and catheter hygiene

• to help promote lifelong health habits that facilitate regular bowel elimination
• alleviate symptoms and prevent complications due to bowel elimination problems

• Age - elderly are at increased risk of incontinence and constipation
• Diet and fluid intake - fiber!
• Physical activity - activity promotes peristalsis
• Psychological factors - stress increases peristalsis, depression reduces
• Personal habits - privacy
• Position - immobilization, laying supine makes it impossible to contract muscles needed
• Pregnancy - constipation and hemorrhoids
• Surgery and anesthesia leading to paralytic ileus
• Medications
• diagnostic tests

• constipation
• fecal impaction
• diarrhea - c.difficile
• incontinence
• flatulence
• hemorrhoids

• Stoma - artificial opening in the abdominal wall
• Colostomy - colon is brought through the abdominal wall
• Ileostomy - ileum is brought through the the abdominal wall.

A temporary colostomy - usually done in emergency - done in the transverse colon. Two openings - one for stool and one for mucus.

Proximal end forms stoma and distal end is either removed or forms "Hartman's pouch" (useless). Often a result of colorectal cancer or diverticulitus.

The bowel is surgically cut and both ends are brought through the abdomen. The proximal end is for stool, distal is nonfunctioning.

• History
• lab data
• diagnostic examinations
• stool characteristics

• bowel incontinence
• constipation (or risk of)
• diarrhea
• toileting self care deficit

• evaluate medications
• increase activity
• assess hydration
• increase fiber to 20gm/day
• caution with stimulant laxatives

• put on clean gloves and provide privacy, gather materials
• assess for abdominal distention and bowel sounds
• place client on left side in sims position
• insert lubricated tip 3-4 inches
• open clamp and allow to flow, raise to appropriate height.

digital removal may be performed if enemas fail. May cause vagal nerve stimulation so monitor heart rate, need provider order

• decreased oxygen carrying capacity - anemia and inhalation of toxic substances (CO)
• decreased inspired oxygen - airway obstruction, decreased environmental O2, decreased inspiration (drugs)
• hypovolemia - decreased circulating blood (shock, severe dehydration)
• increased metabolic rate - pregnancy, wound healing, fever, exercise

• pregnancy
• obesity
• musculoskeletal abnormalities
• trauma
• neuromuscular diseases - myansthenia gravis, guillain-Barre, polio
• CNS alterations - medulla or spinal cord affected
• chronic disease

• hyperventalation
• hypoventalation
• hypoxia - inadequate tissue O2 at cellular level

• TB tests are frequently false positive because of changes in immune system
• mental status changes are the first sign of respiratory distress
• Older adults may not complain of dyspnea until it affects ADLs
• changes in cough lead to retention of secretions, airway plugging and atelectasis. Caution should be used with cough suppressants.

• early - tachycardia, changes in mental status or LOC, restlessness
• late - hypotension, bradycardia, cyanosis, shock

• pain
• dyspnea
• wheezing
• respiratory infections
• health risks
• smoking
• cough
• exposures
• allergies
• medications

• chest x ray
• tb testing
• thoracentesis - perforation of chest wall and pleural space and gathering of plural fluid
• pulmonary function tests
• diagnostic blood tests
• bronchoscopy - looking at bronchi with a fiberoptic scope, specimen is obtained
• ventilation scan
• sputum specimen

• activity intolerance
• anxiety
• impaired gas exchange
• ineffective airway clearance
• ineffective breathing pattern
• fatigue

When patient is unable to clear airway or cough effectively

• sterile procedure
• suction set at 100-150mmHg
• insert catheter, suction intermittantly for 10-15 seconds, rotate slowly and withdraw
• monitor patient for hypoxia, hypotension, arrythmias, trauma, irritation

• potentially hazardous complication from suctioning, can lead to bradycardia
• (Vagus nerve is 10th cranial, has sensory motor functions and a wide distribution)

• used for patients with decreased consciousness or airway obstruction
• Oral airway - displaces tongue
• endotrachial airway - placed for a short term airway to assist with ventalation
• tracheostomy - surgical incision providing a longterm airway

• Positioning (every 2 hours) - semi-fowlers or Fowlers optimal
• Incentive spirometry

• to remove air and fluid
• to prevent air or fluid from reentering the pleural space
• to reestablish normal pulmonary pressures

• maintain secure, airtight seal
• maintain underwater seal
• monitor and secure all connections
• observe for bubbling
• monitor tubing
• record output
• monitor patient
• dressing changes per policy

• room air - 21%
• nasal cannula - 1-6lpm, 24-44% o2
• simple mask - 5-8lpm, 40-60% O2 (estimated)
• Venturi mask - 4-12 lpm, 24-60% O2 (more precise)
• Nonrebreather 6-10 lpm, 60-95% O2

• hydration - thin secretions
• coughing - cascade and huff
• respiratory muscle training
• breathing exercises - pursed lip, diaphragmatic

• Plasma proteins - pre-albumin, albumin, transferrin, iron binding capacity
• Other indicators - urinalysis, stool, h&h, blood glucose, BUN, creatinine, electrolytes

• promote safety, dignity and independence
• speech and swallow consult
• patient in upright position, tuck chin, food in correct side of mouth
• food must be correct consistency
• feed slowly with small bites
• provide rest periods

• clear liquids
• full liquids
• pureed
• mechanical soft
• soft/low residue

• EN - provides nutrition to the GI tract via tubes
• TPN - provides nutrition requirements IV (IV if under 10% dextrose or central line if over)

• Polymeric - Whole nutrient formulas (blenderized or Ensure)
• Modular - single nutrient, not complete (protein, glucose)
• Elemental - predigested - illness specific

Full strength, slow rate. Increase every 8-12 hours and assess for intolerance/complications

• pulmonary aspiration
• diarrhea
• bacterial contamination
• constipation
• tube occlusion
• delayed gastric emptying

• x-ray (best)
• ph of gastric aspirate under 4
• aspirate color
• NOT auscultation

• 24 hour infusion with contents double checked by 2 RNs
• IV bag and tubing changed every 24 hours
• Tubing and ports used for TPN and lipids NOT accessed for any reason
• Dedicated and labeled port