Fundie Final

Antiembolic Stockings - expected outcomes

○ No evidence of skin irritation or breakdown
○ No evidence of VTE
○ Decreased edema in lower extremities
○ Increased circulation to lower extremities
○ Pt able to demonstrate correct application of antiembolic stockings, ifappropriate

Antiembolic Stockings - Gerontological considerations:

○ Perform comprehensive assessments for older adults
○ Normal physiological aging can mask signs of venous insufficiency
○ May experience muscle wasting b/c of aging process
***Ensure correct fit***

Antiembolic Stockings - pediatric considerations

- Not generally used with younger children
○ Used when conditions warrants and sizes are available for pediatric needs
○ When correct size is not available, elastic wraps can be used

Antiembolic Stockings for what?

Sequential compression devices used for venous thromboembolism prevention only and should not be applied if VTE is suspected (s/sx of VTE include a swollen extremity, pain, warm, discolored skin, and elevated temp)

● The use of antiembolic stockings increases the risk of disruption to a pt's skin integrity

arterial blood

oxygenated blood in circulation, found in arteries, pulmonary veins, and left chambers of heart, carries blood away from heart into body, bright red, driving force of this is the heart's contraction/pumping force, normal pressure is 120/80mmhg

biohazard containers: black (4)

(RCRA hazards)

RCRA labeled,
P/U/D/ listed chemicals, aerosols
inhalers

biohazard containers: blue (4)

(pharmaceutical)

antibiotics,
expired pills,
unused drugs
vaccines

biohazard containers: red (5)

sharps

- needles
- staples
- ampules
- glass
- trocars

biohazard containers: red linen/conatiner (6)

(biohazard)

blood items,
PPE,
cultures,
IV tubes,
waste/feces,
infectious things

biohazard containers: Shielded containers w radioactive logo

inorganic compounds like cesium, cobalt, iodine, radium, plutonium, uranium

biohazard containers: yellow (4)

(trace/residual chemo)

empty IV bags,
medication vials,
syringes,
packaging

Body's Defense Against Infection:

§ Body's normal flora
§ Inflammatory response way of protecting itself
§ Immune response body creates antibodies to protect and defend itself from foreign antigens

Charting by exception

A shorthand method of documenting patient systems, using standard practice and pt norms to avoid charting redundancy and saving healthcare providers time and money; e.g. not charting a patient's temperature bec she "charted by exception" due to the fact that the temperature must have been normal bec it wasn't charted

Cleaning a Pressure Injury/Wound

Clean with each dressing change.
· Use new gauze for each wipe and clean from top to bottom and/or from the center to the outside.
· Use 0.9% normal saline solution to irrigate and clean the injury.
o Pressure wound irrigation does NOT count as intake
· Once the wound is cleaned, dry the area using a gauze sponge in the same manner
· Report any drainage or necrotic tissue
· If it's wet, we dry it - if it's dry, we wet it!

close system drains

drain into suction device for drainage to be measured as output

ex: jackson pratt, hemovac, pigtail

Colostomy Care

Keep the patient as free of odors as possible; empty the appliance frequently.
Inspect the patient's stoma regularly.
Note the size, which should stabilize within 6 to 8 weeks.
Keep the skin around the stoma site clean and dry.

Colostomy vs. Ileostomy

A colostomy is an operation that connects the colon to the abdominal wall, while an ileostomy connects the last part of the small intestine (ileum) to the abdominal wall.

Deep tissue pressure injury:

persistent nonblanchable deep red, maroon, or purple discoloration

Depezzer mushroom -

self retaining; for female patients w short urethra

dietary intake food consumption guide
- refused

0%

refused meal completely or consumed only one or two bites of each item

dietary intake food consumption guide - all

entire meal is consumed except for a minimal amt of food

dietary intake food consumption guide - fair

50%
- approx half of food is consumed - 50% ENTRE AND 20% OR VEGETABLE AND SOUP LEFT

- if just entre is consumed but no other food then it would be poor not fair

dietary intake food consumption guide - good

75%

- majority of meal consumed but significant amt of one or more items left

dietary intake food consumption guide - poor

25%

- approx 25% of entre or 50% of one item consumed

Documentation should address what?

Admission data
Assessment
Plan of care
Education
Treatment and interventions
Patient response
Discharge planning

documetnation should be ... ?

- factual
- accurate
- complete
- current
- organized
- confidential
- legally prudent

focus charting

Addressing pt concerns

french sizes
- peds
- adult female
- adult male
- clot retentiion

Peds - 6-10
Adult female- 12-14
Adult male - 14-18
Clot retention - 20-22

Hemovac drain

for large deep wounds bc its too much to pack. Constantly sucks drainage from wound bc healing process takes forever and at risk for infection (continuous drainage system)

how often should foeys be changed?

every 30 days

how often should foly care be performed?

every 4 hours

if idodine allergy, what do you clean the perineal area with for foley care?

surgical alcohol swab

In and out/intermittent catheter

straight cath; one time use then discarded; used when obtaining urine cultures or for those who conduct this at home

incident report

like the patient falling or involving an injury, they do NOT go in the medical record

Jackson-Pratt drain

usually in abdominal cavity, end looks like bulb/grenade

making a bed can be delegated to who?

Can be delegated to UAP, licensed practical/vocational nurses. Decision to delegate must be based on analysis of pt's needs and circumstances and qualifications of person whom the task is being delegated to.

Malecot wing: s

self retaining (shape of catheter holds itself up in the bladder); for patients going into renal or bladder surgery or traumatic procedure

Measurement of Pressure Injury

- Size of wound
- Depth of wound
- Presence of undermining, tunneling, or sinus tract
- PUSH Tool 3.0

nursing process

Assessment
Diagnosis
Planning
Implementation
Evaluation

objective data

what is observable and measurable

open system drains

drains into some gauze or dressing

ex: penrose

penrose drain

a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing

- can't measure exact amount of drainage, can just document saturation appearance on the gauze/dressing

Phases of Wound Healing: Hemostasis

Occurs immediately after initial injury
Involved blood vessels constrict and blood clotting begins.
Exudate is formed, causing swelling and pain.
Increased perfusion results in heat and redness.
Platelets stimulate other cells to migrate to the injury to participate in other phases of healing.

Phases of Wound Healing: Inflammatory Phase

Lasts 3-5 days
White blood cells, predominantly leukocytes and macrophages, move to the wound.
o Macrophages enter the wound area and remain for an extended period ESSENTIAL to the healing process!!!
o They ingest debris and release growth factors that attract fibroblasts to fill in the wound.
o The patient has a generalized body response.
§ increase in body temperature, increase in WBC count, malaise

Phases of Wound Healing: maturation

Final stage of healing
o Begins about 3 weeks after the injury, possibly continuing for months or years.
§ Last between 3 weeks to several months!!!
§ Some patients can take up to YEARS to heal (pressure ulcers, diabetic foot ulcers)
o Collagen is remodeled.
§ Collagen makes the wound stronger in a GOOD way, makes new tissue stronger
o New collagen tissue is deposited.
§ Collagen formation is one of the first signs of healing that we can physically see
o Scar becomes a flat, thin, white line
§scar formation edges of the wound have come together and scabbing has dissolved itself, see a pink flat, white line (dependent on body's choice of formation of scar)

Phases of Wound Healing: proliferation

o Lasts for several weeks. (2-3 weeks)
o New tissue is built to fill the wound space through the action of fibroblasts (connective tissue cells)
o Capillaries grow across the wound.
§ Capillaries bring oxygen and nutrients that are required for wound healing
o A thin NEW layer of epithelial cells forms across the wound.
o Granulation tissue forms a foundation for scar tissue development.
§ Beefy red, new healthy tissue!

Phases of Wound Healing

Hemostasis
Inflammatory
Proliferation
Maturation

PIE charting (problem, intervention, evaluation)

DAR - data, action, response

Incorporates the care plain in progress notes; does not develop a separate care plan; eliminates the need for a traditional nursing care plan because the ongoing plan of care is incorporated into daily documentation

pigtail drain

catheter used to remove unwanted body fluids (bile if the bile duct is blocked or urine if the ureter is blocked/diseased). Inserted by radiologist

problem oriented records

Paper format - organizes the documentation specifically around a problem or chief complaint

SOAP - subjective, objective, assessment, planning

source oriented records

Paper format - providers keep separate records; things are grouped together by point of origin (e.g. nursing records are together, physician records are together, etc); each of the members chart on separate records

stage 1 pressure ulcer

nonblanchable erythema of intact skin

stage 2 pressure ulcer

: partial-thickness skin loss with exposed dermis

stage 3 pressure ulcer

full-thickness skin loss; not involving underlying fascia

stage 4 pressure ulcer

full-thickness skin and tissue loss

stages of infection - Convalescent period:

recovery from the infection
· patient is improving and starting to get better
· usually not infectious but they could be

stages of infection - incubatuon period

pathogen invades the body, growing and multiplying usually asymptomatic, but some start immediately

stages of infection - prodromal stage

- early signs and symptoms become present (fatigue, malaise, fever, etc.)

- most INFECTIOUS/CONTAGIOUS - people are not aware that they know they are contagious

- nonspecific signs of disease

stages of infection -Full stage of illness:

- presence of signs and symptoms
- local: one area | systemic: effects the whole body

stages of infection

Incubation period
Prodromal stage
Full stage of illness
Convalescent period

Standard indwelling -

- most common. For acute management for incontinence and surgery

stoma appearances

Beefy Red: we want this - good blood flow to the area

Pale Stoma: could indicate anemia

Flush Stoma: could be caused by skin eroding

subjective data

what the pt tells you

t/f you can put soiled linens on the floor

NO

Tieman/coude-tipped

for male patients with enlarged prostate

Types of drainage/EXUDATE - purulent

yellow green gray white pus like, indicating infection

Types of drainage/EXUDATE - sanguineous

active bleeding; bloody, bright red

Types of drainage/EXUDATE - serosanguinout

pale red watery, watery blood

Types of drainage/EXUDATE - serous

clear watery

Types of Ostomies

Stoma itself is actually the large intestine
(remember stoma means mouth too!!!)
Sigmoid colostomy (A)
Descending colostomy (B)
Transverse colostomy (C)
Ascending colostomy (D)
Ileostomy (E)

unstageable pressure ulcer

obscured full-thickness skin and tissue loss

urostomy

is a surgically-created opening to drain urine. A urostomy allows urine to flow out of the body after the bladder has been removed or bypassed. The output from a urostomy is urine and possibly some mucus. - generally permenant

Venous blood:

deoxygenated blood, found in veins, pulmonary artery, capillaries of organs except lungs and right chambers of heart, carries blood towards heart, dark red, driving force of this is muscular contractions, normal pressure 5-8mmhg in atrium

what is documentation?

Any information written, printed, or electronically entered into a patient's record

- Helps ensure the continuity of care, provides legal evidence of the process of care delivered, and supports evaluation of patient care

- Main communication tool for patient information

Whistle catheter tip:

straight cath; prevents urine backflow during dye injection during diagnostic procedure; also drains large amount of debris or blood clot

wound care - steps of dressing change

sterile procedure

1. . Check mar for any pain meds and adm it before changing dressing to ensure patient is comfortable
2. Assess patient's pain and ask for allergies
3. Document drainage, type, appearance, color, odor, signs of irritation/infection, signs of wound healing
4. Prepare sterile work field
5. Clean the wound (least contaminated to most)
6. Apply skin protectant in periwound skin to prevent irritation
7. Apply topical meds ON WOUND SITE only if prescribed. Helps with healing process
8. Apply clean dressing
9. LABEL DRESSING with date/time/your initials

Wound Complications

Infection: body is too busy fighting bad bacteria to heal
· Hemorrhage: blot clot, infection wound edges not gumming together, wound drain, etc.
· Dehiscence: where a wound was once together and now it's apart
· Evisceration: organs or something is coming out of wound
· Fistula Formation: abnormal passage from an internal organ to the outside of the body; can have intentional and unintentional
o intentional fistula formation (patient on dialysis)
o unintentional fistula formation (abscess of some sort)

wound healing (arterial vs. venous blood, lab values)

- arterial blood
- venous blood
- wbc can indicate infection
- Albumin is protein that can help rebuild wounds, important in pt with impaired nutrition
- Hct (hematocrit) and hgb (hemoglobin) measures blood loss
- Platelets measure clotting factors needed for stoppage of bleeding

what counts as intake?

- All liquid taken by mouth: water, coffee, tea, milk, juices, and other beverages.
- Any food item that turns to liquid at room temperature (ex: gelatin, ice cream, ice, etc.)
- All fluid taken by IV or tube feeding
- Tube feedings or enteral tube feedings are recorded as oral intake or in a special column
- They are used for patients who are unable to swallow; examples: nasogastric tube, gastrostomy tube

what counts as output?

- If you're irrigating a wound, that does NOT count as output; however, other forms of irrigation can be counted as output.
- Urine, emesis (vomit), suctioned secretion, drainage, excessive perspiration, bowel movement
- BM - liquid bowel movements are usually measured and recorded
- Emesis - anything that is vomited is measured and recorded
- Urine - all urine voided or drained via catheter is measured and recorded
- Irrigation - any irrigation or suction drainage, including drainage from NG tubes, hemo-vacs, chest tubes, and other drainage tubes are measured
- If an irrigating solution is injected into a tube and more solution returns, the excess is considered output
- All amounts must be measured in graduates; a graduate is a container that is made of plastic and has calibrations for milliliters / cc's or ounces on the side (1 mL = 1 cc)

avg urine output / day

1500 ccs

ccs of water lost from skin per day

200-500 ccs

cc or water lost from lungs per day

400 ccs

ccs of water lost from GI tract per day

100 ccs

avg urine output per hour

30 ccs

Fluid Imbalance: Dehydration

Definition: output exceeds intake.

Causes:
- Diarrhea
- Vomiting
- Bleeding
- Excessive perspiration (diaphoresis)
- Poor fluid intake

causes of edema

Fluid intake exceeds output.

cauases
- High salt intake
- Infections
- Injuries or burns
- Certain kidney diseases
- Certain heart diseases or heart inefficiencies
- Sitting too long in one position
- IV infiltration

transfering pt with hemiplegia

may be unaware of one side of the body or the environment, which distorts visual perception

transfering pt with head trauma or stroke

may have perceptual cognitive deficits that create safety risks

transftering Patient with difficult with comprehension

provide instructions step by step one at a time

transferring a patient who recently had a total hip replacement

do not bend the affected hip more than 90 degrees do not rotate the affected leg excessively and do not cross the patient's legs

Transferring

helps weakened or dependent patients or patients with restricted mobility attain positions needed to regain optimal independence as quickly as possible

Physical activity

maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and improves urinary and respiratory functions

benefits a patient psychologically by increasing social activity and mental stimulation and providing a change of environment

How can a nurse prevent self-injury when transferring patients?

using correct posture and body alignment, a low center of gravity, minimal muscle strength, effective body mechanics and lifting techniques, and appropriate lift devices

non-skid soles

decreases the risk of slipping during transfer

bare feet increase the risk of falls

Draw sheet

used to avoid shearing force during repositioning in the bed, protects the patient who has fragile skin

gait belts

Primarily used by physical therapists when they are assisting patients with ambulation

Stand-assist and repositioning aids

Pull bar above bed

Lateral-assist devices

Decreases friction during transfers

Roller boards, slide boards, transfer boards, etc.

Friction-reducing sheets

Reduce the skin shearing when moving patient IN a bed and assisting with lateral transfers

Their use reduces friction and the force required to move the patient.