NURS 3003 (48-50)

pressure injury

localized damage to the skin and the underlying soft tissue that develops around a bony prominence, often related to pressure of a medical device.

Mechanical load

is the force applied to the soft tissue (skin and underlying tissue) by an external object, surface, or device.

pressure exceeds = tissue ischemia

blanchable hyperemia.

erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called

nonblanchable erythema

erythematous area does not blanch when you apply pressure, deep tissue damage is probable.

• tissue damage has occurred

Blanching

occurs when the normal red tones of a light-skinned patient are absent

Duration of pressure

influences the detrimental effects on the skin and underlying tissue

(how long was the patient exposed to pressure)

intensity

how long were they exposed to it or how much pressure they were exposed to

tissue tolerance

the ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structures.

shear

• Shear force occurs due to gravity pushing down on the body and resistance (friction)

• occurs with the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary

friction

The force of two surfaces moving across one another

• skin is dragged across a coarse surface, such as bed linens, is called FRICTION

stage 1 pressure injury

intact skin w/ a localized area of nonblanchable erythema

stage 2 pressure injury

partial thickness skin loss with exposed dermis

stage 3 pressure injury

full thickness skin loss `

stage 4 pressure injury

full thickness sin and tissue loss

exposed everything (muscles, bone, etc)

Deep tissue pressure injury

Persistent nonblanchable deep red, maroon, or purple discoloration

Unstageable pressure injury

obscured full-thickness skin and tissue loss

time nuemonic

T = tissue integrity

I = inflammation or infection

M = moisture (is it dry or moist)

E = edges (should be intact)

medical device–related pressure injury (MDRPI)

occurs when the skin or underlying tissues are subjected to sustained pressure or shear over nonbony locations from a poorly positioned or ill-fitting device or incorrect device use

• masks, nasal cannulas, trachea tubes.

closed wound

the surface of the skin remains intact, but the underlying tissues may be damaged

• contusions, hematomas, closed surgical wounds, and Stage 1 PIs

open wound

open wounds the skin is split, incised, or cracked, and the underlying tissues are exposed to the outside environment

acute wounds

wound edges are clean and intact

• trauma, surgical incision

chronic wound

continued exposure to insult impeds wound healing

• Vascular compromise, chronic inflammation, or repetitive insults to tissue

primary intention

Healing occurs by epithelialization; heals quickly with minimal scar formation

• Hematoma, surgical incision that is sutured or stapled

secondary intention

Wound heals by granulation tissue formation, wound contraction, and epithelialization.

• Surgical wounds that have tissue loss or contamination

teritary intention

Closure of wound is delayed until risk of infection is resolved

• Wounds that are contaminated and require observation for signs of inflammation

Dehiscence

Dehiscence is the partial or total separation of wound layers

evisceration

With total separation of wound layers, evisceration (protrusion of visceral organs through a wound opening) occurs

Sanguineous

Bright red; indicates active bleeding

Serosanguineous

Pale, pink, watery; mixture of clear and red fluid

Braden scale

Braden scale: sensory perception, moisture activity, nutrition, friction and shear

Patients are essential rank highest score is 23 are little to no risk w/ having a skin issue

9 or below they are a high risk

sensory deficit.

When visual or hearing acuity changes or declines, a person may withdraw by avoiding communication or socialization with others to cope with the sensory loss.

sensory deprivation

reduced sensory input (sensory deficit from visual or hearing loss), the elimination of patterns or meaning from input, restrictive environments

• bed rest, things that produce montony & boredom

NOT GOOD FOR PATIENT

sensory overload

When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli

5 senses

Smell, sight, hearing, taste, touch

meaningful stimuli

reduce the incidence of sensory deprivation.

• pets, music, television, pictures of family members, and a calendar and clock

kinesthetic

sense that enables a person to be aware of the position and movement of body parts without seeing them.

Stereognosis

is a sense that allows a person to recognize the size, shape, and texture of an object

Factors that influence sensory function

Age. Meaningful stimuli. Amount of stimuli. Social interaction. Environmental factors. Cultural factors.

Preoperative

Preoperative

When: From the time the decision for surgery is made until the patient is on the operating table and the operation is ready to begin. 

intraoperative

When: From the moment the patient is on the operating table until the surgical wound is closed. 

Postoperative

When: From the time surgery ends until the patient's recovery is complete, which can take weeks or months

surgical risk factors

smoking: = want to get a pap per day on them, and concerns for post op pneumonia & atelecatisis & aspirations

age: very old will have more issues

nutrition: hist. of malnutrition and see low pre-albumin & albumin and concerns for delayed wound healing.

obesity: concern for impaired cardiac and respiratory function

immunosuppression: patients receiving chemo & have AIDS at risk for infection

circulating nurse

• A circulating nurse is an RN who does not scrub in and uses the nursing process in the management of patient care activities in the OR suite

They will initiate the time out that should happen during a procedure before, confirming we have the right patient, right sight, right implants

• Monitor intake and output, assist patient if needed, assist with dressing, monitor sterility

scrub nurse

• scrub nurse must be able to anticipate each instrument and supply item needed by the surgeons

• Set up the table of instruments and will pass tools to surgeron

Circulating nurse

The circulating nurse will start the meds, then the CRNA will take over and allow the circulating nurse to bounce around

Postoperative urinary retention (POUR)

Inability to void is temporary, but it may be prolonged in some patients.

Bladder scanning is used when a patient has risk factors for POUR or is unable to void 4 hours postoperatively

general anesthesia

general anesthesia a patient loses all sensation, consciousness, and reflexes, including gag and blink reflexe

Regional anesthesia

Regional anesthesia results in loss of sensation in an area of the body where sensory pathways are anesthetized

American Society of Anesthesiologists

American Society of Anesthesiologists (ASA, 2020) assigns classification based on a patient’s physiological condition independent of the proposed surgical procedure

malignant hyperthermia

See increase in HR, RR, Higher levels of retained carbon, can progress to various organ failures

• Dantrogen is our reversal agent for this

•Intraop handoff to phase 1 postop (PACU)

•Takes 1-2 hours in PACU