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THE FAMILY

What is a family?

Any group of people with emotional connections who function as a unit; ultimately a family is what the individual believes it to be.

What is family durability?

Support and structure within a family that continue beyond the household despite divorce + death + remarriage + children leaving home + other lifestyle changes.

What is family resiliency?

The ability of a family to cope with expected and unexpected stressors and adapt to role changes + structural changes + developmental milestones + crises.

What is family diversity?

The uniqueness of each family unit in form + culture + strengths + challenges.

What are family dynamics?

Interactions between family members affected by family makeup/configuration + structure + function + problem-solving + coping capacity.

What is the goal of family-centered nursing care?

Address the comprehensive health care needs of the family as a unit + advocate for + promote + support the well-being and health of the patient and family members.

What family structures should the nurse recognize?

Nuclear + extended + single-parent + blended + alternative families.

What is a nuclear family?

A traditional family structure.

What is an extended family?

A family that includes relatives in addition to the nuclear family.

What is a single-parent family?

A family with one parent caring for the children.

What is a blended family?

Parents bring children from previous marriages or parenting relationships into a new joint-living situation.

What is an alternative family structure?

Multi-adult households + grandparents caring for grandchildren + communal groups with children + cohabitating partners + nonfamilies.

What should the nurse remember when caring for different family structures?

Avoid assuming what a family looks like; assess the patient's family definition + strengths + needs.

FAMILY-CENTERED NURSING PROCESS

What is the first step of the nursing process with a family?

Assessment.

What are the steps of the nursing process with families?

Assessment → nursing diagnoses → planning → implementation → evaluation.

What should family assessment include?

The patient's family situation + family dynamics + strengths + resources + coping capacity + barriers to health care.

What is the goal of family nursing?

Help the family and individual members reach and maintain maximum health throughout and beyond the illness experience.

What is respite care?

Temporary relief for caregivers that can decrease caregiver burden and support continued caregiving.

What are the three main family needs in family-centered nursing?

Information → be an educator + reassurance/support → be a considerate communicator + family closeness/involvement → empower the family as care partners.

What should the nurse do during family-centered implementation?

Reduce barriers to health and health care + facilitate transitions + build on family strengths and resources.

How should family-centered evaluation be performed?

Evaluate whether the patient and family outcomes and goals were achieved; evaluation is patient- and family-centered.

COMMUNITY EXAMPLES

How can the community affect individual and family health?

Housing + heat/plumbing + income + safety + nearby family support + childcare/after-school programs + access to local clinics can affect health decisions and outcomes.

Why may a patient avoid taking a child to a local clinic?

Unsafe neighborhoods + fear of crime + lack of nearby support + transportation or access concerns may create barriers to health care.

WOUND CLASSIFICATION

What is an intentional wound?

A planned therapeutic wound made under aseptic or sterile conditions with clean approximated edges and usually controlled bleeding (examples: surgical incision + venipuncture + lumbar puncture).

What is an unintentional wound?

An unexpected traumatic wound that is not acquired under sterile conditions; edges are irregular + bleeding may be uncontrolled (examples: accident-related laceration + burns + penetrating wounds).

What is an open wound?

A break in the skin or mucous membrane → microorganisms can enter; tissue damage and bleeding increase infection and prolonged-healing risk.

What is a closed wound?

Tissue injury from a force or blow without an open skin break (examples: contusion + hematoma).

What is an acute wound?

A wound that usually heals within days to weeks and progresses through the normal stages without disruption (examples: trauma + burns + surgical incisions).

What is a chronic wound?

A wound present for more than 30 days with delayed or interrupted healing; it may remain in the inflammatory stage (examples: pressure injury + diabetic ulcer + vascular-insufficiency ulcer).

What is a pressure injury?

A localized ischemic lesion of the skin and underlying tissue caused by external pressure that impairs blood and lymph flow → decreased oxygen/nutrients + inflammation + edema + necrosis + possible ulceration.

What other names may be used for pressure injuries?

Decubitus ulcers + bedsores + pressure sores.

Where do pressure injuries commonly occur?

Over bony prominences with little subcutaneous cushioning (sacrum + coccyx + trochanter/hip + calcaneus/heel).

How quickly can a pressure injury develop?

As little as 1 hour; a patient may develop one within 1–2 hours without movement or repositioning.

How does external pressure cause a pressure injury?

Pressure over a small area or bony prominence occludes capillaries → poor circulation → ischemia + hypoxia + edema + inflammation → necrosis and ulcer formation.

What is a friction injury?

Two surfaces rub together → heat + removal of the top skin layer + superficial blood-vessel damage; it may look like an abrasion.

What is an example of friction injury?

A patient pushes up in bed using the heels/arms/hands or personnel pull the patient across the bed.

What is a shear injury?

One tissue layer slides over another → skin separates from underlying tissue + blood vessels stretch/bend/tear → thrombosis and impaired circulation.

What are examples of shear injury?

Pulling a patient up in bed or transferring the patient + the patient sliding down in a chair or bed with the head elevated.

What is microclimate?

The temperature and moisture of the skin; excess heat or moisture can contribute to pressure-injury development.

PRESSURE-INJURY RISK + ASSESSMENT

What are major pressure-injury risk factors?

Aging skin + chronic illness + immobility + malnutrition + fecal/urinary incontinence + altered level of consciousness + spinal cord/brain injury + neuromuscular disorders.

Which equipment areas require routine pressure assessment?

Areas under casts + orthopedic devices + support stockings because impaired circulation may contribute to pressure injury.

What forces contribute to pressure-injury development?

External pressure + friction + shearing forces → blood-vessel injury + impaired tissue circulation.

When should pressure-injury risk tools be completed?

On admission to a health care agency + on a regularly scheduled basis afterward.

Which pressure-injury risk tools are listed in the notes?

Braden Scale + Johns Hopkins tool.

What senses are used during skin and wound assessment?

Sight + smell + touch.

PRESSURE-INJURY STAGING

What does Stage 1 pressure injury show?

Nonblanchable erythema of intact skin.

What does Stage 2 pressure injury show?

Partial-thickness skin loss with exposed dermis.

What does Stage 3 pressure injury show?

Full-thickness skin loss not involving the underlying fascia.

What does Stage 4 pressure injury show?

Full-thickness skin and tissue loss.

What is an unstageable pressure injury?

Obscured full-thickness skin and tissue loss.

What is a deep-tissue pressure injury?

Persistent nonblanchable deep red + maroon + purple discoloration.

Why are pressure-injury stages clinically important?

They describe the depth of tissue injury → guide treatment.

What psychological effects can wounds cause?

Pain + anxiety + fear + difficulty with activities of daily living + altered body image.

FACTORS AFFECTING WOUND HEALING

What local factors delay wound healing?

Pressure + desiccation/dehydration + maceration/overhydration + trauma + edema + infection + excessive bleeding + necrosis + biofilm.

What is a biofilm?

A thick grouping of microorganisms in the wound that can delay healing and make treatment more difficult.

What systemic factors affect wound healing?

Age + circulation/oxygenation + nutritional status + wound etiology + health status + immunosuppression + medication use + adherence to the treatment plan.

Which patients may heal more rapidly?

Children and healthy adults generally heal more rapidly than older or medically compromised patients.

Why is circulation and oxygenation important for healing?

Adequate blood flow delivers oxygen and nutrients needed for tissue repair.

Which medications or treatments can delay healing?

Corticosteroid drugs + postoperative radiation therapy; immunosuppression and other medication effects may also delay healing.

What chronic conditions or behaviors should be addressed because they may delay healing?

Diabetes + smoking + vascular compromise + reinjury + chronic inflammation.

Why is adequate protein important for wound healing?

Protein supports tissue repair and should be supported as a positive factor in healing.

WOUND COMPLICATIONS + NURSING DIAGNOSES

What are major wound complications?

Infection + hemorrhage + dehiscence/evisceration + fistula formation.

What nursing diagnoses may be associated with impaired skin integrity?

Impaired skin integrity + risk for impaired skin integrity + risk for infection + acute/chronic pain + impaired mobility + impaired peripheral tissue perfusion.

WOUND PLANNING + EVALUATION

What is an example of a measurable wound goal?

The patient will have reduced pressure at the sacrum and the wound will show healing with a decreased diameter within 1 week.

What are examples of expected wound outcomes?

Wound diameter decreases within 7 days + no further wound formation within 3 days.

Why is normal wound healing important to understand?

Most wounds heal along a normal trajectory; chronic wounds may fail to heal

What is the purpose of nursing evaluation for pressure injuries and wounds?

Determine the patient's response to therapy + determine outcomes + evaluate whether each goal was achieved.

What are optimal wound-care outcomes?

Prevent skin injury + reduce injury to skin and underlying tissue + promote wound healing and restoration of skin integrity.

WOUND HEALING BY INTENTION

What is healing by primary intention?

Wound edges are pulled together and approximated with sutures or staples → connective-tissue deposition closes the surgical incision.

What findings may signal a problem with a primary-intention wound?

Poorly approximated incision line + drainage more than 3 days after closure + increased inflammation during days 3–5 + no healing ridge by day 9.

What is healing by secondary intention?

Wound edges are not approximated → granulation tissue forms and wound edges contract.

What findings may signal a problem with a secondary-intention wound?

Pale/fragile or hypergranulation tissue + purulent exudate + necrotic/slough in the wound base + fruity/earthy/putrid odor after cleansing + fistula + tunneling + undermining.

What factors should be supported or addressed in wound management?

Address negative factors such as diabetes and smoking + support positive factors such as adequate protein intake.

What is important when performing wound irrigation?

Irrigate in a way that removes debris without causing further tissue injury.

What can happen if heat or cold is applied incorrectly?

Heat or cold can cause local/systemic responses and injure the skin if applied too long or incorrectly.

What is the risk of applying an elastic bandage too tightly?

Circulatory impairment.

DUODERM HYDROCOLLOID PATCH

How does a DuoDERM hydrocolloid patch begin the healing process?

Hydrocolloid particles absorb wound exudate → swell and form a soft moist gel over the wound.

What particles may be found in the DuoDERM hydrocolloid layer?

Sodium carboxymethylcellulose + pectin + gelatin.

How does the moist DuoDERM gel help healing?

Maintains a moist environment → promotes new tissue growth + supports autolytic debridement (the body's enzymes break down dead tissue).

How does DuoDERM protect the wound?

Its waterproof outer film provides a protective shield from contaminants and insulates delicate new skin from friction.

What are benefits of DuoDERM?

Maintains moisture balance + supports healing + may reduce pain + protects new tissue + allows gentle removal + may remain in place for several days.

Why is DuoDERM removal less traumatic?

It adheres to surrounding healthy skin rather than the wound bed → less trauma and pain to new tissue.

When is DuoDERM generally most appropriate?

Bed sores with light to moderate fluid; avoid using it for heavily draining or infected wounds.

What should the nurse do before applying DuoDERM?

Clean the wound and surrounding skin with saline + dry thoroughly to promote adhesion.

What changes may be normal when DuoDERM absorbs fluid?

The patch may swell into a visible bubble or turn white; the gel may have a strong odor when the dressing is changed.