test 4 - wounds/oxygenation

risk factors/causes of pressure ulcers

impaired mobility, friction, moisture, stress, pressure

pressure ulcer stage I

non blanchable redness of intact skin

pressure ulcer stage II

partial skin loss (epidermis/dermis), shallow open ulcer with out slough, blister

pressure ulcer stage III

full thickness skin loss, visible tissue

pressure ulcer stage pressure ulcer stage IV

full thickness skin loss, exposed bone/tendon/muscle

unstageable ulcer

base covered by slough or eschar, depth can’t be determined

deep tissue injury

purple or maroon discolored intact skin

full thickness repair

extends into dermis and subcutaneous tissue, heals by scar formation, granulation (pressure ulcers)

partial thickness repair

involves only epidermis, heals via regeneration

primary intention

edges approximated, minimal scarring, surgical incision

secondary intention

loss of tissue, left open until covered in scar tissue, burn or laceration

tertiary intention

wound left open, delayed closure until infection is under control

wound healing complications

hemorrhage

hematoma

infection

dehiscence - separation of wound layers

evisceration - organs protrude

nutrition considerations for wound care

increase need for calories ( min. 1500 a day), protein, vitamins A and C

bradens scale purpose

assess risk for pressure ulcers: sensory perception, moisture, activity, mobility, nutrition, friction b

bradens scale scoring

19-23 : no risk

15-18: mild risk

13-14: moderate

10-12: high

<9: very high

care of wound drains - penrose

passive drainage, under dressing, secured by pin

care of wound drains- jackson pratt

closed suction device, collects drainage, low pressure

care of wound drain benefits

prevent fluid accumulation, reduce infection risk, allows monitoring of output

documentation of wound care

location, size, type and amount of discharge, edges, tissue type

tissue type - granulation

red, moist, indicates healing/healing tissue

tissue type - slough

stringy substance, removed before healing

tissue type - eschar

black or brown necrotic tissue

assessment of skin

skin color, temp, braden scale, pain, nutrition, incontinence

myocardial blood flow

right atrium - right ventricle - left atrium - left ventricle

deoxygenated blood flows from the rights side to the lungs then oxygenated returns fom the lungs to the left side

left sided heart failure

pulmonary congestion, crackles, cough, fatigue, low oxygen, dyspnea (SOB), and orthopnea (discomfort lying supine)

right sided heart failure

edema, JVD, weight gain, hepatomegaly (enlarged liver), Ascites

early signs of hypoxia

restlessness, tachycardia, tachypnea, hypertension

late signs of hypoxia

cyanosis, bradychardia, confusion, hypotension, stupor

blood tests

CBC (O2 carrying capacity), ECG, PFT, TB

oxygen assessment

RR, lung sounds, SPO2, mental status, skin color

oxygen interventions

position upright, incentive spirometry

nasal cannula, simple mask, non rebreather

low flow, comfortable, 1-6L/min

moderate, 6-10 L/min

high flow, 10-15 L/min

when is a bag valve mask used

manual ventilation in emergencies