wounds, sensory, sleep

foundations NURS 411

HOB at 30 degrees or less, changing position every 1.5-2 hrs, redistribute pressure and shearing force

important positioning to minimize skin breakdown?

acute wound

wound goes through normal orderly and timely fashion of repair

ex. trauma, surgical incision

chronic wound

wound fails to heal in an orderly and timely manner

ex. vascular compromise, chronic inflammation

primary intention

healing where wound edges are closed, clean, and well-approximated. Heals quickly and minimal scarring.

secondary intention

wound heals by granulation tissue formation, wound contraction, and epithelialization. Happens with pressure ulcers and surgical wounds that have tissue loss or contamination.

tertiary intention

wound that is left open for days due to contaminated or infected wounds and are later closed when the risk for infection has resolved.

stage 1 pressure ucler

nonblanchable erythema, skin intact

stage 2 pressure ulcer

partial thickness due to abrasion, blister, or shallow wound. Skin is open.

stage 3 pressure ulcer

full thickness due to damage or necrosis of the subcutaneous tissue. Deep crater without undermining surrounding tissue.

stage 4 pressure ulcer

full thickness due to skin loss with tissue necrosis and damage to underlying structures. Sinus tracts may be present.

treatment for pressure ulcers

red → protect skin area

yellow → cleanse skin area

black → debride skin

Dueoderm is used (hydrocolloid dressing)

wound vac

a device that uses negative pressure (suction) to remove excess exudate and infectious material and increasing blood flow to the area to help the wound heal faster by promoting granulation tissue formation and decreasing infection risk.

Must have clean wound bed to use.

best food source for healing wounds

protein (meat, eggs, greek yogurt)

sensory deprivation

condition where pt receives inadequate quality or quantity of sensory stimulation leading to feelings of boredom, confusion, irritability, or decreased ability to concentrate

sensory overload

condition where pt receives too much sensory input at once causing anxiety, restlessness, inability to focus, and feeling overwhelmed

examples of sensory deprivation

isolation rooms, vision/hearing loss, minimal interaction, dark/quiet enviroment

examples of sensory overload

ICU rooms with alarms + lights + lots of ppl, pain, anxiety, too much noise, too much activity around pt

reception

stimulation of a receptor such as light, touch, or sounds

interventions for confused patients

reorient frequently

keep a consistant routine

use clocks and calendars

provide adequate lighting

reduce environmental stimuli

ensure safety (bed in lowest position, alarms, clear pathways)

use simple clear instructions

promote sleep

encourage use of hearing aids and glasses

insomnia

difficulty falling asleep, staying asleep, or waking too early

sleep apnea

repeated episodes of airway obstruction or breathing pauses during sleep

narcolepsy

neurological disorder where a person experiences sudden, uncontrollable sleep attacks during the day

parasomnias

unusual behaviors during sleep, such as sleepwalking, night terrors, talking in sleep

patency and connected

what is important to assess on pts with tubes?

vital signs must checked every 15 mins within the first hr

what must be done for pts recieving a blood transfusion?

when do pts with uncontrolled hypertension become a concern?

if systolic blood pressure rises greater than 190, anything less is not a big concern

administering antipyretics and antihistamines before start of transfusion

how can febrile reactions be prevented?

most common cause of med errors

deficient knowledge

risks for developing deep vein thrombosis (DVT)

smoking, stoke, diabetes

purpose of wet to dry dressing

wet dressing is placed inside of wound and will become dry by soaking up drainage, then the now dry dressing will be pulled out to pull out dead tissue

start with dry dressing instead of wet-dressing

if a wound is continuously draining what is the dressing protocol?