Class 8 (integumentary, pressure injury, nursing care planning)

What are the subjective/symptom analysis of integumentary

skin changes, pruritus (itching), rashes, lesions, ecchymosis (bruises), changes to a mole, hair loss, nail changes

Notice widespread or localized color changes

erythema: redness

cyanosis: bluish

pallor: white

jaundice: yellow

What should you assess for abnormal skin tone

color/pigmentation even all over body, changes in freckles, moles, birthmarks, bruises

How should you palpate skin temp

use backs (dorsa) of own hands, palpate bilaterally (upper/lower extremities)

What is maceration

excessive moisture

What is normal skin

smooth and dry with minimal perspiration and oiliness

what is diaphoresis

excessive or abnormal sweating

how do you palpate texture

use palms of hands or fingertips, assess for smoothness, roughness, thickness, tightness, induration, softness

how do you palpate skin thickness

use palms of hands or fingertips

what is a healthy finding of skin thickness

epidermis is uniformly thin over most of body, thickened areas on palms/soles are normal

What is a bony prominence

any point on the body where the bone is immediately below skin surface

what is erythema

redness of skin due to congestion of the capillaries

What does erythema look like in pale, ivory, beige skin

red, bright pink

what does erythema look like in very dark skinned (difficult to see)

purplish tinge or darkened area, palpate for incr warmth with inflammation, taut skin, induration (hardening of deep tissue)

What should you asses for blanching

blanchable redness is normal, non-blanchable is 1st stage of pressure ulcer development

What is skin mobility

ease of skin to rise

what is tugor

skin ability to return to place promptly when released

what is skin mobility and turgor used to assess

elasticity of skin and hydration status

where do you assess mobility and turgor

anterior chest or forearm do NOT use back of hand

exudate (byproduct of wound healing:

serous: clear liquid (blister)

sero sanguineus: liquid with blood

sanguineus: bloody

pustulant/purulent: pus (infected)

ABCDE for skin cancer (moles) is

A smmetry

B order

C olor

D iamter

E volving

Normal age related skin lesions consist of

senile/solar purpura, solar lentigines (liver or age spots) , seborrheic keratosis

What are healthy nails

pink, translucent, smooth, firm, well rounded, convex, nail angle of 160 degrees, good adherence to nailbed

What is nail clubbing

bulging of nail base leading to abnormal curvature of nail, associated with chronic decreased oxygen levels

How do you assess for clubbing

-flex 1st phalangeal join of L&R back to back

- raise fingers to eye level

- positive - no diamond shape space

Pressure injury ulcer is

localized damage to skin/underlying soft tissue over a boney prominence or related to a medical or other device

Pressure injuries are avoidable

True

What is the development of pressure injury

1) contact b/w boney prominence and surface creates friction, superficial and seen

2) movement creates shearing force, deeper tissue damage

3) moisture creates risk of breakdown

4) pressure decreases circulation to area

common places for pressure injuries

refer to picture

Stage 1 pressure injury

Non-blanchable erythema of intact skin

Stage 2 pressure injury

Part-thickness skin loss with exposed dermis.

Stage 3 pressure injury

Full-thickness skin loss to subcutaneous layer, may have undermining or tunneling; fat may be visible

Stage 4 pressure injury

Full-thickness skin and tissue loss to tendon, cartilage or bone, undermining or tunneling; muscle/bone may be visible

Unstageable pressure injury

obscured full-thickness of tissue loss

Deep tissue injury

persistent non-blanchable deep red, maroon and purple discoloration, intact or non intact skin

What is slough

yellow or white material (dead tissue) in wound bed, by product of inflammatory phase of wound healing

unstageable vs suspected deep tissue injury (SDTI)

Unstageable

• Obscured full-thickness tissue loss

Suspected Deep Tissue Injury (SDTI)

• Deep tissue injuring presented as persistent non-blancheable, deep maroon or purple discoloration to intact or non-intact skin

When should you assess for pressure injury

on admission (24 hrs of arrival), once every shift, when pericare completed, during position changes/turning, every bath, assess for persistent moisture or medical devices, bony prominences, assess for risk (braden scale), focus on elements that help guide skin assessment

What is the braden scale

determine risk for developing pressure ulcers (sensory perception, moisture, activity, mobility, nutrition, friction and shear)

what are the 6 components of the braden scale

1. Sensory Perception

2. Moisture

3. Activity

4. Mobility

5. Nutrition

6. Friction & Shear

How do you intervene immobility

turn/reposition every 2 hours

How do you intervene mositure

assess, provide pericare, avoid diapers, toileting shcedules, dry after bathing, barrier creams

how do you intervene nutrition

adequate feeding, intake, and protein

how do you intervene friction and shear

waffle mattresses, booties, lifting devices, ambulation, pressure relieving surfaces

What are the 3 focuses of nursing diagnosis

1) Determine client/family responses to human problems, level of wellness, and need for assistance;

2) Provide physical care, emotional care, teaching, guidance, and counseling;

3) Implement interventions aimed at prevention and assisting the client to meet his or her own needs and health-related goals.

Arriving at a diagnosis process

Cluster data (S/O, pt history, current symptoms) -> analysis (abnormal, risk, concern) -> identify areas of need (concern about _, pt needs additional _, risk for _) -> elect diagnosis

what is NANDA international

Identified domains -> conducted research -> identified best interventions and outcomes

creates standards, improves consistency, provides for evidence based nursing actions

What are the 3 types of nursing diagnosis?

problem, risk, and health promotion based

What is a problem based diagnosis

1) undesirable situation exists, problem

2) problem related to measurable, observable, reported fact

3) pt actively experiencing sign or symptom, evidence

what is a risk based nursing diagnosis

1) reason to believe problem may result; risk

2) concern is related to circumstances, evidence, observed behaviors

3) there is no active symptom or complain but has risk factors

what is health promotion based nursing diagnosis

1) readiness or expressed desire to improve (promote) health

2) evidence exists to support claim or readiness

Components of a problem

P: problem statement/NANDA-I diagnostic label

RELATED TO (r/t)...

E: etiology/related factors

AS EVIDENCED BY (aeb)...

S: defining characteristics/signs & symptoms

NANDA-I label

A concise term or phrase that represents a pattern of related cues. The nursing diagnosis label is taken from the official NANDA-I list.

What is an example of a NANDA-I label

qualifier: decreased

health problem/focus of diagnosis: cardiac output

Etiology/related factors

factors that are related to a cause or contributor to the problem, pathophysiological, treatment related, situational, maturational, secondary to statements

"as evidenced by" statement (risk factors):

NANDA label r/t _____ (etiology) aeb ______ (min 2 defining characteristics [signs/symptoms])

Defining characteristics

as evidenced by, clusters of signs and symptoms (2 or more) that the nurse identified in the assessment

actual nursing diagnosis vs risk nursing diagnosis

risk:

- do not have related to statements

- only lists risk factors

- risk factors are written following the phrase "aeb"

- risk factors are written following a colon ":"

What is an example of the use of aeb and :

Risk for impaired skin integrity aeb excessive moisture and immobility

Risk for impaired skin integrity: excessive moisture and immobility

Planning phase

3rd phase: "how to manage the problem" consists of writing pt centered goals and measurable expected outcomes, nursing interventions to achieve expected outomces, rationale using evidence (research) to support interventions

The writing expected outcomes goals is

S pecific

M easurable

A ttainable

R ealistic

T imed

"outcomes are pt focused, pt will..."

What is an example of SMART outcome statement (patient-centere)

Target client + verb + measurable outcome + timeframe

E.g.: The patient will be able to eat at least 60% of each meal by the end of the week

For nursing interventions should note that

Interventions are NURSING based and begin with the statement "Nurse will"

Implementation is

4th phase: actual initiation and implementation of nursing care plan, putting plan into action

Evaluation is

5th phase: "did the plan work", examine results, compare achieved effects with goals and expected outcomes, revise care plan