foundations exam 2

open wounds: incision

wound created by a surgical operation

open wounds: laceration

irregular, jagged tear caused by blunt force trauma

open wounds: abrasions

caused by friction that rubs off the outermost layer of skin (epidermis)

open wounds: puncture

deep, narrow injury caused by a pointed object (nail, needle)

open wound: penetrating

stab wound, gunshot wound (penetrates underlying tissues, organs, body cavity)

open wound: avulsion

forcible tearing off of skin or another part of the body (ear, muscle, tendon, bone)

phases of wound healing: homeostasis

• immediately after injury

• blood vessels constrict to stop blood loss

• clotting begins - platelet aggregation

• blood vessels dilate - increased blood flow with plasma components

• exudate forms - made up of plasma and blood

phases of wound healing: inflammatory

• lasts 2-3 days

• leukocytes come in to clean the wound

• macrophages come to clean and also promote growth of new epithelial cells

• fibroblasts move in to help fill in the wound

phases of wound healing: proliferation

• lasts several weeks

• fibroblasts secrete collagen and growth factors for blood vessel and endothelial regeneration

• granulation tissue forms

• collagen deposit continues for weeks to years

phases of wound healing: maturation

• begins around 3 weeks and can last years

• collagen remodeling and additional deposits

• scar finalizes

nutrition for healing: vitamin a

needed for protein synthesis, immune function, maintenance of epithelial tissues

nutrition for healing: vitamin c

needed for collagen formation and absorption of iron

nutrition for healing: zinc

serves as co-factor for collagen formation and many aspects of cell metabolism. assists in immune function

nutrition for healing: copper

• preserves strength of skin, blood vessels, connective tissue

• plays a role in enzymatic reactions in the body

nutrition for healing: iron

• helps form red blood cells

• transports oxygen and collagen formation

• supports a healthy immune system

complications of wound healing

• infection

• hemorrhage

• dehiscence and evisceration

• fistula formation

most serious wound complication

• evisceration: most serious complication of dehiscence

  • place moist saline soaked gauze

  • call provider for pt to go back to OR

types of wound healing: primary intention

• surgeon did incision and stitched, glued, or stapled back up

types of wound healing: secondary intention

• natural repair process in which an open wound is left not stitched/glued up

• the wound heals gradually from bottom up through granulation tissue formation, wound contraction, and re-epithelialization

types of wound healing: tertiary intention

• delayed primary closure

• you have surgery and provider leaves you open for a day or so and says they will take you back into surgery later and close it

• most common in abdominal surgery

• let wound drain or swell for a few days and then close it up

• pack wound with gauze and leave it open

types of drainage systems: open systems

• penrose drain

types of drainage systems: closed systems

• jackson-pratt drain

• hemovac drain

arterial

• cause: insufficient blood supply to area, causing ischemia (tissue death)

• risk factors: vascular insufficiency, uncontrolled blood sugars in pt w diabetes, limited joint mobility or joint problems, improper footwear

• characteristics:

  • punched out appearance

  • smooth wound edges

  • pain at night and relieved by elevating leg

  • lower extremities are cool to touch

  • pale, shiny, thin skin

  • minimal no hair growth

  • minimal drainage from wound

venous

• cause: pooling of blood causing increased pressure in veins

• risk factors: varicose veins, DVT, muscle weakness in legs, immobility, pregnancy

• characteristics

  • shallow and superficial

  • irregular shape

  • painful from edema, phlebitis, or infection

  • usually in lower legs/ankles

factors included in braden scale

• sensory perception

• moisture

• activity

• mobility

• nutrition

• friction and shear

shear

• one layer of tissue slides over another layer

• shear separates the skin from underlying tissues

wound assessment

• size

• depth

• general appearance: location, drainage (color, amount, odor, consistency)

• presence of undermining, tunneling, sinus tracts

• surrounding skin

stage 1 pressure ulcer

• non-blanchable erythema

• skin intact

stage 2 pressure ulcer

• partial-thickness skin loss involving epidermis and dermis

• presents clinically as a blister, abrasion, or shallow crater

stage 3 pressure ulcer

• full-thickness skin loss involving subcutaneous issue

• presents as deep crater with or without undermining

stage 4 pressure ulcer

• full-thickness skin loss involving muscle, bone

• sinus tracts may be involved in stage 4

unstageable pressure ulcers

• covered in eschar and slough

• have to debride eschar and slough in surgery and then stage the ulcer

R = red

• protect

• wound should be beefy red = granulation tissue = protect with dressing, moisture, keep clean with prescribed dressing changes

y = yellow

• cleanse

• yellow exudate

• dead cells, could be infection

B = black

• debride

• necrotic eschar needs to be removed

hyponatremia

• headache

• N & V

• confusion

• muscle twitching

• tremors

• irritability

• weakness

hypernatremia

• extreme thirst

• dry mouth and mucous membranes

• restlessness

• agitation

• disorientation

• hyperactive reflexes

hypokalemia

• muscle weakness

• leg cramps

• EKG changes

• paresthesia

• fatigue

• decreased reflexes

hyperkalemia

• cardiac arrhythmias

• paresthesia

• peaked T waves

• irritability

hypocalcemia

• muscle cramps

• tremors

• positive trousseau’s and chvostek’s sign

• irritability

• bradycardia

• hypotension

hypercalcemia

• lethargy

• muscle weakness

• polyuria

• polydipsia

• arrhythmias

• hyporeflexia and decreased muscle tone

hypomagnesemia

• muscle tremors

• convulsions

• dizziness

• weakness

• cardiac irritation

• tetany

hypermagnesemia

• hypotension

• drowsiness

• shortness of breath

• hypoactive reflexes

• renal failure

steps of the nursing process: ADPIE - A

assessing: collecting, validating, and communicating patient data

steps of the nursing process: ADPIE - D

diagnosing: analyzing patients data to identify patient strengths and problems

steps of the nursing process: ADPIE - P

outcome identification/planning: specifying patient outcomes and related nursing interventions

steps of the nursing process: ADPIE - I

implementing: carrying out the care plans

steps of the nursing process: ADPIE - E

evaluating: measuring the extent to which patient achieved outcomes

clinical judgement

an iterative decision-making process that uses nursing knowledge to:

• observe and assess presenting situations

• identify a prioritized client concern

• generate the best possible evidence-based solutions in order to deliver safe client care

what is clinical reasoning

the process

what is clinical judgement

making the decisions

the 6 functions of clinical assessment

1. recognize cues → what matters most?

2. analyze cues → what does it mean?

3. prioritize hypotheses → where do i start?

4. generate solutions → what can i do?

5. take action → what will i do?

6. evaluate outcomes → did it help?

the nursing process

1. assessment

2. analysis

3. planning

4. implementation

5. evaluation

types of nursing assessments

• initial: establish a complete database and provides reference base for problem identification, reference, and future comparison

• problem-focused: ongoing process to determine the status of a specific problem identified in an earlier assessment; short focused prioritized assessment; “flag” risks

• emergency: occurs during physiologic or psychological crisis to identify life threatening problem and identify new or overlooked problems

medical diagnosis vs nursing diagnosis

• medical diagnosis: describes a disease, illness a pathologic condition

  • remain the same as long as the disease/condition is present

  • treated by physicians/advanced practice providers

• nursing diagnosis: focuses on the harmful responses to health and illness

  • change as the patient’s needs and condition evolve

  • classify health problems within the domain of nursing

types of nursing diagnosis

• problem-focused nursing diagnosis: current/actual problem

• “risk for” nursing diagnosis: potential complication

problem focused nursing diagnosis - 3 PARTS

• diagnosis/problem: impaired urinary elimination

• related to (etiology/cause): pain, frequency, urgency

• as evidenced by (which data support the diagnosis?): patient complains of dysuria, having to urinate every hour/waking up at night to urinate

formulating the plan of care

• setting priorities

  • which problems require my immediate attention or that of the team?

  • which problems are my responsibilities and which should i refer to someone else?

  • which problems are most important to the patient?

3 main types of interventions

• independent:

  • independent nurse-initiated interventions

  • in the realm of independent nursing practice

  • no provider order required

• dependent:

  • provider initiated interventions

  • require MD or APP order

• collaborative:

  • coordination of multiple professionals

prioritization: ABCs

• airway patency

• breathing and ventilation

• circulation

• disability (assessing neurologic status)

• exposure and environmental control

SBAR: s

• situation

  • identify the patient, yourself, your unit

  • briefly describe the problem and your concern

  • what is going on with the patient?

  • give the headline — one to two sentences describing the reason for communication

SBAR: b

• background

  • provide the patient’s diagnosis or reason for admission, medical status, relevant history

  • have the chart available

  • give the clinical context — as much info as required to quickly and clearly set up for the assessment data

SBAR: a

• assessment

  • provide specific info on vital signs, recent labs, other quantitative or qualitative data

  • offer a provisional diagnosis or clinical impression

  • if offering a diagnosis is inappropriate, express your concern

  • give the problem as you see it, again using a headline describing the problem

SBAR: r

• recommendation

  • explain what you need

  • be clear and specific regarding your expectations and time frame

  • read back orders

  • figure out what is needed immediately to correct the problem