Studied by 8 people
what’re the 3 layers of the skin
epidermis
dermis
subcutaneous
what factors can affect skin integrity
wounds
vascular wounds
vascular disease
diabetes
malnutrition
cholesterol and fatty acids
vitamins and minerals
medications
excessive moisture
external forces (pressure, shear, friction)
aging (skin elastic decreases)
what is an open wound
actual break in the skins surface
what is a closed wound
the skin is still intact
what are 3 terms used to describe wound depth
superficial: involves only the dermis
partial thickness: involves the epidermis and dermis but doesn’t extend through eh dermis to the subQ
full thickness wound: extends through the dermis to the subQ layer and could extend farther to muscle or bone
what is the definition of a clean wound
no infection and the risk o one is low
what is the definition of a contaminated wound
results from a break in sterile technique during surgery
what is the definition of a clean contaminated wound
it is like a clean wound but because the surgery involves organ systems that are likely to contain bacteria the risk of infection is greater
what is the definition of an infected wound
shows clinical signs of infection (redness, warmth, increased drainage that may or may not be purulent (pus containing), and has bacterial counts in the tissue when sampled)
what is the definition of a colonized wound
1 or more organisms are present of the surface of the wound when a culture is obtained but theres no overt sign of an infection in the tissue below the surface
what is an acute wound (healing process term)
a wound that progresses through the phases of wound healing in rapid uncomplicated manner (healed by primary intention) → surgical incisions or traumatic wounds which the edges can be approximated (brought together) to heal
what is a chronic wound (healing process term)
commonly heals by secondary intention → when a wound heals this way new tissue must fill in from the bottom and sides of the wound nail the wound bed is filled with entirely new tissue (these wounds are associated with disease processes → diabetes/vascular disease or wounds that have inhibited proper wound healing)
what are the 3 phases of wound healing
inflammatory
proliferative
maturation
what’re the 3 types of healing intentions
primary intention: wounds that tend to heal quickly and result in minor scar formation because the edges of the skin can be brought together
secondary intention: new tissue fills in from the bottom and sides of the wound until the wound bed is filled
tertiary intention: a delay in wound healing between injury and closure
what is an approximated wound
a wound that can be brought together by the edges
what is the inflammatory healing process
the body initial inflame response happens and lasts about 3 days
when the injury fort happens bleeding occurs triggering the coagulation cascade which forms a clot to prevent the bleeding
there is an increased pain, warmth, and swelling in the injured area since the blood vessels are dilated and leak fluid into the tissue surrounding the injury
what is the proliferative phase
when the wound is filled with new granulated tissue (theres development of new blood vessels that are needed to support the new tissue, wound contraction, and epithelialization)
this lasts usually several weeks (can be shorter if its a surgical closed wound or longer if the wound is larger or left to heal via secondary intention)
epithelial cells move laterally form the edges of the wound across the granulated moist tissue until the wound has been resurfaced with epithelial cells and normal skin layers are reestablished (THIS IS WHY WE USE MOIST WOUND DRESSINGS TO PROMOTE AND SUPPORT WOUND HEALING IN THIS WAY)
what is the maturation phase
this is remodeling that can last up to a year
collagen is deposited more cuasing scar tissue formation thats strengthened due to the collagen
the strength of scar tissue only can reach 80% of its previous strength
what factors affect wound healing
oxygenation and tissue perfusion
diabetes
nutrition
age
infection
what is dehiscence
a PARTIALof separation of the tissue layers during the healing process (usually deals with connection with surgical incisions) → if sutures break open because of something you possibly did
what is evisceration
TOTAL separation of the tissue layer allowing the protrusion of visceral organs through the incision
what is the best form of action for an eviscerate wound
splinting (if its not splinted it will create a FISTULA/hole)
what is a stage 1 pressure ulcer description
an intact, non-blistered skin with non-blanchable erythema (persistent redness) → NO SKIN BREAK DOWN YET
what is a stage 2 pressure ulcer description
a PARTIAL THICKNESS skin loss that involves the EPIDERMIS and exposes some of the DERMIS → blistering skin
what is a stage 3 pressure ulcer description
a FULL THICKNESS tissue loss the extends to the SUBQ layer but doesn’t go to the muscles or bones → can have tunneling that must be measured and recorded
what is a stage 4 pressure ulcer description
a FULL THICKNESS tissue loss with exposed MUSCLE AND BONE → osteomyelitis is a risk for this stage since exposed bone is possible (this stage MAY need to have slough cleaned out to determine the true depth and levels of tunneling thats occurred)
what is an unstageable pressure ulcer description
an OBSCURED FULL THICKNESS tissue/skin loss where the amount of necrotic tissue and eschar (black/brown) /slough (white/cream/yellow) in the wound makes it impossible to determine the true depth of wound and tunneling → just can tell how bad it is
what increases the risk for pressure ulcers
patients inability to feel pain
unable to respond to pain appropriately
limited to their ability to move/maintain position
what tools are used to assess pressure ulcers
braden scale → ranks the risk factor, sensory perception, moisture, activity, mobility, nutrition, and friction
Norton scale → ranks the physical condition, mental state, activity, mobility, continence of patient (low risk = 16-30 / moderate risk = 11-15 or below / high risk = 10 or below)
what are the score description for Braden scale
23 means theres NO RISK for developing ulcer
high risk = 10-12
VERY high risk = 9 or less
the lowest possible score of SIX means there at the highest risk for an ulcer
what assessments need to be done if a patient has a wound
location
size
presence of undermining or tunneling
drainage (COCA)
conditions of wound edges and surrounding tissue (white ring around wounds and fresh tissue growing right next to the wounds barrier → this is maceration (due to being exposed to excess moisture))
what is the difference between serous, serosanguineous, and sanguineous
serous: clear watery fluid from plasma
serosanguineous: pink to pale red and contain a MIX of serous fluid and red bloody fluid
sanguineous: indicates bleeding and is BRIGHT red
what does COCA stand for
color
odor
consistency
amount
what does maceration mean
condition where excessive moisture causes a softening of the skin (white ring forms around a wound)
what’re ways to prevent a pressure ulcer
frequent position changes: every 2 hours, elevate egad NO MORE than 30 degrees to reduce shear effects, when side lying position patient at 30 degrees rather than 90 to prevent pressure on bony prominences
use cushions (waffle padded boots)
skin hygiene
spread out body weight over a greater surface area
what is a Jackson Pratt (JP) drain
a closed drainage system (usually sutured in place) where a soft drain is attached to a springlike suction device → these deal with orthopedic and abdominal surgery patients
this promotes healing and reduces number of microorganism entering because its closed (no open ends)
what is a hemovac drain
a closed drainage system (usually sutured in place) where a soft drain is attached to a springlike suction device → these deal with orthopedic and abdominal surgery patients
this promotes healing and reduces number of microorganism entering because its closed (no open ends)
what is a Penrose drain
an open drainage system thats a flexible piece of tubing not surgically sutured inplace
*abdominal surgery* particularly after incision and drainage procedures, gallbladder surgery, or other operative procedures involving the common bile duct
The system drains excess fluid to the outside of the body (the pressure inside the wound is greater than the pressure outside the body; therefore the drainage flows out of the tube onto the dressing)
the drains typically are inserted through stab wounds a few centimeters away from the surgical incision line, to prevent any interference with healing of the main surgical site
what is a wound va drain
uses negative pressure to remove excess wound fluid, stabilize wound edges, and stimulate granulated tissues
what is an infection
a disease state caused by an infectious agent that occurs when a pathogen multiplies in a susceptible host
what is asepsis
freedom from and prevention of disease causing contamination
what is sepsis
a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body’s response to their presence, potentially leading to the malfunctioning of various organs, shock, and death
what is a sterile body area vs a non sterile body area
sterile: any place a microorganism can’t reach (blood, urine, CSF)
unsterile: any place where microorganisms can reach (skin, mouth, organs)
what’re the lines fo defense of the body
normal flora
inflammatory
immune response (innate (immediate defense)/adaptive (long term immunity))
what normal flora may cause problems
S. aureus
C. Diff
signs and symptoms of inflammation
fever
chills
malaise
altered mental status
redness
heat
pain and swelling at the site
what is an ANTIGEN
substance that provokes adaptive immune response (nonliving things: toxins chemicals, drugs, foreign particles)
what is an ANTIBODY
immunoglobulin molecules that recognizes foreign invaders
what is innate immunity
(nonspecific) provides immediate defense against foreign antigens, produces chemical mediators that fight infection, remove foreign substance (activate the adaptive immune system)
what is adaptive immunity
(specific/aquired) provides long-term immunity when the body is exposed to an antigen
Humoral (antibody-mediated → WBC involvement, and happens within lamp and and blood)
Cellular (cell-mediated → WBC involvement when body doesn’t know whats attacking it)
both are types of adaptive immunity
what is active immunity
immunity to a pathogen that occurs following exposure to said pathogen (vaccines)
what is passive immunity
immunity given from one person to another (breastfeeding or placenta)
what are the steps in chain of infection (with examples)
what is HAI
healthcare associated infections → formerly referred to as NOSOCOMIAL infections
infections acquired while the patient is receiving treatment in a facility (hospital, long term care, nursing home)
HAIs are associated with the use of medical devices such as catheters and ventilators, complications after a surgical procedure, contagious transmission between patients and health care workers, and the overuse of antibiotics
what is the most effective method to fighting infections
hand washing/ alcohol based sanitizer
precautions and isolation (airborne, droplet, contact precautions)
what is an acute infection
develop and run their coarse rapidly (coughs, colds, ear infections) → last 10-14 days
what is a chronic infection
may persist for months/years (wounds, bone infections, hepatitis, AIDS)
what’re are signs and symptoms of systemic infections
infections that infiltrate the bloodstream → can cause fever, increases in heart and respiratory rates, lethargy, anorexia, and tenderness or enlargement of lymph nodes
what patients are risk for infection
people with chronic diseases, alterations in the immune system, medications such as chemotherapeutic drugs, alterations in skin integrity, malnutrition, indwelling medical devices such as urinary catheters, lack of proper immunizations
what is the complete blood count (CBC) lab
identifies and counts the 7 types of cells found in the blood, red blood cell, neutrophil, eosinophil, basophil, lymphocyte, monocyte, and platelet
it can detect: Anemia, Autoimmune disorders, Bone marrow disorders, Dehydration, Infections, Inflammation, Hemoglobin abnormalities, Leukemia.
what is a differential white blood cell count (WBC) lab
It helps determine whether the body is mounting an immune response to an infection
a normal level is 4500-10500 → anything higher than this can indicate infection
what is an erythrocyte sedimentation rate (ESR) lab
it measures the degree of inflammation in the body
An ESR that remains elevated indicates a poor response to current therapy, whereas an ESR that decreases indicates a good response
what is a culture and sensitivity test (C&S)
this is used to determine what kind of bacteria is in a possible infection → the presence of bacteria has a positive result
there is a blood, urine, stool, or wound drainage
the culture parts determine the pathogen and the sensitivity determines the nit biotic needed
who should we use standard precaution on and what is standard precaution
everyone
hand washing/sanitizing and gloving
what is contact isolation
transmission of contagious disease may occur through several routes: direct and indirect
disease requiring contact precaution: multi drug resistant organisms, scabies and herpes simplex virus, and draining wounds where they have been cultured (USE GLOVES AND GOWN)
what is airborne isolation
this is used when known or suspected contagious diseases can be transmitted via small droplets or particles that’re suspended in the air
this type requires negative pressure rooms with high efficiency particulate air (HEPA) filtration system
people need to wear N95 mask (needs to be fitted)
diseases that require this: varicella, rubella/measles, TB
what is droplet isolation
this is used when known contagious disease can be transmitted through large droplet suspended in the air (coughing, sneezing, or talks)
diseases that use this: pharyngeal diphtheria, mumps, rubella, pertussis, scarlet fever, meningococcal sepsis, and influenza
what is protective isolation
this is used for patients who have a compromised immune systems (protects the patients from microorganisms)
diseases that need this: immunosuppression, including leukemia, myelodysplastic syndrome, aplastic anemia, systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), human immunodeficiency virus (HIV) infection, and severe sepsis
patients rooms need positive pressure HEPA filtration, anyone entering needs a mask and wash hands, nothing alive in the room or fresh fruits/veggies in the room
what is medical asepsis
(often referred to as clean technique) procedures include handwashing, wearing gloves, gowning, and disinfecting
what is surgical asepsis
(sterile technique) is used to prevent the introduction of microorganisms from the environment to the patient
Surgical asepsis is used for: surgical procedures, invasive procedures such as catheterization, procedures that invade the bloodstream or break the skin, dressing changes, and wound care
what is the definition of pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such
what does nociception mean
process when the sensation of tissue injury is conducted from the peripheral to the central nervous system
what is pain threshold
lowest intensity at which the brain recognizes the stimulus as pain
what is pain tolerance
intensity/duration of pain that a patient is able or willing to endure
what is acute pain
occurs abruptly after an injury or disease, persists until healing occurs, and often is intensified by anxiety or fear
lasts LESS THAN 6 months
what is chronic pain
may be malignant or nonmalignant but lasts for a prolonged period of time during prolonged tissue pathology or pain that persists beyond the normal healing period for an acute injury or disease
lasts MORE THAN 6 months
what is nociceptive pain
Physiologic pain in response to trauma, injury, or inflammation
what is visceral pain
inner pain with the organs (appendix, pancreas, bowels)
what is somatic pain
outer pain with the body (skin, muscles, bones, and joints)
what is neuropathic pain
pain with the nerves
what is phantom pain
brain receives pain message from area of amputation
what is psychogenic pain
no physical cause but can be caused by mental, emotional, or behavioral factors
what are (physiologic) vital sign changes for acute pain
increased blood pressure, heart rate, increased respirations
diabetics have increased blood glucose due to stress or pain
what are the types of pain assessment tools to use
10cm visual analog scale (0-10)
Wong-baker faces pain scale
the nonverbal pain scale
SOCRATES (site, onset, character, radiation, associations, time course, exacerbating relieving factors, severity)
what is the purpose for documenting and what is documenting
to describe facts clearly and concisely to improve communication
´the written, or electronically generated, information about a patient that describes the patient, the patient’s health, and a care and service provided, including the dates of care.
what’re the purposes of patient record
Communication
Reimbursement
Care Planning
Education
Quality Review
Decision Analysis
Legal
Documentation
Research
Historical Documentation
what’re important considerations for guidelines for documenting
timing: needs the date and time of any recording
confidentiality: keep this as a legal private record (access is restricted to health professionals)
permanent: enteries made in dark colored black so its permanent and changes can be indicated
signature: each recording is signed by the nurse doing the assessment/charting (needs name and title → O. Rose R.N.) → don’t walk away before logging off
accuracy: all recordings must be accurate and correct → with facts and exact observations (quote directly, spell correctly, avoid general words, draw a line through errors needing corrected and blank spaces)
sequence: recording events in the order they occurred (assessments, interventions, and patients response)
appropriateness: only record info that pertains to patients health and care
use of standard terminology: use only commonly accepted symbols, abbreviation, and terms specified by agency
what’re the formats for nursing documentation
Initial Nursing Assessment
Kardex Care Plan
Plan of Nursing Care
Critical/Collaborative Pathways
Progress Notes
Flow Sheets
Discharge and Transfer Summary
´Home Healthcare Documentation
what’re components of Flow sheets
Graphic Sheet
24-Hour Fluid Balance Record
Medication Record
24-Hour Patient Care Record
what’re some problems with documentation
1 in 4 malpractice suits are determined on the basis of patient record
documentation content that increases risk for legal problems (objective things)
documentation mechanics that increases risk for legal problems
whats the difference between EMR and EHR
EMR: record of one episode→ certain patients current chart
EHR: record from different doctors and long term view
what is CPOE
computer physicians order entry → access via password and verification codes
providers entering and sending treatment instructions (including medication, laboratory, and radiology orders) – via a computer application rather than paper, fax, or telephone
what is MAR
medication administration record: a drug chart that tells you the patients 6 rights of med administration (nurse must go over them 3 times prior to giving med)
whatre some issues of not giving good report
When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or omissions in care often occur
what is SBAR and what it used for
s: situation
B: background
A: assessment
R: recommendation
its used for communication between health care professionals
what an incident report
When an unusual and unexpected event involving a patient, visitor, or staff member occurs, an incident report is completed → falls, med errors, equipment malfunctions
not apart of medical record
factual only, objective, nonjudgemental
what the importance of using informatics in nursing
The use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research
this is recognized as a specialty in nursing
what does DIKW stand for and what does it mean
D= data (facts)
I= information (organized data)
K= knowledge ( organized info thats meaningful)
W= wisdom (appropriate application of knowledge)
what is BCMA used for
bar-code medication administration is used as a part of the process of med administration (fewer errors made)
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