Core Concepts of Nursing - Exam 4 Blueprint

Factors Affecting Skin Integrity

- Genetics and Heredity

- Age

- Chronic Illness and its Treatment

- Medications

- Poor Nutrition

Normal Findings for a Skin Assessment

- skin color should be normal for ethnicity and the same (objective)

- skin temperature should be warm

- skin turgor should be elastic

best time to assess skin is when bathing, helping the patient use the restroom, etc

Changes in Skin Color

Pallor (pale; loss of color)

- due to lack of blood flow, anemia, shock, etc

Cyanosis (blue tint)

- late sign of hypoxia or impaired venous return

Jaundice (yellow-orange tint)

- liver dysfunction or RBC destruction

Erythema (redness)

- inflammation, rash, sun exposure, etc

Primary Lesions vs Secondary Lesions

Primary lesions: arise from healthy skin tissue (first lesion)

- macule, papule, nodule, vesicle, pustule, tumor, wheal

Secondary lesions: results from change in primary lesions

- erosion, crust, scale, fissure, ulcer

Assessment of Lesions

A - asymmetry of shape

B - border irregularity

C - color variation within one lesion

D - diameter greater than 6 mm

E - evolving in change of color/shape/size or development of itching/crusting/burning

Etiology of Wounds

Pressure Injury: caused by external pressure that impairs blood flow (tissue ischemia over a bony part)

Shearing forces: caused by forces that tear and injure vessels

shearing forces

two surfaces rub together and the friction causes skin breakdown (dragging a patient across a sheet)

Risk Factors that Impair Skin Integrity

1. immobility

2. shearing & friction (due to poor lifting techniques and incorrect positioning)

3. inadequate nutrition (protein)

- hypoproteinemia - albumin < 3.5

4. Sensory deficit

- excessive body heat (may not be able to feel something hurt you)

5. Vascular Disorders - restricted blood flow in part of you body

6. obesity or malnourished (emaciated - very thin)

7. incontinence/poor hygiene/smoking

8. Decreased LOC

“ISIS VOID”

Risk factors for alterations in tissue integrity (specifically with advanced aged people):

1. Loss of lean body mass

2. Generalized thinning of epidermis

3. Decreased strength, elasticity of skin

4. Increased dryness

5. Diminished pain perception

6. Diminished venous, arterial flow

Other factors include chronic medical conditions, medications, and smoking

Preventative Measures to Reduce Pressure Ulcers

- providing nutrition (protein, vit c, minerals)

- maintaining skin hygiene

- smooth, firm, wrinkle-free sheets

- frequent shifts in position (turn every 2 hrs in bed or every hour in chair)

- proper lifting (best is using lift equipment)

- providing supportive devices

Existing Pressure Injuries

MUST BE ASSESSED FOR UPON ADMISSION!! if not:

- prolong treatment for other problems

- increase healthcare costs

- diminish the client's quality of life

- can become so severe that the patient becomes septic and dies

Skin Integrity Order of Assessment:

1. Inspect

2. Palpate

3. Document

Documentation of Wounds

ALWAYS ALWAYS ALWAYS

- location (EXACT; use clock method)

- size

- drainage

- color

- pain

- position changes

approximated

closed, with the wound's edges touching each other

separated

open wound

Risk Assessment Tools for Wounds

1. Braden Scale for Predicting Pressure Sore Risk

- 23 total possible points

- Less than 18 = at risk for pressure sores

- Greater than 19 = low risk for pressure sores

2. Norton Scale - LOWER scale indicates higher risk for pressure sore

3. Waterlow Scale - HIGHER score indicates higher risk

Use: upon admission, at discharge, if there's a change in condition

Treatments for wounds

Debridement:

- Removal of foreign material and dead or damaged tissue from a wound.

Autolytic debridement

- natural process by which endogenous phagocytic cells and proteolytic enzymes break down necrotic tissue.

Pressure Injury Stages

- Deep tissue pressure injury

- Stage 1: non-blanchable erythema of intact skin

- Stage 2: partial thickness skin loss with exposed dermis

- Stage 3: full-thickness skin loss

- Stage 4: full-thickness skin and tissue loss

- Unstageable, obscured, full-thickness skin and tissue loss

Stage 1 Pressure Injury

Non-blanchable erythema of intact skin

- just the epidermis

- the skin stays red/pink after you push on it

- feels warmer or cooler than the adjacent tissue

- swollen with different texture

Treatment: pressure-relieving devices, encourage turning every 2 hrs, better nutrition

Stage 2 Pressure Injury

Partial-thickness skin loss with exposed dermis

- involves the epidermis and dermis

- looks like a ruptured blister or ulcer (reddish-pinkish)

- slough is a yellow, gooey substance that should be cleaned off the wound

Treatment: add a bandaid or wound dressing, assess for pain

as well as increase vitamin D, E, A, Zinc

Stage 3 Pressure Injury

Full-thickness skin loss

- involves the epidermis, dermis, and subcutaneous tissue

- visible adipose tissue w/ possible granulation tissue (good sign)

- wound edges appear rolled under, some slough and eschar

Unstageable: Obscured Full-Thickness Tissue Loss Pressure Injury

stage not determined due to slough or eschar

- eschar takes up 50% of the wound (dead tissue that forms over healthy skin and then over time falls off)

- must debride the eschar first then restage the wound

Stage 4 Pressure Injury

Full-thickness skin and tissue loss

- involves the epidermis, dermis, subcutaneous tissue, muscles, and bone

- EVERYTHING EXPOSED; MOST SEVERE

- rolled-under wound edges, tunneling, and undermining are common

- rid the infection prior to treating wound

Treatment: keep moist, change dressing frequently, nutritional supplements, antibiotics, fill the dead space (w/ gauze or gel)

Deep Tissue Pressure Injury

the skin is intact, yet the underlying tissue is compromised

- skin is nonblanchable with deep red, maroon, or purple discoloration

- feels like a sponge when pressed

Wound Closure Types (Healing Processes)

Primary Intention

Secondary Intention

Tertiary Intention

Primary Intention

- little or no tissue loss

- edges approximated

- heals rapidly

- low risk of infection

- no or minimal scarring

EX: closed surgical incision w/ staples, sutures, or glue

Secondary Intention

- loss of tissue

- wound edges WIDELY separated (unapproximated)

- longer healing time

EX: pressure injury left open to heal

Ex: Laceration from a car accident; A bit of the tissue is missing; Still kinda matches up but not quite

Tertiary Intention

- WIDELY separated

- deep

- closed later (Healed)

EX: abdominal wound initially left open until infection is resolved and then closed

What is the difference between secondary and tertiary?

The depth of the wound

What form of asepsis do you use when handling wounds?

SURGICAL asepsis

- sterile

Pharmacologic Therapy for Wounds

- topicals, systemic antibiotics

- dressings that maintain moisture to take the dead stuff out (medical-grade honey, hydrocolloids, alginates, hydrogel, and damp to damp dressings)

Phases of Wound Healing

Inflammatory Stage

Proliferative Stage

Maturation or Remodeling Stage

Inflammatory Stage

begins with the injury and lasts 3-6 days

Proliferative Stage

lasts the next 3 to 24 days

- replacing lost tissue w/ connective or granulated tissue and collagen

- resurfacing of new epithelial cells

Maturation or Remodeling Stage

occurs on or about day 21

- restoration of a more normal appearance

- scar formation

- can take more than 1 year to complete

Prompt Treatment of a Pressure Injury

- minimize direct pressure

- clean pressure ulcer at dressing changes

- use surgical asepsis

- if infected, obtain sample for analysis

- teach client to move to alleviate pressure

- provide ROM exercises and mobility

- irrigate with 5-8psi of pressure w/ a large syringe

Serous Drainage

watery and clear or slightly yellow (fluid in blisters)

Sanguineous Drainage

thick and red

Serosanguineous Drainage

watery and looks pale and pink due to a mixture of red and clear fluid

Purulent Drainage

thick and yellow, tan, green, or brown (pus)

- result of infection

Purosanguineous

mixture of pus and blood

- indicates a newly infected wound

Complications of Wound Healing

- hemorrhage (risk is greatest 24-48hrs after injury/surgery)

- infection (clean from the inside of the wound to the outside)

- dehiscence (separation of a closed wound)

- evisceration (organs fall out the wound opening)

Nursing Interventions for Evisceration and Dehiscence

REQUIRES EMERGENCY TREATMENT

- call for help

- stay with the client

- cover wound with sterile towels

- do not put the organs back in

- position the client supine with the hips and knees bent to reduce pressure

DONTS for Wounds

- do not use cotton balls or pipe cleaners

- do not massage bony prominences

- do not use alcohol, hydrogen peroxide, Dakin's, and other solutions

Color Guide for Wound Care

Red = protect (keep it covered)

- healthy regeneration of tissue

Yellow = cleanse

- presence of purulent drainage and slough (aka drainage from wound)

Black = debride (remove damaged tissue)

- presence of eschar that hinders healing and requires removal

Components of the Upper Urinary Tract

Kidneys and the Ureters

- the nephrons of the kidneys perform most function

Components of the Lower Urinary Tract

Bladder, Urethra, and the Pelvic floor

Importance of the Nervous System in Urinary Elimination

an intact nervous system must be present to allow transmission of impulses between the urinary tract and the brain

The Primary Functions of the Urinary System

1. Filtration: removes solute waste from blood

2. Reabsorption: controls blood concentration and composition

3. Excretion: rids the body of excess fluids and electrolytes

Normal Findings of a Bladder Assessment

the bladder normally is not palpable, but it should be midline

Assessment Findings of a Distended Bladder

- can be palpated at any point between symphysis pubis to umbilicus

- felt as a firm, rounded organ

- indicates urinary retention

- palpation may produce overflow incontinence in older adults

Laboratory Tests for Urinary Elimination

- Urinalysis

- BUN/Creatinine Test

- 24 Hour Urine Collection

Urinalysis

can be collected midstream or via catheter to identify UTI, presence of RBCs and WBCs, culture and sensitivity, specific gravity, pH, glucose, etc

- clean catch technique

- use a sterile container

- clean the area, pee in the toilet a little, then pee in the cup

BUN/Creatinine Test

a common blood test used to assess renal function (elevated with renal dysfunction)

24 Hour Urine Collection

determines glomerular filtration rate (GFR) and the amount of creatinine cleared through the kidneys; determines how well the kidneys are filtering the urine

- discard the first void

- collect urine for 24 hours and refrigerate it or put the samples on ice

- if you miss a void, START OVER

Diagnostic Tests for Urinary Elimination

- Bedside sonography with a bladder scanner

- Kidneys, ureters, bladder (KUB)

- Intravenous pyelogram

Bedside Sonography with a Bladder Scanner

measures bladder volume and residual volume after peeing (how much urine is in bladder)

- point of care testing

Kidneys, Ureters, Bladder (KUB)

an x-ray of the abdominal area to determine size, shape, and position of these structures

- not as clear as a IVP

Intravenous Pyelogram (IVP)

involves the injection of x-ray detectable contrast media (iodine) for viewing of urinary ducts, renal pelvis, ureters, bladder, and urethra

- often used to detect kidney stones

- allergy to shellfish or iodine contraindicates use

- Metformin must be stopped prior to x-ray and held for 48hrs after (risk for kidney failure and lactic acidosis)

Signs and Symptoms of Kidney Stones

- mild to severe pain in the side, back, abdomen, or during urination (stones are moving)

- cloudy or foul-smelling urine

- frequent urination (body trying to eliminate the stone)

- nausea and vomiting (due to the pain)

Interventions for Kidney Stones

- administer analgesics (opioids/narcotics)

- lithotripsy (shock wave therapy to break up the stone)

- reduce sodium

- reduce oxalate (spinach, rhubarb, nuts, wheat bran)

- reduce animal protein

- increase fluids

Fracture Bed Pan

for clients who must remain supine and clients in body or leg casts, or hip/pelvic fractures

- risk for skin breakdown

Regular Bed Pan

for clients who can sit up

- risk for skin breakdown

How to Promote Urination

- run water

- sit the patient up

- pour warm (tepid) water over the bladder

- put them in a warm bath

- provide privacy

- allow adequate time

What is the most important electrolyte to monitor related to the urinary system?

Potassium

Process of Urination

1. urine collects in the bladder

2. stretch receptors are stimulated (usually when 250mL to 450mL collects)

3. impulses transmitted to voiding reflex center

4. internal sphincter relaxes (results in the urge to void)

5. external urethral sphincter muscle relaxes

6. urine is eliminated through the urethra

Who is at a higher risk for fluid volume overload?

Infants because their immature kidneys are unable to rapidly excrete excess fluid

General Principles of Urinary Drainage Systems

- use sterile asepsis for any procedure that can introduce bacteria into the urinary tract

- maintain a closed urinary collection system

- keep the collection bag below the level of the bladder

- if the patient reports fullness in the bladder check for kinks in tubing and sediment in tubing

- assess the abdomen for a distended bladder

How often do you perform Peri-Care?

3 times a day or after defecation

- or q 8 hrs

- only use povidone-iodine and alcohol upon INSERTION of the catheter, not for regular cleaning

Peri-Care for Females

1. Retract the labia

2. Cleanse from symphysis pubis to anus (front to back)

3. Use a different part of the washcloth with each swipe

4. rinse well and pat dry

5. cleanse first few inches of the external portion of the catheter

Peri-Care for Males

- clean the meatus/glans (opening of the urethra) then the shaft of the penis

- clean the first 4 inches of external portion closest to the patient

- if uncircumcised, retract the foreskin then replace when done

Application of a Condom Catheter

1. Secure the condom catheter over the penis

2. Leave 2.5cm (1 in) between the end of the penis and the plastic tubing (potential pressure point)

3. Ensure the tip of the penis is not touching the plastic tubing and that the condom is not twisted

- inspect the penis 30 mins after application

- assess for impaired circulation or latex allergy

- reassess q 4 hrs (urine flow, swelling, discoloration)

Catheter and Bladder (Open) Irrigation

- use sterile technique because you're opening the system (high infection risk)

- draw up sterile solution in catheter tip syringe

- 30-40mL for catheter irrigation

- 100-200mL for bladder irrigation

- instill at a rate of 3mL per second (SLOW) to prevent mucosal damage and bladder spasms

- allow the fluid to drain by gravity

Alterations in Urine Production

Polyuria

Anuria

Oliguria

healthcare provider should be notified promptly

Polyuria

production of abnormally large amounts of urine

Anuria

absence of urine production

Oliguria

scant urine output (little to none)

- may be the result of abnormal fluid losses or lack of fluid intake

- often indicates impaired blood flow to the kidneys or impending renal failure

Alterations in Urine Elimination

Urinary Frequency

Urinary Retention

Urinary Incontinence

Nocturia

Dysuria

Urinary Hesitancy

Neurogenic Bladder

Urinary Frequency

voiding at frequent intervals, more than 4-6 times per day

- total I & O may appear normal

Nocturia

excessive nighttime urination

Urinary Incontinence

inability to control urination

Dysuria

painful urination

Urinary Hesitancy

delay, difficulty in initiating voiding

Neurogenic Bladder

impairment of bladder control due to brain or nerve conduction

- bladder muscle not working properly

- does not perceive bladder fullness

- unable to control urinary sphincters

EX: spinal cord injury

Risk Factors for UTIs

- Females have a small distance between the anus and urethra

- frequent intercourse

- decreased levels of estrogen (menopause)

- uncircumcised males

- use of indwelling catheters

- incontinence

- holding in pee

Urinary Stress Incontinence

loss of small amounts of urine from increased abdominal pressure with pregnancy, laughing, sneezing, or lifting

Urinary Urge Incontinence

inability to stop urine flow long enough to reach the bathroom due to an overactive detrusor muscle with increased bladder pressure

Urinary Overflow Incontinence

bladder over-distention and frequent loss of small amounts of urine due to obstruction of the urinary outlet or an impaired detrusor muscle

- sign of urinary retention

Urinary Functional Incontinence

loss of urine due to factors that interfere with responding to the need to urinate (cognitive, mobility, and environmental barriers)

Independent Nursing Interventions for Urinary Incontinence

Kegal Exercises and Bladder Training

Collaborative Nursing Interventions for Urinary Incontinence

Anticholinergics and surgery

For Functional: remove environmental barriers (no tight clothing)

Kegal Exercises

Tighten pelvic muscles for a count of 10 sec, relax slowly for a count of 10 sec, and repeat in sequences of 15 in the lying-down, sitting, and standing positions

Bladder Training

- urinate at scheduled intervals

- gradually increase urination intervals, working toward the optimal 4 hr intervals

- hold urine until the scheduled toileting time

- keep track of urination times

Urinary Retention is not...

...a lack of urine production (anuria)

Crede's Maneuver

manual exertion of pressure on the bladder to force urine out

- be careful so you do not rupture the bladder

- an independent nursing intervention for urinary retention

Interventions for Renal Failure

- administer diuretics (some kidney function MUST remain)

- dialysis if severe (chronic renal failure = dialysis forever)

- kidney transplant

Dialysis

a procedure to remove waste products from the blood of patients whose kidneys no longer function

Hemodialysis

the patient's entire blood is circulated outside the body in a machine placed outside the body known as a dialyzer

- clean blood returns back to the patient

Includes: AV grafts, AV fistulas

Peritoneal Dialysis

the dialysis solution is instilled into the abdominal cavity through a catheter

- extremely high risk for infection

Why is sleep essential?

for normal physiological functioning of the body