Fundamentals Exam 2 TMR

Factors affecting skin integrity

-Mobility/activity

-nutritional status

-impaired tissue perfusion or circulation

-sensory perception

-moisture

-shearing/friction

-chronic illness (diabetes or PVD).

Open wound

An injury in which the skin is interrupted, exposing the tissue beneath.

Closed wound

An internal injury with no open pathway from the outside.

Wound measurements

Length, width, depth.

Wound classification

underlying cause

skin integrity

wound depth

amount of contamination

healing process

Clean wound

A wound that does not have any foreign material or debris inside.

Contaminated wound

A wound that may have dirt, bacteria, or other foreign objects.

Clean-contaminated wound

A clean wound with a higher risk of infection.

Dirty/infected wound

A wound with current exposure to objects, debris, pus, feces, etc., showing signs of infection.

Colonized wound

A wound where organisms are found on the surface via swab culture, but no signs of infection are present.

Acute wound

A wound that starts and progresses through the expected healing process.

Chronic wound

A wound that does not move through an expected or predictable rate of healing.

Phases of wound healing

Inflammatory, proliferative, maturation.

Inflammatory phase

The initial phase of wound healing that lasts about 3 days, includes coagulation cascade.

Proliferative phase

The phase of wound healing lasting several weeks where granulation tissue forms.

Maturation phase

The final phase of wound healing that can last up to 1 year, involving scar tissue.

Primary intention healing

Healing where the edges of the wound are approximated.

Secondary intention healing

Healing where edges cannot be approximated due to tissue loss.

Tertiary intention healing

Healing where the wound is left open and later closed due to infection risk.

Factors affecting wound healing

oxygen

infection

age/sex

chronic illness (diabetes or obesity)

stress

nutrition

medications

Dehiscence

Partial or complete separation of tissue layers during healing.

Evisceration

Total separation of tissue layers, allowing protrusion of visceral organs through the incision.

Stage 1 pressure injury

Non-blanchable erythema of intact skin.

Stage 2 pressure injury

Partial-thickness loss with exposed dermis, may include blisters.

Stage 3 pressure injury

Full thickness skin loss with undermining and/or tunneling.

Stage 4 pressure injury

Full thickness skin and tissue loss, may involve osteomyelitis.

Unstageable pressure injury

Obscured full-thickness skin and tissue loss that cannot be assessed until eschar is removed.

Deep tissue pressure injury

Persistent non-blanchable deep red, maroon, or purple discoloration.

Risk factors for pressure injuries

-impaired sensory perception

-excess moisture

-decreased activity/mobility

-friction & shear,

-incontinence

-poor nutrition

-poor circulation.

What is used for a risk assessment for pressure ulcers?

Braden scale, norton assessment 

What assessments need to be done if a patient has a wound?

Include location, size, tunneling or undermining, drainage, condition of wound edges and surrounding tissues.

Serous drainage

Clear and thin drainage.

Serosanguineous drainage

A mixture of serum and blood, pinkish in color.

Sanguineous drainage

Primarily blood drainage.

Purulent drainage

Thick, white, pus-like drainage, an indicator of infection.

COCA

Color

Odor

Consistency

Amount

used for assessing wound drainage.

Maceration

Softening and breakdown of skin due to excess moisture.

Pressure injury prevention methods

proper hygiene

nutrition

adequate incontinence care

barrier creams

avoiding skin trauma

rotating patient position

JP drain

Used to prevent fluid collection underneath the incision site.

Hemovac drain

Placed under skin during surgery to remove blood or other fluids that build up.

Penrose drain

A straight, flexible tube that drains fluid from a surgery site.

Wound vac

A device that gently pulls fluid from the wound and may stimulate new tissue growth.

Exposure vs infection

Exposure means coming into contact with a virus or bacteria; infection occurs when someone becomes sick from the exposure.

Asepsis vs sepsis

Asepsis refers to prevention of contamination, while sepsis refers to being infected.

Lines of defense

1. Normal flora 2. Inflammatory response 3. Immune response.

Systemic defenses

1. Integumentary 2. Respiratory system 3. GI system.

Sterile body areas

Areas not exposed to the external environment, such as blood and CSF.

Non-sterile body areas

Parts of the body exposed to the environment and may contain microorganisms.

Normal body flora problems

C. diff may arise from disease processes or antibiotic use.

Signs and symptoms of inflammation

Swelling, redness, warmth, and pain.

Antigens

Foreign substances that enter the body, creating an immune response. (virus)

Antibodies

Proteins produced by the immune system to attack and fight off antigens. (immunohemoglobin)

Innate immunity

Non-specific immunity that is present at birth.

Acquired immunity

Specific immunity that develops following exposure or vaccination.

Active immunity

Immunity produced by a person's own immune system, lasting many years.

Passive immunity

Temporary immunity transferred from one person to another, lasting 1-6 weeks.

Chain of infection steps

1 agent/germs (virus)

2 reservoir/where the germs live (people)

3 port of exit

(mouth)

4 mode of transmission (droplets/sneezing)

5 portal of entry (mouth)

6 susceptible host/next sick person (baby)

Healthcare acquired infection (HAI)

An infection a patient develops while receiving care for another condition in a healthcare setting.

Effective method of fighting infection

Good hygiene; washing hands.

Acute infection

An infection that is acquired, treated, and resolves.

Chronic infection

An infection that continues after the primary infection, usually lasting over 6 months.

Systemic signs and symptoms of infection

Confusion

fever or hypothermia

hypotension

tachycardia

chills

headache

lightheadedness

High-risk patients for infection

babies

pregnant

immuno-compromised

elderly

obese

chronically ill patients.

WBC count indicative of infection

Increased; above 10,000/mm3.

ESR

Degree of inflammation in the body, increased above 100mm/hr.

C&S

Culture and sensitivity test to identify present organisms like bacteria or fungi.

WBC differential

Shows amounts of each type of WBCs

neutrophils indicate bacterial infection

lymphocytes indicate viral

monocytes indicate long-term infections

Standard precautions apply to

Everyone in the healthcare setting.

Glove use protocols

Wear gloves for contact with blood, bodily fluids, tissues, mucous membranes, or broken skin.

Contact isolation

Requires gowns and gloves for transmission that occurs directly or indirectly.

Airborne isolation

Requires N95 masks and negative pressure rooms for small airborne particles.

Droplet isolation

Uses surgical masks for droplets from coughing, sneezing, or talking.

Protective isolation purpose

Used for patients with compromised immune systems.

Medical vs surgical asepsis

Medical asepsis is a clean technique; surgical asepsis is a sterile technique.

Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Pain threshold

The point at which a person perceives pain.

Pain tolerance

The level of pain a person can endure.

Acute pain duration

Occurs abruptly after injury and persists until healing; usually lasts less than 6 months.

Chronic pain duration

Lasts for a prolonged period; persists beyond normal healing, typically over 6 months.

Nociceptive pain

Physiologic pain in response to trauma, injury, or inflammation.

Visceral pain

Pain that refers to organs within the body.

Somatic pain

Pain from skin, muscles, bones, and joints.

Neuropathic pain

Pain resulting from damage to neurons or nerve injury.

Phantom pain

Pain felt in an amputated limb.

Psychogenic pain

Pain with no physical cause, often influenced by mental or emotional factors.

Consequences of uncontrolled pain

high HR, BP, RESP RATE, and intracranial pressure.

Response differences in acute vs chronic pain

Patients with chronic pain may not show visible signs compared to those with acute pain who typically display clear signs.

Diversity considerations in pain assessment

- traditions, customs, & spirituality.
- uses of gender roles & sexual orientation
- issues related to pain, suffering, & distress
- attitudes about discussing serious illness & death

SOCRATES pain assessment

Site, Onset, Character, Radiates, Associated symptoms, Time/duration, Exacerbating/relieving factors, Severity.

VAS pain assessment scale

A straight line scale indicating levels of pain from no pain to worst possible pain.

Wong-Baker FACES scale

A pain assessment tool using caricatures representing pain levels for children.

FLACC scale

A behavioral pain assessment scale for nonverbal or preverbal patients.

Purpose of documentation

Protects the healthcare team and patients; ensures continuity of care.

Timing guidelines for documentation

Document date and time for each notion accurately.

Confidentiality guidelines for documentation

Access restricted to health professionals involved in care.

Permanence guidelines for documentation

Entries made in black ink to maintain permanence and identify changes.

Signature guidelines for documentation

Each entry should be signed by the nurse, including name and title.

Accuracy guidelines for documentation

All entries must be accurate, fact-based, and correct.

Sequence guidelines for documentation

Document events in the order they occur.

Appropriateness guidelines for documentation

Only relevant information pertaining to patient health is recorded.