Comprehensive Nursing Study Notes: Modules 4A through 4E

Factors Impairing Skin Integrity

• Shearing and Friction: Resulting from poor lifting techniques or inappropriate positioning techniques.
• Immobility: Extended periods without movement increase the risk of skin breakdown.
• Incontinence: Fecal or urinary incontinence exposes skin to moisture and irritants.
• Decreased Mental Status: Reduced awareness leads to a lack of self-repositioning.

Stages of Wound Healing

• Inflammatory Phase: Begins at the time of injury and lasts for $3$ to $6$ days.
• Proliferative Phase: Lasts from $3$ to $24$ days and involves replacing damaged tissue with granulation tissue.
• Maturation/Remodeling Phase: Begins on day $21$ and continues onward; characterized by scar formation and the return of a more normal skin appearance.

Braden Scale and Risk Assessment

• Risk Thresholds:
  • A score of $\le 18$ indicates the patient is at risk for skin breakdown.
  • A score of $\ge 19$ indicates a low risk for skin breakdown.
• Scoring Logic: The lower the overall score on the Braden Scale, the higher the risk for pressure injury development.

Stages of Pressure Injury

• Stage 1: Intact skin presenting with nonblanchable redness; the wound remains closed.
• Stage 2: Partial-thickness skin loss characterized by a shallow open ulcer with a red wound bed; no slough is present.
• Stage 3: Full-thickness skin loss; subcutaneous fat (subfat) is visible, but bone, tendon, and muscle are not.
• Stage 4: Full-thickness skin loss where bone, muscle, or tendon is clearly visible.
• Unstageable: Full-thickness tissue loss in which the base of the ulcer is covered by necrotic tissue, slough, or eschar.

Types of Wound Healing and Exudate

• Healing Intentions:
  • Primary Intention: Characterized by little to no tissue loss (e.g., a surgical incision secured with staples).
  • Secondary Intention: Involves tissue loss and requires a longer healing time (e.g., an open pressure wound).
  • Tertiary Intention: A deep wound that is initially left open to heal and is then closed at a later date.
• Wound Exudate Types:
  • Serous: Clear fluid.
  • Serosanguinous: Clear fluid mixed with a small amount of blood, appearing pink.
  • Purulent: White, yellow, or green thick drainage; indicates the presence of infection.
  • Purosanguous: A combination of pus and blood, typically seen in newly infected wounds.

Preventive Measures and Management of Wound Complications

• Standard Prevention:
  • Turn patients every $2$ hours while in bed and every $1$ hour while in a chair.
  • Promote walking and mobility exercises.
  • Protect bony prominences using pillows or Allevyn dressings.
  • Do not massage bony prominences.
  • Float the heels to remove pressure.
  • Keep the skin dry and increase protein intake.
• Complications:
  • Infection: Indicated by purulent drainage and delayed healing.
  • Hemorrhage: Excessive bleeding from the wound site.
  • Dehiscence: Partial or total separation of wound layers. Notify the provider and cover the area with a sterile towel soaked in normal saline.
  • Evisceration: Protrusion of visceral organs through a wound opening. This is a medical emergency. Notify the provider immediately, cover with a sterile towel soaked in saline, place the patient in a supine position with knees bent, keep the patient NPO (nothing by mouth), and do not leave the patient alone.

Wound Assessment and Healing Factors

• Factors Effecting Healing: Medication (e.g., those that decrease leukocyte counts), malnourishment, obesity, low hemoglobin levels, chronic disease, and wound stress.
• Wound Color Guide:
  • Red: Protect the wound and keep it covered; signifies healthy tissue regeneration.
  • Yellow: Cleanse the wound; signifies drainage is present.
  • Black: Debride the wound; signifies the presence of eschar which requires removal.
• Assessment of Lesions (ABCDE):
  • A: Asymmetry of shape.
  • B: Border irregularity.
  • C: Color variation.
  • D: Diameter greater than $6\,mm$.
  • E: Evolving changes in color, shape, or symptoms such as burning and itching.

Documentation and Urinary Tract Anatomy

• Wound Documentation Requirements: Exact location (using the clock method), size, drainage, color, pain, and position changes.
• Upper Urinary Tract: Comprised of the kidneys and ureters.
• Lower Urinary Tract: Comprised of the bladder, urethra, and pelvic floor.
• Neurological Role: The nervous system must be intact to allow the transmission of impulses between the urinary system and the brain.
• Primary Functions of the Urinary System:
  1. Filtration: Removes waste from the blood.
  2. Reabsorption: Controls blood concentration and composition.
  3. Excretion: Rids the body of excess fluid and electrolytes.

Urinary Assessment and Laboratory Tests

• Bladder Findings:
  • Normal: Non-palpable and located at the midline.
  • Distended: Palpable between the symphysis pubis and the umbilicus; felt as firm and rounded. In older patients, palpation may cause overflow.
• Laboratory Tests:
  • Urinalysis: Collected via midstream or catheter. Tests for UTIs, WBCs, RBCs, specific gravity, pH, glucose, and culture/sensitivity. Use the clean catch technique (clean area, void a little in the toilet, then pee in the cup).
  • BUN/Creatinine: Common blood sample used to assess renal function. Levels will be elevated with renal dysfunction.
  • 24-Hour Urine Collection: Determines Glomerular Filtration Rate (GFR) and creatinine clearance. For the test, discard the first void, then collect for $24$ hours. Keep the sample refrigerated or on ice. Discarding any void during the period requires restarting the test.

Diagnostic Tests for Urinary Elimination

• Bedside Sonography (Bladder Scanner): Point-of-care testing used to measure bladder volume and residual volume after voiding.
• KUB (Kidneys, Ureters, Bladder): An X-ray of the abdominal area to determine the size, shape, and position of structures. It is not as clear as a CT scan.
• Intravenous Pyelogram (IVP): Involves an injection of contrast to view urinary ducts, renal pelvis, ureters, bladder, and urethra. It is used to detect kidney stones.
  • Contraindications: Shellfish or iodine allergies.
  • Medication Warning: Metformin must be stopped prior to the X-ray and held for $48$ hours afterward due to risks of kidney failure and lactic acidosis.

Management of Kidney Stones

• Symptoms: Mild to severe pain in the side, back, abdomen, or during urination; cloudy or foul-smelling odor; frequent urination; nausea and vomiting.
• Interventions:
  • Administer analgesics (opioids/narcotics).
  • Lithotripsy (shock wave therapy to break up stones).
  • Increase fluid intake.
  • Dietary changes: Reduce oxalate (spinach, nuts, wheat), reduce sodium, and reduce animal proteins.

Bedpans and Promotion of Urination

• Fracture Bedpan: Designed for clients who must remain supine, those in leg casts, or those with hip/pelvic fractures. These carry a risk for skin breakdown.
• Regular Bedpan: For clients who can sit up. These also carry a risk for skin breakdown.
• Promoting Voiding: Run water, pour warm water over the bladder, place the patient in a warm bath, sit the patient up, and allow adequate time and privacy.
• Fluid Volume Overload Risk: Infants are at high risk due to immature organs.

Process of Urination and Drainage Systems

1. Urine collects in the bladder.
2. Stretch receptors are stimulated.
3. Impulses travel to the voiding reflex center.
4. The internal sphincter relaxes (creating the urge to go).
5. The external sphincter relaxes.
6. Urine is eliminated through the urethra.

• General Principles for Drainage Systems:
  • Maintain sterile asepsis.
  • Maintain a closed collection system.
  • Keep the collection bag below the level of the bladder.
  • Check for kinks if the patient reports a sensation of fullness.

Perineal Care and Catheter Management

• Frequency: Perform peri-care $3$ times a day, after defecation, or every $8$ hours. Use iodine only for insertion, not for regular cleaning.
• Female Care: Retract labia, cleanse from symphysis pubis to anus (front to back), use a different part of the washcloth for each swipe, rinse well, pat dry, and cleanse the first few inches of the catheter.
• Male Care: Clean the meatus/glans then the shaft from top to bottom. Clean the first few inches of the catheter. If uncircumcised, retract the foreskin and replace it afterward.
• Condom Catheter: Secure the condom over the penis leaving $2.5\,cm$ between the tip and the tubing. The tip of the penis should not touch the plastic. Inspect the penis $30$ minutes after application and reassess every $4$ hours.
• Irrigation: Use sterile technique. Draw up sterile solution ($30$ to $40\,mL$ for catheter irrigation; $100$ to $200\,mL$ for bladder irrigation). Push at a rate of $3\,mL$ per second to prevent mucosal damage or spasms. Allow fluid to drain by gravity.

Alterations in Urine Production and Incontinence

• Definitions:
  • Polyuria: Large amounts of urine.
  • Anuria: No urine output (absent pee).
  • Oliguria: Little to no urine; often signifies poor blood flow to the kidneys or impending renal failure.
  • Frequency: Voiding more than $4$ to $6$ times per day.
  • Nocturia: Frequent urination at night.
  • Dysuria: Painful urination.
  • Urinary Hesitancy: Delay or difficulty in initiating urination.
  • Neurogenic Bladder: Impairment of bladder control due to brain or nerve problems (e.g., spinal cord injury).
• Incontinence Types:
  • Stress: Loss of small amounts of urine due to increased abdominal pressure (laughing, sneezing, pregnancy).
  • Urge: Inability to stop urine flow long enough to reach a bathroom; caused by an overactive detrusor muscle.
  • Overflow: Small losses of urine with a distended bladder; caused by an obstruction of the urinary outlet.
  • Functional: Urine loss due to factors unrelated to the urinary system (cognitive, mobility, or environmental barriers).

Urinary Interventions and Renal Failure

• Interventions:
  • Kegel Exercises: Tighten pelvic muscles for $10$ seconds, relax slowly for $10$ seconds, and repeat in sets of $15$. Can be performed lying, sitting, or standing.
  • Bladder Training: Voiding on a schedule (working toward $4\,hr$ intervals). Support holding urine until the scheduled time and keep a log.
  • Crede's Maneuver: Manual pressure on the bladder to push out urine; used for urinary retention.
• Renal Failure Management:
  • Diuretics (requires some remaining kidney function).
  • Dialysis (Hemodialysis circulates blood through a machine; Peritoneal dialysis instills solution into the abdominal cavity via catheter—carries an extreme infection risk).
  • Kidney Transplant.

Sleep Requirements and Cycles

• Consequences of Poor Sleep: Obesity, hypertension (HTN), diabetes, depression, heart attack, or stroke.
• Average Sleep Needs:
  • Toddler/Infant: $12$ to $15\,hr$ per day.
  • Child/Adolescent: $9$ to $10\,hr$ per day.
  • Adult: $7$ to $9\,hr$ per day.
  • Older Adult: $7$ to $8\,hr$ per day.
• The Sleep Cycle (4 Cycles across 2 states):
  • Stage 1 NREM: Very light sleep lasting a few minutes. Vital signs and metabolism decrease. The patient is easily awakened and feels relaxed/drowsy.
  • Stage 2 NREM: Deeper sleep lasting $10$ to $20$ minutes. Vital signs/metabolism continues to slow. Requires more stimulation to awaken.
  • Stage 3 NREM: Slow-wave/Delta sleep. Deepest stage where psychological rest and restoration occur. Brain waves are very slow with reduced sympathetic activity.
  • REM Sleep: Vivid dreaming occurs. Brain is highly active. Starts $90$ minutes after falling asleep and recurs every $90$ minutes, lasting about $20$ minutes. Hardest to awaken; provides cognitive restoration.

Sleep Disorders and Diagnostics

• Insomnia: The most common disorder. Higher risk in women and older adults. Acute (days, due to stress), Chronic (a month or more), and Intermittent (alternating quality).
• Sleep Apnea: Breathing stops more than $5$ times per hour for longer than $10$ seconds. Common in males.
  • Risks: Obesity, large neck circumference, sleeping supine, smoking, COPD.
  • Central Sleep Apnea: CNS dysfunction; the respiratory control center fails.
  • Obstructive Sleep Apnea: Structures in the mouth/throat relax and block the airway.
• Narcolepsy (Hypersomnia): Chemical imbalance causing sudden sleep attacks. High risk of injury. Sufficient sleep is obtained, but daytime drowsiness persists.
• Hypersomnolence: Excessive daytime sleepiness lasting longer than $6$ months.
• Restless Leg Syndrome: Neurological disorder with an urge to move legs. Risk factors include kidney disease, stress, diabetes, and Parkinson's.
• Parasomnias: Somnambulism (sleepwalking), sleep eating, bruxism (teeth grinding), and enuresis (bed wetting).
• Diagnostics: Polysomnography (recording HR, breathing, oxygen, eye movement) and EEG (monitoring brain waves).

Interventions for Rest and Mobility

• Non-Medication Sleep Promotion: Exercise at least $2\,hr$ before bed; establish a routine; limit alcohol, caffeine, and nicotine $4\,hr$ before bed; limit fluids $2$ to $4\,hr$ before bed.
• Medication: Benzodiazepines are the first choice for insomnia. Herbal remedies (valerian root, melatonin, chamomile) are inconsistent.
• Mobility vs. Immobility: Independence in purposeful movement versus the inability to move freely.
• Bone and Muscle Conditions:
  • Sarcopenia: Decrease in muscle mass and fibers caused by aging.
  • Sprain: Stretching or tearing of ligaments.
  • Fracture: A break in the bone, sometimes accompanied by crepitation (grinding sound).
  • Spine Curvatures: Lordosis (concave lumbar - toddlers/pregnancy); Kyphosis (hunchback - older adults); Scoliosis (lateral C-shape - middle school).
  • Contracture: Permanent tightening of fascia/muscles replaced with non-elastic tissue. Requires surgery to fix. Use ankle boots or footboards to prevent.

Anatomy, Therapies, and Assistive Devices

• Physiology: Axial skeleton (head, trunk, spine) and Appendicular skeleton (arms, legs) total $206$ bones. Muscles include smooth (lungs), cardiac (heart), and skeletal (on bone).
• Neurovascular Assessment (5 P's): Pain, pulse, pallor, paresthesia, and paralysis.
• Therapy Education:
  • Heat: Increases blood flow and metabolism. Relaxes muscles and relieves stiffness. Avoid on metal, under immobile patients, on pregnant abdomens, or over bony parts.
  • Cold: Decreases swelling, bleeding, fever, and muscle spasms. Watch for cold intolerance (Raynaud's phenomenon).
• Assistive Devices:
  • Cane: Hold on the stronger side. Move the cane forward $6$ to $10\,inches$, move the weak leg to the cane, then move the strong leg past the cane.
  • Crutches: Should be $2\,inches$ below the underarm. Position on the unaffected side of the chair when sitting/standing.
  • Crutch Gaits: Four-point (weight on both legs, alternate leg with opposite crutch); Three-point (all weight on one foot, affected leg never touches ground); Two-point (partial weight on both feet, move crutch and opposite leg simultaneously).
  • Walker: Move the walker and affected leg forward $6$ to $8\,inches$ together. Shift weight to arms and step into the walker. Do not use as support to sit or stand.