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Wound Dressings

  • Selection Criteria: Depends on wound descriptors (e.g., moisture level).
  • Types of Dressings:
    • Hydrocolloid/Hydrogel: Adds moisture; ideal for dry/stable wounds but not for over-moisturizing wounds.
    • Alginates: Versatile; used for various wounds, akin to normal saline dressings.
    • Polyurethane Foam: Commonly used with negative pressure therapy for draining wounds.
  • Moisture Balance: Important to maintain balance for skin regeneration; avoid excessive moisture that hampers healing.

Pressure Ulcers

  • Definition: Caused by continuous pressure, leading to decreased blood flow and skin integrity breakdown.
  • Staging Guidelines:
    • Stage 1: Non-blanchable erythema, intact skin.
    • Stage 2: Partial thickness skin loss; blisters are included.
    • Stage 3: Full thickness skin loss involving subcutaneous tissue.
    • Stage 4: Full thickness with involvement of muscle/bone.
  • Blanching: Good indicator; it means blood flow is still present.
  • Deep Tissue Injury: Similar to a bruise; non-blanchable, indicating underlying necrosis from pressure.

Nutritional Assessment and Intake/Output (I&O)

  • Purpose: Monitors fluid balance and nutritional needs.
  • Calculating I&O: Convert everything to mL for consistency.
    • e.g., 1 oz = 30 mL; track total intake and output over 24 hours.
  • Special Cases:
    • Ice chips count for half the volume.
    • Bladder irrigation: Volume in - Volume out = Net Output.
  • Indicators of Nutritional Status: Weight, appetite, digestion, energy levels.

Diabetes and Insulin Management

  • Insulin Types: Two main types, rapid-acting and long-acting; monitor blood glucose closely.
  • Administration Guidelines:
    • Clear to cloudy when drawing insulin; prepare vials by injecting air (cloudy to clear).
    • Rotate injection sites to prevent necrosis.

Enteral Feeding Considerations

  • Reasons for Use: Suitable for patients unable to consume food orally.
  • Risk of Aspiration: Keep head elevated (minimum 30 degrees during feedings).
  • Monitoring Residuals: Assess volume to prevent aspiration risk.
  • Indicators of Adequacy: Weight gain, energy levels, absence of nausea/vomiting.

Informed Consent

  • Requirements: Essential for invasive procedures; not needed for non-invasive ones.
  • Components: Patient understanding of risks, using certified translators if needed.
  • Signatures: Nurse's role includes verifying that consent is informed and witnessing the patient signing the consent form.