NHA review

Wound Management and Pressure Ulcers

• Nasty Dead Tissue Overview
    - Dead tissue forms a scab over the wound.
    - This condition is termed unstageable because the depth of the tissue damage is not visible.
    - Generally, if this type of tissue damage is suspected, it is likely at least a Stage Four pressure ulcer.
    - Surgical removal of dead tissue is required.
    - Following surgery, a wound back may be applied to increase circulation in the area and promote healing.

• Prevention of Pressure Ulcers
    - Pressure ulcers are fully preventable.
    - If a patient develops a pressure ulcer while in care (long-term care facility or hospital), the facility is financially responsible (Medicare/Medicaid will not reimburse for treatment of the wound).
    - This situation can lead to significant costs for the facility if surgical intervention is required.

Wound Drainage Characteristics

• Serosanguineous Drainage
    - Defined as drainage that is a combination of serous fluid and blood.
    - It is usually described as a white or yellowish fluid with a small amount of blood, often compared to the residue seen on a Band-Aid after bleeding has stopped.
    - Presence of this drainage, especially in surgical wounds, is typical, but excessive drainage, causing saturation of dressings, indicates a problem.

• Purulent Drainage
    - Described as green or yellow pus, indicating infection.
    - If dressing is loose or soaked, notify the nurse.
    - If the dressing is nonsterile, you may reinforce it; otherwise, the nurse must handle sterile dressings.

Fire Safety in Healthcare Settings

• Ignition Sources Awareness
    - Oxygen acts as an accelerant in fire, especially near ignition sources (e.g., sparking electrical devices).
    - Ensure no loose electrical connections and maintain caution with heating devices.
    - Patients using oxygen may experience drying due to forced air (e.g., in homes), prompting use of humidifiers.

• Hypoxia Indicators
    - Low oxygen levels can result in increased respiratory and heart rates as the body compensates to raise oxygen intake.
    - Signs of hypoxia may include anxiety and changes in respiratory patterns.

Oxygen Management

• Oxygen Administration Protocol
    - Oxygen is considered a medication requiring a physician's order.
    - Nurses may adjust prescribed oxygen levels (e.g., titration orders range from 2-6 L/min) based on specific patient needs (e.g., maintain SpO2 above 95%).

• COPD Considerations
    - Patients with Chronic Obstructive Pulmonary Disease (COPD) may experience respiratory rate reduction if given excessive oxygen, as their respiratory drive is often hypoxic-driven.

Patient Transport and Safety

• Transport Protocol
    - During patient transports, side rails must be up to ensure safety.
    - The position of the healthcare worker during patient assessment (sitting directly across from the patient) facilitates better observation of swallowing and communication.

Dental and Oral Care

• Oral Pharyngeal Suctioning
    - Recommended to position the head of the bed at 45 degrees for effective suctioning.
    - Ensure cooperation between healthcare tasks such as suctioning, dressing changes, and managing shared equipment.

Bedmaking Techniques

• Types of Beds
    - Occupied Bed: Change linens while the patient is in bed.
    - Surgical Bed: Fold linens to one side to facilitate safe patient transfers.
    - Closed Bed: Completely made bed with linens tucked in.
    - Open Bed: Sheets are turned down towards the foot of the bed.

Staging Pressure Ulcers

• Pressure Ulcer Stages
    - Stage One: Non-blanchable redness of intact skin.
    - Stage Two: Partial thickness skin loss with exposed dermis.
    - Stage Three: Full thickness skin loss, visible subcutaneous fat.
    - Stage Four: Full thickness with exposed bone, tendon, or muscle.
    - Unstageable: Full thickness tissue loss where depth cannot be determined.

Post-Mortem Care

• Post-Mortem Procedures
    - Secure the deceased's personal belongings first and position the body appropriately for viewing.
    - Before rigor mortis sets in, position the body respectfully and remove any medical tubes (unless necessary for examination).
    - Tubes and equipment must be removed with care to avoid contaminating the body, followed by cleaning it and preparing it for viewing.

Nutritional Observations

• Urinary Output
    - Changes in urine output or unusual smells can indicate underlying issues (e.g., likely UTI or dehydration).

Patient Interaction Techniques

• Effective Communication
    - Use therapeutic communication techniques when interacting with patients.
    - Ensure patients are informed when walking with them, especially in unfamiliar settings, and maintain awareness of the patient's physical boundaries.

Preparing for Examinations and Tests

• Study Recommendations
    - Review vital signs and blood glucose charts as part of exam preparations (memorization is essential for success).
    - Engage with Kahoot quizzes and interactive resources to reinforce learning and recall.

General Nursing Care Principles

• Always ask for clarifications from nurses regarding any potentially ambiguous instructions or tasks to ensure patient safety and compliance with protocols.
• Adjust care strategies based on patient feedback and documented observations to maintain comfort and health.