195 exam 2 Flashcards
What diet should a person w/ burns be on?
High calorie & high protein
Increased fluids
Increased vit. & minerals
What diet should a person Dx w/ hyperlipemia be on?
Low cholesterol & saturated trans fats
High fibers
What diet should a person w/ wounds be on?
High protien
Increased carbohydrates & fat
Increased fluid intake
Increase Vit (C) & minerals (Zinc/Iron)
What is the healing process of a wound based on?
Pattern
Type of wound
Severity of wound
Overall condition
Time it takes to heal
Begins as soon as wound / injury occurs
Blood platelets adhere to the walls of the injured vessel, a clot begins to form
Fibrin in the clot begins to hold wounds together & bleeding subsides
hemostasis (Termination of bleeding)
Initial increase in the flow of blood elements (antibodies, electrolytes, plasma protein) & water out of the blood vessel into the vascular space
Repair cells to move toward the wound site & causes cardinal
S/s of inflammation
* erythema (redness)
* Heat
* Edema (swelling)
* Pain
* Tissue dysfunction
Cells in injured tissue migrate, divide, & form new cells w/in 24-48 hours
As this ends, new cells & capillaries refill in the wound from the underlying tissue to the skin surface
Inflammitory Phase of wounds
Myofibroblasts produce collagen (glue like protein strengthening wound tissue)
Collagen formation increases rapidly between postoperative days 5-25
Wound fills w/ granulation tissue & takes on the appearance of an irregular, raised, purplish, immature scar
* wound dehiscence most frequent in this pase
Reconstruction / proliferation phase of wounds
Wounds in which skin edges are closed together and little tissue is lost
* minimal scarring
Begins during inflammatory phase of healing in surgery
* usually in closure of wound
Primary Intention of wounds
When a wound must gradulate during healing
Occurs when skin edges are not close together (approximated), or when pus is formed
Some wounds develope purluent exudate (fluid, cells, or other that have been excreted from cells or blood through small pores/breaks in skin)
Slowly necrotized tissue decomposes & escapes , & the cavity begins to fill w/ granulation tissue, or soft, pink, fleshy projections that consist of capillaries surrounding by fibrous collagen
Secondary intention
Practitioner leaves contaminated wounds open & closes it later, after infection is controlled, by suturing two layers of granulation tissue together in the wound
* occurs when a wond becomes infected , opened, allowed to granulate, & and then sutured
Tertiary intention
What nutritional needs should be monitored in a pt w/ wounds?
Protein
Carbs
Fats
Vitamins
What can you do for a client who is unable to tolerate large meals or solid foods?
Eat small frequent meals
What food class helps promote wound repair?
Protein
* Meats
* Peanut butter
* Legumes
Vit A
* Dark leafy veg.
* Yellow/orange fruits & veg.
Vit C
* Strawberries
* Tomatoes
* Spinach
* Broccoli, califlower, cabbage
Zinc
* Fortified cereals
* Red meat
* sea food
What are some interventions for a pt w/ a wound?
Encourage fluid intake of 2000-2400mL in 24hrs
Monitor I/Os
* until stable (48-72hrs)
Balance rest & activity
Encourage to move one body part at a time
* To sit up, pt should roll to the side, use elbow as lever, & push into sitting position
If coughing occurs, apply pillow, rolled blanket, or palms of hands to incision area and apply pressure (Splinting)
Monitor for malnutrition, & chronic disease (HTN, DM, arthritis)
* these add stress to body & need ongoing monitoring
Watery plasma that is mostly clear, but may have some pink/yellow tinge to it
Thin, composed of serum portion of blood
Serous drainage
Thick
Yellow/green/tan/brown drainage
Indicates infection
Purulent drainage
Pale
Red, watery
Mixture of serous & sanguineous drainage
Thin
Can occur on the day of surgery
Serosanguineous
Bright red
Indicates active bleeding
Can occurs on day of surgery
Sanguineous
Closed drainage system that uses a bulb to provide the needed vacuum
Have wide, flat areas that must be brought through stab wound w/ great foce
Jackson-Pratt drainage device
Used after removal of gallbladder (via open cholecystectomy), the bile duct often is inflamed & edematous
* Drainage tube goes into duct to maintain free flow of bile until edema subsides
Long end of tube inserted through abdominal incision or through seperate surgical wound
Tube drains by gravity into closed drainage system
Collection bag emptied & measure Q shift
T-Tube drainage system
Used to treat acute wounds (traumatic wounds, flaps, & grafts) & chronic wounds
* Functions by applying negative pressure to wounds
Healing of wounds if facilitated by increased blood flow, improved/ increased fluid drainage, & enhance wound closure as pressure draws wounds together
Accelerated wound healing by promoting granulation tissue, collagen, fibroblasts, & inflammatory cells to close completely/ improve confition for skin graft
Negative pressure removes fluid from surrounding areas, thus reducing local edema & improving circulation
* After 3-4 days bacteria count drops
Wound-Vacuum-Assisted Closure (Wound vac)
Heart is not as effiecient as it should be
Ventricle is loaded with blood to the point where the heart muscle contraction becomes less efficient
Labs:
* CBC, MP
* Cardiac enzymes
* T3/T4, TSH
* C-reactive protein (If infection is suspected)
* B-type natrietic peptide (BNP)
* N-terminal pro b-type natiuretic peptide (NT-proBNP
Heart Failure
Often the choice for management of a wound w/ little exudate or drainage, such as abrasions and nondraining postoperative incisions
Keeps initial bleeding to a minimum & protects wounds from injury
Prevents introduction of bacteria, reduces discomfort, & speed healing
Prevents deeper tissues fromm drying out by keeping the wound surface moist
If dressing adheres to a wound, moisten dressing w/ sterile normal saline solution or sterile water before removing the gauze
Dry Dressing
Most appropriate for wounds that do not have significant amounts of ischemic or necrotic tissue or large amounts of drainage or exudate
Purpose is to keep wound bed moist or provide mechanical debridement
* Used NS & LR (Isotonic solutions)
Wet-to-dry dressing
Gentle washing of an area with a stream of solution delivered through an irrigating syringe
Benefits include cleansing & medication
Soulutions include topical cleansers, antibiodics, antifungals, antiseptics, & anesthetics
* Most common is NS solution
Promotes wound healing by removing debris from the wound surface, decreasing bacterial counts,
& loosening/removing eschar
Irrigation
What does the principles of basic wound irrigation include?
Cleansing in direction from least contaminated area to most contaminated
What are some complications of wound healing?
Abscess: contains pus & surrounds inflammed tissue
Adhesion: Scar tissue that binds 2 anatomic surfaces
* Most commonly found in the abdomen
Cellulitis: Infection of skin characterized by heat, pain, erythema, & edema
Dehiscence: Seperation/rupture of surgical incision or wound
* Sometimes preceded by serosanguineous drainage
Evisceration: Protrusion of internal organ through a surgical incision or wound
Extravasation Passage/escape into tissues
* Usually blood, serum, or lymph
Hematoma: Collection of extravasated blood trapped in the tissues or organ that results from incomplete hemostasis after surgery/injury
What are nursing interventions for Evisceration (Medical emergency)?
Remain w/ pt & notify HCP
Place pt in low fowlers position w/ knees slightly flexed
* Relieves pressure wounds, prevents dehiscence of the wound edges, & reduces the risk of further evisceration
Cover protruding organ w/. saline dressing moistened w/ sterile NS
Monitor closely & assess vitals
* Pulse ox readings determine if the pt is showing signs of shock
Keep NPO for surgery
Reassure the pt & family because occurance if frightening
Interventions for dehiscence
Bed rest
NPO
Encourage pt not to cough
Place warm, moist, sterile dressing over area until seen by surgeon
Provide reassurance
What are some cardiovascular changes w/ aging & their results?
Decreased cardiac o/p:
* Increased risk of HF
* Decreased peripheral circulation
Decreased elasticity of heart muscle & blood vessles:
* Decreased venous return
* Increased dependent edema
* Increased risk of orthostatic hypotension
* Increased risk of varicosities & hemorrhoids
Increased atherosclerosis:
* Increased BP
* Increased MI
What other Dx does HTN contribute too?
CAD
Stroke
HF
PVD
Renal failure
What are nursing interventions for a pt having dysrhythmias?
Monitor vitals
Note rate, regurality, & strength of pulse
Monitor I/O
Observe & report reaction to meds
Keep stress to a minimum
* Balance rest & activity
What interventions would you provide a pt w/ CAD?
Assess knowledge & understanding of disease process
* Discuss Dx, s/s, & potential complications
Explain purpose, dosage, side effects, & special effects of meds
Assess modifiable cardiac risk factors
Assess diet:
* Intake, intake of processed/canned foods
* Salt intake
Exercise:
* 150 min/week
Obesity:
* Manage caloric intake
Smoking:
* Avoid tobacco
* Avoid second hand smoke
Identify source of stress & sleeping habits
DM
What interventions would you provide a pt w/ COPD?
Ask if smoker
* if so, how many packs a day
Assess lung sounds
* Diminished
* Crackles, wheezes
* Barrek chest d/t increased anteroposterior diameter
Pulmonary hygiene, breath retraining
Meds, exercise
chest physiotherapy (CPT)
Smoking cessation
Encourage fluids, deep breathing exercises, & pured -lip breathing
Education on lifestyle changes
What lab should you draw if an Infection is suspected in a post-op pt?
Culture of any drainage taken before antibiodics
What interventions would you perform for a pt w/ inadequate oxygenation?
Prevent pneumonia & atelectasis by frequent position changes & deep breathing
Instruct pt to breath through the nose & gradually blow out of the mouth
Use incentive spirometer 10x/hr
* Ball rises w/ inhale
Splint when coughing
What are some S/s of diverticulitis?
Often asymptomatic
Changes in bowel habits
* Constipation
* Diarrhea
* Periodic bouts of each
Rectal bleeding
Pain in left lower abdomen
N/V
Urinary problems
Elevated BP
* Confirmed by repeat BP findings averaging 140/90mm Hg or higher
Most serious complications include MI, HF, stroke, kidney disease & blindness
* Assess more frequently
S/s:
* Occipital headaches (more severe when arising)
* Lightheadedness, blurred vision
* Epistaxis (nosebleeds), “Silent killer”
emergency crisis: 180/100
Tx:
* Monitor vital (esp. BP)
* EKG
* Blood studies: Glucose, Hct, K, Ca, Cr, Liped profile
(Elevated Cr = kidney damage, abnorm serum lipids & lipoprotein may indicate artheroscleosis)
* CXR (May show enlargment of heart/pulmonary blood vessels)
* Education on weight reduction, smoking cessation, Na & alcohol reduction, exercise, & relaxation techs.
* Education on Dietary Approaches to Stop HTN (DASH diet - Fruit/veg, whole grains, low fat dairy)
* Medications (Beta-blocker, ACE inhibit., Thiazide/Diuretics, ect)
HTN
protein hormone synthesized in the pancreas that regulates blood sugar levels by facilitating the uptake of glucose into tissues
Rotate injection site to prevent lipohypertrophy & lipoatrophy
- DO NOT massage
- Heat & exercise increase absorption rate
lowers blood glucose
AKA “beta cells”
- acts as key that allows sugar into the cell
Insulin
Elevated BS (>100)
- occurs in type 2 DM
Can result from:
- Insufficient insulin production / secretions
- Deficient hormone signaling
- Excessive counterregulatory hormone secretion
S/s: (Think “FLUSHED”)
- F: Flushed skin/ fruit like breath (acetone)
- L: Listless/ lethargic
- U: Unusual thirst, hunger,urine o/p (3 p’s)
- S: Skin warm/ dry, poor wound healing
- H: hyperventilation (kussmaul RR - deep/rapid breathing)
- E: Emesis, increased N/V ( late findings)
- D: Drowsiness, decreased appetite (N/V)
Hyperglycemia
BS less than normal (<70)
- occurs in type 1 & 2
S/s:
- Tremors, tachycardia
- Clammy skin, cold
- Alt consciousness, irritability
- Hunger
- seizure/ stroke like s/s
- diaphoresis
- Apathy (severe lethargy)
Can result from:
- Insufficient intake
- Adverse reaction to meds
- Excessive exercise
Hypoglycemia
What are some diagnostic testing for diabetes?
Glucose screening:
- Fasting (> 100 and < 126 = prediabetes)
- GTT (Detects early Diabetes)
- Glycosylated hemoglobin (HgbA1c; below 7%)
Antibody testing:
- Glutamic acid decarboxylase (GAD ; most common)
- C-peptide
lipid analysis:
- Triglycerides, HDL, LDL
Renal function tests:
- BUN/Cr, albumin in urine,
C-reactive peptide
What is the lab value for cholesterol?
< 200 mg/dL
What is the lab value for HDL?
Males: > 45mg/dl
Females: > 55mg/dl
(want high)
T/F: When glucose levels are high, triglyceride levels will also be high
True
- Triglycerides are general reflection of glycemic control
What is the lab value for LDL?
< 70 mg/dL
What is the lab value for triglycerides?
<150 mg/dL
What is the lab value for C-reactive protein?
< 1.0 mg/L
Lispro (Humalog)
Aspart (Novolog) - Given AC
Clear insulin; most common
Given before pt eats
Onset: 10-30 minutes
Peak: 2hrs
Duration 3-5hrs
Rapid insulin
Humulin R
Novolin R
Clear
Only insulin able to be administered by IV
- Takes longer to kick in
Onset: 30min-1hr
Peak: 2-3hrs
Duration: 5-8hrs
Short/ Regular insulin
Humilin N
Novolin N
Cloudy; roll to mix
Onset: 2-4hrs
Peak: 4-12hrs
Duration: 12-16hrs
Intermediate Insulin/ NPH
Glargine (lantus) - give seperatly
Detemir (levemir)
Clear; given in AM/PM
Onset: 1hr
Peak: N/A
Duration: up to 24hrs
Long acting insulin
T/F - You should not mix short and rapid insulin together
True
