Exam 1: Modules 1-4 Flashcards
Types of IV Solutions
- isotonic
- hypotonic
- hypertonic
Isotonic
Remain in intravascular compartment without any net flow across the semipermeable membrane - same as blood
Helps treat hypovolemia
Two Types
* Saline 0.9%
* Lactated Ringers
Hypotonic
Less osmolarity than plasma, solution in intravascular space moves out and into ICF – cells swell and possibly burst
Helps treat hypernatremia
Types
* 0.33% normal saline
* 0.45% sodium
* D5W in the body
Hypertonic
Greater osmolarity than plasma, water moves out of the cell and is drawn into the intravascular compartment – cell shrinks
Types
* 5% dextrose in lactated ringers
* 5% dextrose in 0.9% normal saline
* TPN
Reasons for IV Therapy
- Fluid administration: replace fluid and electrolyte losses or correct fluid and electrolytes
- Med admin
- Blood
- IV contrast dye
Benefits of IV Therapy
- Rapid administration of fluid into vascular compartment: bypasses GI tract for direct absorption
- Maintain therapeutic med levels within the blood
- Quicker absorption and onset of action for most meds
Crystalloids
isotonic, hypotonic, and hypertonic solutions
Colloids
Hypertonic solution with proteins
Pull fluid from interstitial and intracellular spaces by increasing intravascular colloid osmotic pressure
* blood and blood products, albumin, dextran
IV Patient Considerations
- volume of fluid being infused
- long/short term therapy
- history of drug abuse
- surgerys - mastectomy on that side
- type of med
Peripheral IV
- most common
- short term therapy
- placed in superficial veins of hand and forearm
- uses: fluids, meds, blood products
Types of Peripheral IV Catheters
- Automatic retraction: Reduce the risk of accidental needle sticks and possible exposure to blood-borne pathogens
- Over the Needle catheters: most common, gauge and length determined by solution and vein condition
- Winged: reduce risk of contamination, stable, needle is still there, no flexible placement
- OSHA safety needles: active - user activated, passive - automatic retraction
Peripheral IV Considerations
- Medical Hx, age, body size, condition of veins, duration of IV therapy, fluid/med being infused, level of activity
- Can be used more than 6 days
- Start as distal as possoble
- Smallest gauge
- Not appropriate for TPN, pH <5 or >9,
osmolality >600 mOsm/L - Supine with head elevated, arms supported
(risk for vasovagal if sitting up) - Apply tourniquet 5-6 in above site
- Bevel up, 10-30 degree angle
- Common sites: cephalic, basilic, metacarpal
Peripheral IV - What to Avoid
- Wrist → close proximity to nerves
- Legs/feet/ankles → lead to DVT
- Veins below an area of phlebitis/sclerosed/thrombus
- Skin inflammation/bruising/breakdown
- AV shunt/fistula
- Lymph nodes removed
- Infection
Primary Lines
- Continuous infusion - either pump ot gravity
- Increasing height of IV increases flow rate when flow is by gravity
- Vented or unvented - in the airspike
Intermittent Access Devices - Saline Locks
- Replaced every 72-96 hrs
- Intermittent Infusion
- Saline lock: IV catheter and short piece of extension tubing
Flushing Guidelines
- 2-3 mL saline q8 hr. or with each use
- Pulsatile method (push-pause) - inhibits backflow of blood
- Positive pressure method - Slide clamp closed as you instill last mL
How to Administer Venipuncture
- Apply turnicate 5-6 in above intended venipuncture site
- Dilate vein: Pump first with hand lower than heart, stroke downward, friction from cleaning, warm wrap
- Cleanse with chlorohexidine
- Pull skin taut to stabilize vein
- Bevel up, 10-30 degree angle
Monitoring IV
- every hour
- look at tolerance to fluid volume, dressing integrity, and any complications
Complications
By location
* Local complication: at or near the insertion site or as a result of mechanical failure
* Systemic complications: occur within the vascular system, remote from IV site. Can be serious or life threatening.
Infection Control
- Hand hygiene
- change IV site every 72-96 hours
- aseptic technique
- change secondary tubing every 24 hours
- change dressing q 24 hrs
- Discontinue IV as soon as clinically indicated
- Avoid writing on IV bags with pens/markers
- Wipe all ports with antiseptic swab before using
Local Complication: Infiltration
Leakage of IV fluid into surrounding tissue
Caused by improper placement/dislodgement
S/S: edema, coolness, pain, burning, pale, decreased/stopped flow rate
* 0 = no symptoms
* 1 = edema <1”, cool, pale
* 2 = edema 1-6” cool, pale
* 3 = gross edema > 6” cool, pale, pain, possible numbness
* 4 = gross edema > 6”, pitting edema, skintight, leaking, bruised, mod/severe pain
Treatment:
* Removal/restart
* elevate, check cap refill
* Warm Compress for normal and basic pH (8-9)
* Cold Compress for acidic (5-6)
Local Complication: Phlebitis
Inflammation of a vein associated with acidic/alkaline solutions with high osmolality
S/S
* wamth
* swelling
Scale
* 0: no symptoms
* 1: erythema, possible pain
* 2: erythema, edema, pain
* 3: same as 2 with streak formation (go up the vein), palpable venous cord
* 4: same as with palpable venous cord >1 cm, purulent drainage
Risk Factors
* Mechanical irritation: lumen of vein or inappropriate gauge
* Chemical irritation
* Bacterial contamination
* Prolonged use of site
Treatment
* remove cathete when redness/pain is there
* warm compress
* restart using larger vein or smaller device but not near phlebitis
Local Complications: Extravasation
Leakage of vesicant in surrounding tissue
Vesicant: any medication that can cause blistering, severe tissue injury, or tissue necrosis
* chemotherapeutic agents, catecholamiens, digoxin
S/S
* blistering
* blanching
* swelling
Can Cause
* tissue damage/necrosis
* delayed healing
* infection
* loss of function
* possible amputation
Treatment
* immediately stop infustion
* aspirate med
* notify MD how much was infused
* elevate
* call pharmacy for antitote
* apply ice for 15-20 min x 48 hrs for all meds
Systemic Complications: Fluid Overload
Dyspnea, high BP/HR/RR, crackles, JVD, edema
Systemic Complications: Speed Shock
Reach toxic levels with medication when introduced too fast in places that are rich in blood
Dizziness, chest tightness, flushed, pounding headache, chills, back pain, dyspnea, apprehension
Systemic Complications: Sepsis
Red, tender IV site, fever, malaise, VS changes
Systemic Complications: Air Embolism
Air traps blood and goes into right ventricle
Resp distress, low HR, high BP, cyanosis, change in LOC, wheezes, cough
Central Venous Access Device: CVAD
For extensive IV therapy, poor peripheral access, infusing vesicants, hypertonic solutions, and chemotherapy – high osmolarity or pH extremes
* Terminal line ends in Superior Vena Cava: need radiological confirmation of placement or use fluoroscopy
* Multiple lumens: to infuse multiple meds, TPN and blood have separate line
* Hemodynamic monitoring
* Frequent blood sampling
Short term: non-tunneled and PICC lines
Long term: tunneled and implantable port
Non-Tunneled CVAD
Duration: short term (3-10 days)
Uses: patients who are unstable
Placement: inserted in jugular or subclavian, put patient in trendelenburg for sub, Sutured in place, no sedation for insertion
Indications: IV therapy, blood sampling, central venous monitoring
Disadvantage: High risk for central line associated bloodstream infection (CLABSI) and pneumothorax
PICC Line
Duration: Short-term (6 weeks-6 months)
Uses: IV therapy at home & acute care settings
Placement: upper arm (antecubital fossa) to superior vena cava, secured with wound closure strips (not suture since this can create infection), need X-ray to confirm placement
Advantages: eliminates risk for pneumothorax, use for all ages, easier to ahve labs drawn, replace only as needed
Implanted Port
Duration: Long-Term, permanent device
Placement: upper chest wall, antecubital area of arm
need radiology to confirm placement
Advantages: no visible external port/lines, minimal daily care, good for kids, low risk for infection, improved self-image
Disadvantages: discomfort when accessing, inserting needle into skin
Tunneled CVAD
Duration: Long-Term
Placement: Jugular or subclavian vein, Sutured in place but stitches are removed after 7-14 days, Dacron → seal to prevent bacteria under the skin & prevent dislodgement - takes 3 weeks for catheter to heal
Advantages: lower risk for CLABSI, allows for ease of movement
Assessing CVADs
- integrity of dressings
- infection
- tenderness
- measure length of exposed catheter
Flushing CVADs
- push-pause method
- use 10mL or larger syringe - less pressure
- 3-5mL of saline before and after
- 3mL of heparin 100u for catheter patency
- q7 days if not in use
Dressing Changes for CVAD
- sterile procedure with masks, gowns, and gloves
- change every 24 hrs or when soiled
- antimicrobial swab over site for 30 seconds, 2” radius
- change caps
- change tubing every 24 hours for TPN
Complications for CVAD
Pneumothorax/hemothorax:
* Sudden onset of chest pain/SOB due to air accumulation in the lungs
* Give oxygen, monitor vitals, pressure on entry site, remove catheter
CLABSI
* Central line associated bloodstream infection & catheter related bloodstream infection
* If WBC low → will not see drainage or pus, will see fever/chills
Air Embolism
Thrombosis
* start IV somewhere else and give warm compress
* S/S: fullness in face, swelling
Catheter Migration
* Occurs when catheter moves from where it was placed
* Risks: physical activity, vomiting
* Signs: swelling of neck/chest during infusion, pain
Primary Line: IV Med Admin
- Primary IV bag (directly attached to patient)
○ Piggyback (medication is piggybacked on primary IV infusion)
○ IV push (through a primary line)
○ Syringe pump (either primary line or piggy backed onto primary line)
○ Volume controlled (primary line or piggybacked onto primary line)
Saline Lock: IV Med Admin
- intermittent infusion
- IV push directly
IV Push through Primary Line
- infuses rate faster
- clamp tubing above distal port, proximal to patinet
- check for blood return
- admin slowly
Admin Meds Via Mini-Infusion Pump
- controls the rate, can program the rate
- infuse using distal port on primary line or saline lock
- used for peds
Volume Controlled Infusion
Purpose: for peds, small amount of controlled substance, diluted with IV solution, do not fluid overload
IV Push via Lock
- flush with 1-3mL saline before and after for patency
- instill flush as same rate as med
Physical Incompatability
One drug is MIXED with another drug/solution to produce a product UNSAFE for administration
Chemical Incompatability
REACTION of drug with other drugs/solutions → ALTERATIONS in integrity and potency of active ingredient
Therapeutic Incompatability
Undesirable effect occurring as a result of 2 or more drugs being given concurrently - Can have an increased or decreased therapeutic response
Blood Transfusion: Assessment
- Baseline vitals, taken periodically once transfusion starts based on protocol
- Kidney function, cardiovascular, lung sounds
- Evaluate IV site, gauge of needle - 18 gauge needle for rapid, 20 gauge for slow
- Blood matches patient
- Identify unit label of blood and patient by TWO nurses before hanging blood
- Check for expiration by TWO nurses (both nurses must document that check occurred)
- need Y set filters and normal saline
Blood Transfusion: Guidelines
- Pump can inform us of phlebitis, easier for 4 hour period
- Infuse slowly: Large enough dose that can alert the nurse of a reaction but small enough that it can be successfully treated
- If pt shows signs of an adverse reaction, transfusion is stopped IMMEDIATELY & hang NS alone in separate tubing
- After 15 mins have passed safely, flow rate can be increased
- RBCs should be infused within a 4 hour period
- RBCs should be hung within 30 mins of obtaining from blood bank
ABO Blood Grouping
Group A – Recipient Antigens A – Antibodies present – Anti B
Group B – Recipient Antigens B – Antibodies present - Anti A
Group AB – Recipient Antigens A&B – Antibodies none
Group O – Recipient Antigens none – Antibodies Anti A and B
Mild Reaction
Within 1 hr
S/S: Urticaria, localized erythema, facial flushing, dyspnea, wheezing
Nursing Action: Pause transfusion, keep vein open, notify
provider, monitor vital signs, administer antihistamine orders (or benadryl 30 mins before)
Severe Reaction (Anaphylaxis)
Within 1 hr
S/S: Anxiety, hypotension, shock, wheezing, urticaria
Nursing Actions: Discontinue transfusion, keep vein open with just NS, administer CPR, anticipate order for steroids, maintain BP; prevention using well washed RBCs where plasma has been extracted
Febrile Reaction
Reactions to antibodies directed against leukocytes/platelets
Occurs immediately or 1-2 hours after transfusion is completed
PreventionL use leukocyte-reduced blood components
S/S: fever, chills, N/V/headache, tachycardia, nonproductive cough
Nursing Actions: Discontinue transfusion, Keep vein open with NS, notify provider, monitor vitals, administer antipyretic
Acute Hemolytic Transfusion Reaction
Most life-threatening
Occurs after infusion of incompatable RBCs
Leads to activation of coagulation system and release of vasoactive enzymes that result in vasomotor instability, cardiorespiratory collapse, and DIC
Prevention: extreme care in identification process
S/S: fever, Lumbar, Flank, Chest Pain, flushing of face, tachycardia
Nursing Actions: stop transfusion, disconnect tubing, infuse saline, call provider, monitor need for dialysis
Wound Assessment
- check 24 hrs of admission
- location and shape
- temp: warm = infection, cold = vascular compromise
- texture: roughened or raised that interrupt natural contour of skin
- size: length, width, and depth, use clock terms to describe
- bed: granulation tissue, necrotic tissue, slough tissue
- drainage: color, odor, amount
- surrounding tissue
- pain
Tunneling - Size
presence of one or more channels
Undermining - Size
wider below the surface, erosion under the wound edges
* large wound with small opening
* use prove held parellel to wound surface
Bed
- Necrotic: Dead tissue, frequently black in color
- Sloughy: Contain layer of viscous adherent slough, generally yellow or grey in color
- Granulating: Contains significant amounts of highly vascularized granulation tissue, generally red or deep pink color
- Eschar: Dead tissue that appears black and leathery, impairs healing
Drainage
- Serous: Clear, watery discharge that is usually considered normal
- Serosanguineous: Thin, pink-colored discharge that is usually part of normal wound recovery
- Sanguineous: Dark red color normally associated with broken capillaries
- Purulent: Generally thick green or yellow discharge, may mean infection
Pressure Ulcer Assessment: Braden Scale
6 Subscales = score from 6-23
Lower the score, greater the risk for pressure ulcer
1. Sensory Perception: Ability to respond meaningfully to pressure-related discomfort
2. Moisture: Degree to which the skin is exposed to moisture
3. Activity: Degree of physical activity
4. Mobility: Ability to change/control body position
5. Nutrition: Usual food intake patterns
6. Friction and Shear: Muscle strength/ability to move freely and independently
Stage I Pressure Ulcer
- Non blanchable erythema of localized area of skin, usually over bony prominence.
- Skin intact and red in color
Stage 2 Pressure Ulcer
- Partial thickness loss of epidermis and some of dermis
- Shallow, open, superficial erosion with pink-red wound bed, no slough
Stage 3 Pressure Ulcer
- Full-thickness loss of the skin and necrosis of sub-q tissue.
- Sub-q fat may be visible, but not tendon, muscle, or bone
- May have undermining and tunneling with slough or necrosis
Stage 4 Pressure Ulcer
- Full thickness loss of skin including epidermis, dermis, and sub-q tissue
- Muscle, bone, or tendon may be exposed
- May have slough, undermining, and tunneling
Unstageable Pressure Ulcer
- Has full thickness tissue covered by either eschar or extensive necrotic tissue
- Must be cleared away before depth can be determined
Suspect Deep Tissue Injury
- Localized area of discolored skin that is purple or maroon
- Non blanching with an intact epidermis
- Skin may feel boggy
Infection: Wound Complications
- S/S: purulent drainage, pain, redness around wound, edema, increased temp, elevated WBC
Hemorrhage: Wound Complications
S/S: large amounts of sanguineous drainage and symptoms of hypovolemic shock
Check under patients
Dehiscence: Wound Complications
S/S: wound edges pull away, not well approximated
Early sign: increased serosanguinous drainage, risk for evisceration
Evisceration: Wound Complications
S/S: wound opens revealing internal organs
Emergency – use sterile NS gauze to cover and prepare for OR
Fistula: Wound Complications
Abnormal connection between two parts of the body
Ex: esophagus and windpipe, artery and vein
Wound Healing Principles
- Remove exudate through drains, wound vac, irrigation
- Remove nonviable tissue: cleansing (clean to dirty) and debridement
- Pack wounds loosly: Allows for growth factors of numerous cell types to migrate – wound end contraction
- Nutritional interventions
- Ideal healing environment: moist wound bed and dry surrounding skin
- Red = protect
- Yellow = clean
- Black = debride
Integrity of Dressings
- Dry or desiccated = needs hydration
- Produced excessive exudates = fluid needs to be absorbed
- Necrotic tissue = debride
- Infected = treat with appropriate antibacterial agent
- Wound environment changes mean dressing also needs to change: Provide protection to peri wound skin, forming bacterial barrier, conforming to wound shape to have minimal pain during application and removal, being free of irritants, maintain wound at optimal temperature and pH
Gauze: Dressings
- Dry gauze: Absorbs wound drainage; impregnated with agents to promote healing
- Nonadherent gauze: telfa, designed not to stick to the drying secretions of the wound
Transparent Dressings
- gas exchanged between wound and environment, but bacteria are prevented from entering
- moist healing environment
- used for necrotic tissue
- can damage skin around
- Tegaderm
Hydrogels
- High water content enhances epithelialization and autolytic debridement.
- Needs cover dressing and wound edge barrier
- Carrasyn
Hydrocolloid Dressings
- hydrophilic particles mix with water to form a gel and wound stays moist
- do not use for infected wounds
- protects against contamination and provides cushioning
- can keep on up to 7 days
- Duoderm
Alginate Dressings
- absorb large amount of exudate
- maintain moist wound environment
- establish hemostasis
Foam Dressings
- made of hydrophilic material
- highly absorbent
- moist and protect over bony parts
Antimicrobial Dressings
- Reduce infection/prevent infection
Cleaning a Wound
- only when infection, slough, or fecal material present
- new gauze for each wipe
- clean top to bottom or center to outside
- use normal saline to irrigate and clean
- to dry, use gauze sponge in same manner
- report any drainage or necrotic tissue
- do not clean with every dressing change: can take off granulation for healing
- consider environment and pain
Saline Moistened Dressings
- can have wet to moist or wet to dry - more for mechanical debridement, nonselective, allow to dry, removes tissue but may take healthy tissue
- clean from center to periphery/clean to dirty
- pack lightly but not completely: unfold the dressing to get better contact with wound bed
Obtaining Wound Culture
- clean wound before culturing to eradicate bioburden
- roll swab to maximize contact
- use different swabs for each site
Irrigating Wounds
- Steady flow of solution to achieve wound hydration, get rid of debris, and help with visual examination
- gentle pressure (4-18psi) with isotonic NaCl
- can also irrigate with meds and enzymes
- note: granulation, necrotic tissue, tunneling/undermining, drainage, surrounding tissue
- irrigate until solution flows clear
Penrose Drain
- passive drain, surgically placed through stab wound when excess wound drainage is expected
- reduces risk of abscesses forming
- drains blood and lymph
- not sutured into place - use of safety pin at end
- pulled out a little as drainage lessens with forceps and turned lightly
Jackson-Pratt Drain
- gently negative pressure suction, must have bulb squeezed
- sutured in place in surgery, located along side of wound
- holds 50-100mL
- empty when half full
- protect from pulling
Hemovac Drain
- negative pressure through stab wound
- sutured in place
- holds 400-800mL
- protect from pulling when it gets heavy - pinned onto gown
Vacuum-Assisted Closure: VAC
- negative pressure to remove edema, increase blood flow, greater cell proliferation, reduce bacterial colonization, and enhance granulation
- fenestrated tube embedded in foam that is cut to wound healing by secondary intention
- occlusive dressing covered over it: prevents air, makes vac, facilitates removal of fluid
- tube connected to vac source
Negative Pressure Wound Therapy
- Benefits: promotes wound bed circ, reduces risk for infection, promotes wound contraction, used for: pressure, diabetic, dehisced wounds
- Cautions: anticoagulants, immunosup, bleeding problems
- Contra: active bleeding, malignancy, exposed nerves, tendons or ligaments
Mechanical Debridement
- moist to wet dressings that are manually removed
- causes non-selective debridement, can remove healthy tissue
- advantages: cost effective, dressing changes are simple
- disadvantages: can remove healthy tissue, pain
Autolytic Debridement
- uses body’s own processes, enzymes, moisture to break down eschar and slough
- use semi-occlusive dressings: transparent films, hydrogels, and hydrocolloids
- does not damage healthy skin but breaks down dead tissue over time
- advantages: no damage to surrounding skin; it’s selective for necrotic tissue, easy/effective non-painful
- disadvantages: takes time, constantly monitored for infection or anaerobic growth
Enzymatic Debridement
- uses chemical agents to breakdown necrotic tissue
- useful for debriding wounds with large amounts of necrotic tissue
- advantages: works faster than autolytic, little risk to healthy tissue
- disadvantages: expensive, prescribed, pain and burning
Surgical Debridement
- use of sharp instruments or laser to remove necrotic tissue
- advantages: best for large wounds, excellent control over what tissues need to be removes, clean bed and can speed healing process
- disadvantages: not cost effective, can be painful
Maggot Debridement
- use of maggots that have been grown in a sterile environment
- eat only necrotic tissue
- can be painful, concept is frightening
Pneumatic Compression Devices
- purpose: promote venous return and prevent DVT when immobile with inflating and deflating
- considerations: calf or full leg sleeves, attaches to air pump, used with TEDS, used until ambulatory
- assessment: skin integrity q8 hrs
- contra: current DVT
Functions of Skin
- protection: mechanical, temp, radiation, has acidic pH so pathogens cannot grow
- body temp regulation: dilate to dissipate heat
- sensation: nerve cells that detect changes in env, neuropathy
- psychosocial, vit d production, immunologic, absorption, elimination
- too much or not enough of subq tissues: pressure ulcers
Factors Affecting the Skin
- Intact skin is the first line of defense against microorganisms with maintenance of natural moisture - too much moisture will cause skin to breakdown
- careful hand hygiene when caring for wound
- normal healing promoted with wound is free of foreign material
- need adequate circulation
- well-balanced diet - not enough protein or calories produces abnormal skin changes
Skin and Developmental Considerations
- younger than 2: skin is thinner and weaker, can be easily injured and subject to infection
- as aging occurs: maturation for epidermal cells is prolonged, creates thin, damaged skin; sebaceous glands do not work as well = dry skin
- circ and collagen formation are impaired - leads to decreased elasticity and risk for pressure damage, healing is slower, nails are brittle
Causes of Skin Alterations
- being very thin or very obese - fluid loss during illness creates dehydration, skin appears lose and flabby, bony prom are more exposed with little subq, circ not great for obese
- excessive perspiration during illness or incontinence - can cause skin to break down
- jaundice: causes yellow, itchy skin
- diseases of skin (eczema and psoriasis) may cause lesions that need special care
- bacteria and viruses
Intentional Wound
- done via surgery, starting IV, less room for infection
Unintentional Wound
- gunshot wounds, stabbing, more room for infection
Open Wound
- exposed body tissue from penetrating objects, blunt trauma or internal problems
- venous stasis ulcers from chronic venous insuff
Closed Wound
- wound is not exposing body tissue
- bruises, hematomas
Acute Wound
newly formed wounds that orderly heal
* abrasion
* laceration
* contusion: bruise
* puncture: high risk for infections
Chronic Wound
do not heal to normal healing ways
Partial or Full Thickness
P: limited to epi and dermis
F: beyond dermal layers
tears can occur from: friction, force, being too old/young, hydration and nutrition status, adhesives on fragile skin
* have fall precautions
* keep nails short
* minimize bathing and bathe with warm water and neutral cleanser
* ensure proper transfers
Regeneration: Wound Healing
- skin is replaced by tissue of the same type
- preserve proper functioning and normal appearance
- shallow wounds: epi and part of dermis are capabale of healing like this
Scar Formation: Wound Healing
- healing is replaced by fibrous tissue
- does not have the same properties as the original tissue and is unable to carry out same functions
- deep wounds that affect multiple layers are unable to reproduce themselves
Phase 1: Hemostasis
Purpose: stop bleeding
Duration: immediately after injury occurs
Involved blood vessels constrict, blood clotting begins (clotting cascade)
* Exudate is formed → causes swelling and pain
* Increased perfusion → results in heat and redness
* Platelets stimulate other cells to migrate to the injury to participate in other phases of healing
* Fibrin clot → stops bleeding; serves as initial matrix within wound that provides framework for cellular repair; clot formation happens rapidly (unless bleeding abnormalities)
* Larger severed blood vessels → need further measures (tourniquet or manual pressure or suture or catheterization)
Phase 2: Inflammatory
Purpose: establish clean wound bed
Duration: 2-3 days
* WBCs (leukocytes & macrophages) move to wound
* Neutrophils are first to respond to wound, remove bacteria from wound through enzymatic activity
* Macrophages enter wound and remain for long time; ingest debris and release growth factors that attract fibroblasts to fill in the wound
* Patient has a generalized body response/local inflammation
* 3rd day: macrophages predominant, continue to cleanse wound by removing dead tissue
* DECREASED level of macrophage is associated w/ prolonged or delayed wound healing (uncontrolled diabetes or diabetic wounds)
Phase 3: Proliferation
Purpose: build new tissue
Duration: several weeks
* New tissue is built to fill the wound space through the action of fibroblasts
* Acute wounds: collagen production around 5th day of injury (structural tissue protein, provides strength and support to connective tissue and adequate collagen production is essential) + new blood vessels
* A thin layer of epithelial cells forms across the wound
* Granulation tissue forms a foundation for scar tissue development; fills the base of an open wound; healthy tissue contains newly grown blood vessels and should be beefy red with uneven surface
Phase 4: Maturation
Purpose: strengthen, define, remodel
Duration: 3 weeks after injury
* Collagen is remodeled/new collagen tissue is deposited
* Scar becomes a flat, thin, white line
* Will achieve 80% skin integrity/tensile strength; will never regain 100% strength
* Can make area prone to further wound development
Local Factors that Affect Wound Healing
- pressure: Internal/external pressure can delay healing (gas or tight belt)
- desiccation: dehydration, makes scab or crust
- maceration: overhydration, incontinence
- infection: drainage, exudate, erythema, fever; need wound culture
- edema: wounds heal slowly due to deprived blood supply
- necrosis: must be removed in order for healing to occur
- slough: moist, loose, stringy tissue, yellow
- eschar: dry, thick, leather, black
- presence of biofilm: thick grouping of microorg
Systemic Factors that Affect Wound Healing
- age: children and healthy adults heal more rapidly
- circ and oxy: need adequate blood flow, obesity = poor blood flow to adipose tissues
- nutritional status: need protein, test for albumin, prealbumin, and lymphocyte count - can see malnutrition
- wound etiology: specific condition can affect healing
- health status that delay healing: cortiocosteroids and radiation, chronic diseases (cad and diabetes), immunosup
Principles of Surgical Asepsis
- above waist or on top of field
- sterile on sterile only
- turn back = contaminated
- keep movements controlled
- moisture or spills = contaminated
- edges of sterile field = contaminated
- pour off lip of bottle of solution
- exposed to air for too long = contaminated
- never reach across sterile field
- keep transfer forceps tip down if they are stored in a
disinfectant solution
Performing Sterile Procedures
- check expiration dates
- kept in different room away from dirty equiptment
- check integrity of packaging
- sterile gloving techniques
- pour off 2mL into plastic lined trash if lipping
Primary Intention Wound Healing
- Occurs when tissue surfaces have been approximated (closed) by stitches, staples, skin glue, tapes
- This kind of closure is used when there has been very little tissue loss
- Rapid healing
Secondary Intention Wound Healing
- Wound that is extensive and involves considerable tissue loss, edges cannot be brought together
- Larger wounds with tissue loss, edges not approx., heals from inside out, granulation tissue fills in wound
- Longer healing time with larger scar tissue
- Chances of infection are higher
Tertiary Intention Wound Healing
- Delayed or secondary closure
- There is a reason to delay suturing or closing a wound in some other way - Abdominal wound left open to allow drainage but will be later closed, poor circ
- Require more connective tissue (scar tissue) than wounds that heal by secondary
Wound Closure
- sutures: never pull visible portion through underlying tissue for sutures
- staples
- steristrips
- wound glue
Heat Application
- causes vasodilation - increases blood flow and O2 and nutrients
- helps with pain, stiffness, aching, reduce inflammation and infection, raises body temperature, promotes drainage
- burns may happen: observe for pale skin (less blood)
- need order for heating pad
- aquathermia pad: tubes filled w/ water, allows specific temperature control
- bair hugger: reusable warming agent and single use disposable warming blanket
Moist Heat
- Warms skin more quickly, more penetrative than dry heat
- Compress, soaps, sitz bath
- No longer than 20-30 min
Dry Heat
- Stays at desire temp longer, doesn’t penetrate as deep
- Risk of burns
- Observe for pale skin (too much heat causes vessels to constrict)
- No longer than 20-30 min
Cold Application
- Used to reduce pain, prevent swelling, decrease circulation/bleeding, cool body with high fever
- Blood vessels constrict, tissues receive less oxygen/nutrients, used right after an injury
- Complications: burns, blisters, impaired circulations, on too long = vessels dilate
Edema Relief
- Assist patient with ambulation
- Elevation several times a day
- Massage toward heart using firm pressure
- Protect skin (dry/cracked → r/o infection)
- Reduce salt intake (salt can ↑ edema)
CAUTI Prevention
- most reported HAI
- perform hand hygiene before and after insertion
- only use when necessary and for shortest time possible
- assess q2 times a day
- keep free from kinking and keep bag below bladder
Appropriate Indications for Indwelling Catheter
- Acute urinary retention or obstruction
- Accurate measurement of urinary output in critically ill patients
- Perioperative use in selected surgeries
- Assistance with healing stage III or IV perineal and sacral wounds in incontinent patients
- Hospice/comfort/palliative care
- Required immobilization for trauma/surgery
Inappropriate Indications for Indwelling Catheter
- As a substitute for nursing care of patients with incontinence
- For patient or healthcare provider convenience
- For an extended period of time after surgery
- Urine Output monitoring that can be obtained by means other than an indwelling urinary catheter
Causes of Urinary Retention
- obstruction of urethra: BPH, scar tissue, tumor, UT stones, Cysticil or rectocil, constipation
- nerve problems: brain and the bladder; diabetes, stroke, MS, pelvic injury/trauma, spina bifida
- meds: opioids or anethestics, anti-chol, TCAs, anti-psych
- weakened bladder muscles as aging occurs
Urinary Bladder Scanners
- Portable handheld ultrasound device that calculates bladder’s volume, Get three scans and take average of them
- Purposes: prevent unnec cath, painless, minimize risk of cauti and upper urinary tract damage, see dry or retaining urine, see of they have post void residual - have them void and if there is more than 100mL left = positive
Suprapubic Cath
- Put in surgically through opening in the abdomen rather than urethra
- Prone to colonization of bacteria, assess every 8 hrs
- Replace bandage if it becomes moist
Indwelling (Foley)
- Remains in place
- 2 lumens - one is for urine, one is for inflating balloon
Interrmittent Cath
- One-time use, sterile technique
- Removed immediatelt after insertion and drainage of urine
- can be use in home setting - patient uses clean technique
External Cath
- Texas cath/purewick/condom
- For patients who are incontinent externally; place device in perineal region and attach to suction to collect incontinence & keep patient dry
Coude Cath
- for patients with BPH
- curved tip, less flexible, allows for easier insertion
Drainage Systems
- Bags: large capacity, empty every 8 hrs not when completely full
- Leg bag: wear under clothing, smaller in size
- Urine meter: Follow strict I&O for this
Cath Assessment
- Allergies: latex and iodine
- Privacy and Comfort
- Appropriate lumen size
Perineal Care
- Female: front to back, outer to inner, Different part of washcloth with each swipe
- Male: circular motion in to outward, Cleanse foreskin, clean down the shaft, then scrotum
Female Positions for Cath
- Dorsal recumbent or side lying
- Maintain separation of labia until catheter inserted
- Insert about 2-3 inches until urine return
Male Positions for Cath
- Supine
- Hold penis shaft until catheter inserted
- Insert up to bifurcation
Specimen Collection
- Infection and hydration status
- Collect from tubing area port
- Urine dipstick: match color with tube; sees pH, gravity, leukocytes, blood, ketones, glucose
- Urinalysis: lab test to confirm bacteria
- Culture and sensitivity: Grow the bacteria to determine what type and see what type of antibiotic needed
Irrigation of Catheter
- Purpose: urine output has decreased with full bladder on scanner, may be blocked
- Procedure: irrigate through port, use room temp solution to prevent bladder spasm, instill 30-60mL, goes directly into bladder
- Document: amout and type of irrigate, characteristics of drainage, pt tolerance
Continuous Irrigation
- Used after surgeries for removal of prostate
- Use three-way foley
- Flushes debris and clots out of cath
- Can instill med into bladder lining
- Maintain accurate records of the amount of fluid used for irrigation and total amount of urinary drainage
Documenting Cath
- Date & time of catheterization
- Type of catheter inserted (straight, indwelling, condom, suprapubic)
- Size of catheter
- Amount of fluid used to inflate balloon (indwelling)
- Urinary output
- Catheter patency
- Urine quality, quantity, color
- Patient’s alertness, orientation, abdominal assessment, skin assessment
- Patient & family teaching
