Exam 2 Flashcards
Functions of the skin
- Protection: the best first level of protection against infection
- Homeostasis: plays a role in maintaining the temperature inside the body.
- Thermoregulation:Skin helps regulate the body temperature
- Sensation
- Vitamin synthesis: We process vitamin D better than we can absorb it through the GI tract
- Psychosocial: Touch each other and hold hands
age related changes in skin
- skin thins & loses anchoring»> increased vulnerability to sheer and tears
- loss of subcutaneous elastin, collagen and fat
- Decreased cellular turn over
- Decreased blood supply and sensitivity
- Dry skin due to a decrease in sweat and sebaceous gland function
- Decreased hair growth
- Decreased hormone functions
- Photoaging- wrinkles and age related lesions
- There is decreased elasticity and slower wound healing
What is a pressure ulcer?
- localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.
complications of pressure ulcers
If left Undiagnosed/Untreated :
- Worsening of Ulcer
- Increased Pain/Suffering
- Increased Immobility
- Increased Risk for Infection and Spread from Localized Cellulitis
- Bacteremia
- Osteomyelitis
- Amputation
- Sepsis and Death
- Extended Hospital Stay
- Long Term Subacute Care
- Depression
- Poor Body Image
- Litigation.
Risk factors for pressure ulcers (6)
- advanced age
- immobility
- incontinence
- infection
- Low blood pressure
- malnutrition
pressure ulcer assessment
- Perform Complete Head to Toe Assessment.
- Know your Anatomical Landmarks
- Know the Norm from Abnorm.
- Remember!!! “We are treating the Whole patient not just the Hole in the patient”
Documenting an ulcer
LOCATION:
- Right, left, upper, lower, distal, proximal, inner, outer, medial, lateral, anterior, posterior, plantar, dorsal……
- Heel, malleolus, coccyx, gluteus, gluteal cleft, gluteal fold, trochanter, ischium, sacral, iliac crest, spine, scapula, metatarsal head….
SIZE: (cm),LxWxD
- Length: Head to Toe(Think Anatomical Planes)
- Width: Shoulder to Shoulder,(Perpendicular)
- Depth: Use Q-tip, lay on measuring guide.
- Presence of tunneling or undermining
- WOUND SURFACE: ( base, bed)
- Color: pink, red, yellow, burgundy, brown, tan, gray, black, beige…
- Describe: granulation, epithelium, necrotic slough, necrotic eschar.
- Necrotic Slough: moist, stringy, adhered to wound bed(yellow, tan, gray, green, brown)
- Necrotic Eschar: thick leathery hard scab(tan, brown, black)
DRAINAGE: (Exudate)
- Color: Serous, Sanguineous, Serosanguineous, yellow, pink, green, red…
- Amount: moist, small/scant/minimal, moderate/medium, large/copious
SURROUNDING SKIN: (periwound)
- Describe: intact, erythema/red, macerated, indurated/firm, blistered, ecchymotic, denuded, excoriated, edematous…
Stage I pressure ulcer
- Non-blanchable erythema on intact skin, usually over a bony prominence.
- Always compare area to surrounding skin, esp. in darker skin
- Area may be firmer or softer, warmer or cooler than adjacent tissue.
- Relieve pressure
- Do NOT massage the area
Stage II pressure ulcer
- Partial thickness loss of dermis, epidermis or both
- The ulcer is superficial and presents as an abrasion, blister or shallow crater.
- Ulcer has measurable edges
Pinkish/red base without slough or debris
Stage III pressure ulcer
- Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia
- Subcutaneous fat and slough (dead tissue) may be visible, but doesn’t obscure the depth of the wound
- May or may not have undermining
Stage IV pressure ulcer
- Full thickness skin loss with exposure of underlying structures such as muscle, tendon and bone.
- Devitalized or necrotic tissue is usually present
- Often include undermining or tunneling
- Depth varies depending upon location
Unstageable
- Full thickness tissue loss in which actual depth of the ulcer is completelyobscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brownor black) in the wound bed.
- Until enough slough and/or eschar are removed toexpose the base of the wound, the true depth cannot be determined; but it will beeither a Category/Stage III or IV.
- Stable (dry, adherent, intact without erythema orfluctuance) eschar on the heels serves as “the body’s natural (biological) cover”and should not be removed.
- We do not know what the base of wound shows
- If moist and surrounded by painful red, warm tissue it is infected and will be removed
- If dry and intact they may leave it
- Removing bodies biological cover
- Wipe with beta-dine and keep it dry
Deep Tissue Injury
- Purple or maroon localized area of discolored intact skin or blood-filled blisterdue to damage of underlying soft tissue from pressure and/or shear.
- The areamay be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooleras compared to adjacent tissue. - Deep tissue injury may be difficult to detect inindividuals with dark skin tones.
- Evolution may include a thin blister over a darkwound bed.
- The wound may further evolve and become covered by thin eschar.
- Evolution may be rapid exposing additional layers of tissue even with optimaltreatment.
Pressure beds
- Reduce pressure on beds
- Low air loss bed
- Clinitron bed- air being transferred from tiny beads (most aggressive care, requires a lot of knowledge to use it)
- Cushion in wheelchairs
- Static or moving (air)
Hot and Cold therapies for pressure ulcers
- Be sure to assess a patient’s mental status to be sure that they can communicate any issues with the hot or cold therapy.
- Hot and cold therapies are contraindicates in patients who have neuropathy or who can’t feel a body part.
- Check the skin integrity frequently under these therapies.
- You must have an order for certain therapies.
- goal: Increase circulation & Decrease inflammation
Stress
Describes a process that begins with an event that evokes a degree of tension or anxiety
Stressor
- Tension producing stimuli operating within or on any system and the appraisal or perception of the stressor
- Education, money, work, people, events, environment.
Appraisal
How people interpret the impact of the stressor on themselves or on what is happening and what they are able to do with it.
Stress can be good when:
- Stimulates the thinking process and helps people stay alert to their environment
- Results in personal growth and facilitates development
Stress can be bad when:
- When coping mechanisms become overwhelmed a crisis can result
- If symptoms of stress persist beyond the duration of the stressor then the person has experienced a trauma
Chronic Stress
- Prolonged Period
- Occurs in stable conditions and results from stressful roles
- ex: Drive to work, annoying boss, bad work schedule, a difficult spouse, poor sleep habits, negative friends.
Acute Stress
- Time-limited events
- Threaten a person for a brief period
- ex; New challenge, athletic competition, presentation at work, lifting heavy weights, intermittent fasting, running sprints.
Fight or Flight Response
- Arousal of the sympathetic nervous system and prepares a person for action
- Can cause alterations in heart rate, blood pressure, respirations, level of consciousness
- Increased mental activity, dilated pupils, bronchiolar dilation, increased heart rate, increased respiratory rate, increased cardiac output, increased glucose, increased arterial blood pressure, increased fatty acids, increased blood flow to skeletal muscles.
General Adaptation Syndrome (GAS)
- A three stage reaction to stress
- Describes how the body responds to stressors through the alarm reaction, the resistance stage, and the exhaustion stage
- Triggered by a physical or psychological event
- Alarm reaction
- Resistance stage
- Exhaustion stage
what happens during an Alarm Reaction?
- Central nervous system is aroused
- Hypothalamus
- Posterior Pituitary:
- Increased water reabsorption
- Decreased urine output
- Anterior-Pituitary:
- Increased water and sodium reabsorption
- Decreased urine output
- Increased potassium secretion
- Sympathetic nervous system and adrenals:
- Increased heart rate
- Increased O2 intake
- Increased blood glucose
- Increased mental acuity
- Increased blood flow to muscles
- Increased blood pressure
- Flight-or-flight response
Resistance Stage
-Continues the flight or fight response and the body stabilizes and responds in an attempt to compensate for the changes induced by the alarm stage
-Hormone levels return to normal
-Parasympathetic nervous system activity
-Adaptation to stressors
. Hormone levels, heart rate blood pressure, and cardiac output return to normal and the body repairs any damage that has occurred, can lead to chronic illness due to wear and tear on the body from fluctuating hormone levels, can cause long term problems such as chronic hypertension, depression, sleep deprivation, chronic fatigue syndrome and autoimmune disorder
Body continues to try and compensate at peak capacity as it is trying to adapt to the stressor
These compensation efforts consume energy and other body resources
Exhaustion Stage
-Increased physiological response
-Decreased energy levels
-Decreased adaptation
-Exhaustion-occurs when the body is no longer able to resist the effects of the stressor and has depleted the energy necessary to maintain adaptation
Progressive breakdown of the compensatory mechanisms
-Causes the bodies natural defenses to breakdown and the body becomes susceptible to illness, tissue damage, ulcers, high blood pressure and chronic health conditions
-Allostatic load: chronic arousal with the presence of powerful hormones causing excessive wear and tear on body organs
-Can cause long term problems such as htn, depression, sleep deprivation, chronic fatigue syndrome, autoimmune disorders
Factors Influencing Stress and Coping
-Situational Factors: Personal, job, or family changes.
-Maturational Factors: Stressors vary with life stage.
Younger-physical appearance, self esteem, peers
Mid-focus of changes in life situations
Older-loss of loved ones, disease
-Sociocultural Factors: Environmental and social stressors often lead to developmental problems.
Nursing Process- Assessment
- First have to establish a trusting nurse patient relationship
- Ask questions and observe nonverbal communication
- Often have difficulty expressing exactly is most bothersome about the situation
- Begin by using open ended questions
- Assess patient’s perception of the event, available situational supports and how they normally hand a problem they can’t solve
- Determine if there is suicidal or homicidal intent
- Subjective-create a nonthreatening environment for the interaction, assume same height as patient
- Objective-observation of physical appearance and nonverbal behavior, grooming, hygiene, gait, characteristics of handshake, quality of speech, eye contact and attitude during the interview
Symptoms of Stress
- Flight or fight response
- Fatigue and low energy
- Emotional reactions such as crying, anger, sadness, frustration, helplessness, tension, irritability
- Difficulty making decisions
- Difficulty falling asleep, interrupted sleep, insomnia
- Jaw pain, tooth pain, and grinding of teeth
- Hair loss
- Intestinal disturbances
- Muscle twitching, aches, muscle and nerve pain
- Acne development
Pediatric Traumatic Stressors
- Witness to community violence
- Domestic violence
- Early childhood trauma
- School violence
- Physical abuse, sexual abuse, neglect
- Medical trauma
- Exposure to natural disasters
Family Stress
- Stress causer
- Invades your privacy
- Tells you what to do
- No bend and unable to tear
Major Types of stress Pediatrics
-Positive: encountering a new experience and it brings few or only minor changes in emotions, hormonal response or heart rate change
-Tolerable: more intense experience such as a family death and the adaptation
-Toxic: stressor is severe, intense and sustained. Leads to prolonged stress activation
Can have profound alterations in brain structure and functioning particularly in the developmental period.
Can affect immune system function and reduce learning and memory leading to cognitive defects, can also cause damage to the brain causing problems with memory, learning and cognitive processing
Developmental Stages Stress
- Infants: Irritable, crying, fearful, GI distress
- Toddler: Aggressiveness, regressive behaviors
- Preschool: Acting out, fearful of separation/abandonment, nightmares
- School age: Poor school performance, aggression, increased acting out behaviors
- Adolescents: Poor self esteem, delinquency, high-risk behaviors, problems in relationships
Response to Psychological Stress
-Anticipation of the stressor influences its effect, More difficult to cope with an unexpected stressor
-Primary appraisal: evaluating the event for its personal meaning
Secondary appraisal: focuses on possible coping strategies.
-Coping: person’s effort to manage psychological stress, effectiveness of strategies depends on the individual’s need,
-No single coping strategy will work for every person
-Ego-defense mechanisms: regulate emotional distress and give a person protection from anxiety and stress, offer psychological protection from a stressful event
Post Traumatic Stress Disorder
- Begins when a person experiences, witnesses, or is confronted with a traumatic event and responds with intense fear or helplessness
- Manifested by nightmares, emotional detachment, flashbacks
- Responses can include self destructive behavior such as suicide attempts and substance abuse
- Manifested by nightmares, emotional detachment, flashbacks
Crisis
- Crisis implies that a person is facing a turning point in life, this means that previous ways of coping are not effective and the person must change
- Developmental Crisis: Occur as a person moves through the stages of life.
- Situational Crisis: Job change, motor vehicle crash, or severe illness.
- Adventitious crisis: Major natural disaster, manmade disaster, or crime of violence.
- Vital questions for a person in a crisis
- What does this mean to you?
- How is it going to affect your life?
- What does this mean to you?
Crisis Intervention
- Intervention aimed at returning person to a precrisis level of functioning and promote growth
- Nurse helps the patient make the mental connection between the stressful event and their reaction to it
- Help the patient explore new coping mechanisms
Secondary traumatic Stress
- Common in healthcare workers
- Experience from witnessing other people suffer
- Manifested by:
- Nightmares and anxiety
- Avoid interactions
- Difficulty relating to friends or family
Nurse Burnout
- Burnout develops after a clinician experiences chronic and excessive stress without adequate coping mechanisms
- Causes can include:
- Long shifts
- Staffing ratios
- Dealing with death on a regular basis
- Assisting grieving family members
- Symptoms:
- Irritability
- Frequently calling in sick
- Exhaustion
Restorative Care
Recovers when the stress is removed or coping strategies are successful
-Final stage of adaptation is acknowledgement of the long term implications from the crisis and its consequences
Nursing Process- Diagnosis (for stress)
- Anxiety
- Caregiver role strain
- Ineffective coping
- Fear
- Risk for PTSD
- Insomnia
- Situational low self-esteem
- Stress overload
- Review of data leads the nurse to cluster data that indicate a potential or actual stressor and the patient’s response
- Focus is generally on coping
Nursing Process- Planning (for stress)
- Desirable outcomes include effective coping, family coping, caregiver emotional health, and psychosocial adjustments
- Selects interventions for stress and improved coping such as coping enhancement and crisis intervention
- At the primary level of prevention you direct nursing activities to identifying individuals and populations who are possibly at risk for stress.
- Nursing interventions at the secondary level include actions directed at symptoms such as protecting the patient from self-harm.
- Tertiary-level interventions assist the patient in readapting and can include relaxation training and time-management training. The nurse and the patient assess the level and source of the existing stress and determine the appropriate points for intervention to reduce it.
- Involve the patient and family
- Identify community resources accessible to the patient
- Safety of the patient and others in their surrounding is always the first priority
- Collaboration with healthcare team to help meet needs
Nursing Process- Implementation (for stress)
- Three modes of interventions for stress
- Decrease stress producing situations
- Increase resistance to stress
- Learn skills that reduce physiological response to stress
- Education about health promotion
- A regular exercise program improves muscle tone and posture, controls weight, reduces tension, and promotes relaxation. In addition, exercise reduces the risk of cardiovascular disease and improves cardiopulmonary functioning.
- Patients who have a history of a chronic illness, are at risk for developing an illness, or are older than 35 years of age should begin a physical exercise program only after discussing the plan with a health care provider.
- Patients and family members who are well rested are able to manage stress, problem solve, and maintain as sense of control over the situation.
Pediatric Nursing Interventions (for stress)
- Anticipate behaviors
- Teaching coping skills
- Self-soothing techniques
- Meditation, therapeutic play
- Ensure child’s safety
- Listen carefully and encourage child to talk, draw, or engage in play to express fears or concerns
- Promote self care
- Maintain normal routine
Patient Teaching Stress Management
- Meditation
- Deep breathing
- Progressive muscle relaxation: Diminish physiological tension through a systematic approach to releasing tension in major muscle groups.
- Guided imagery
- Hypnosis
- Biofeedback:learned behavior of monitoring physical characteristics of stress-hr, blood pressure and then relaxing to get back to normal level
- Assertiveness training
- Yoga
- Regular exercise: improves muscle tone, posture, control weight, reduces tension, promotes relaxation
- Limit caffeine intake
- Music therapy
- Journaling
- Use of humor
- Time management
Self- Care for Nurses
- Very important for nurses to participate in self-care practices
- Recognize the areas over which you have control and can change and those for which you do not have responsibility
- Clear separation between work and home life is crucial
Nursing Process- Evaluation (for stress)
- Report feeling better after the stressor is gone
- Observe patient behaviors
- Ask about sleep patterns, appetite, ability to concentrate
- Ask about coping strategies
- Refer to appropriate resources for follow up care
- If he or she reports continued acute stress, assess for safety by asking about whether or not there have been any recent accidents at home, in the car, or at work. Ask about coping mechanisms used.
- An essential part of the evaluation process is collaborating with patients to determine if their own expectations from nursing have been met. Any revision in the plan of care includes steps to address patient expectations.
Nutrition
is a basic component of health and is essential for normal growth and development, tissue repair and maintenance, cellular metabolism, and organ function.
Basal Metabolic Rate
Energy needed at rest to maintain life-sustaining activities for a specific amount of time
Resting Energy Expenditure
Amount of energy needed to consume over 24-hour period for the body to maintain internal working activities while at rest
Nutrients
- Energy necessary for the normal function of numerous body processes.
- The Biochemical Units of Nutrition
Carbohydrates
Provides energy, fiber, and glucose
Proteins
Contribute to growth, maintenance and repair of body tissues
Fats
- Provide energy and vitamins
- should have less 35% of calorie intake from fats.
- are the most calorie-dense nutrient, providing 9kcal/g.
- Fats are composed of triglycerides and fatty acids.
Water
- Critical for cell function and replaces fluid lost through sweat, elimination and respiration
- Water makes up 60% to 70% of total body weight.
- Infants have the greatest percentage of total body water due to greater surface area, and older people have the least. When deprived of water, a person usually cannot survive for more than a few days.
- We meet our fluid needs by drinking liquids and eating solid foods high in water content such as fresh fruits and vegetables.
- Digestion produces fluid during food oxidation.
- In a healthy individual, fluid intake from all sources equals fluid output through elimination, respiration, and sweating. An ill person has an increased need for fluid (e.g., with fever or gastrointestinal [GI] losses). By contrast, he or she also has a decreased ability to excrete fluid (e.g., with cardiopulmonary or renal disease), which often leads to the need for fluid restriction.
Vitamins
- Necessary for metabolism(a, d, e, k, c and b)
- are organic substances present in small amounts in foods that are essential to normal metabolism. They are chemicals that act as catalysts in biochemical reactions.
- Certain vitamins are currently of interest in their role as antioxidants. These vitamins neutralize substances called free radicals, which produce oxidative damage to body cells and tissues. Researchers think that oxidative damage increases a person’s risk for various cancers. Antioxidant vitamins include beta-carotene and vitamins A, C, and E.
- Vitamin synthesis depends on dietary intake. Vitamin content is usually highest in fresh foods that have minimal exposure to heat, air, or water prior to their use. Vitamin classifications include either the labels of fat-soluble or water-soluble.
- The fat-soluble vitamins (A, D, E, and K) are stored in the fatty compartments of the body. With the exception of vitamin D, people acquire vitamins through dietary intake.
- The water-soluble vitamins are vitamin C and the B complex (which is eight vitamins). Water-soluble vitamins absorb easily from the GI tract. Although they are not stored, toxicity can still occur.
Minerals
- Complete essential biochemical reactions in the body(calcium, potassium, sodium and iron)
- are inorganic elements essential to the body as catalysts in biochemical reactions.
- They are classified as macro minerals when the daily requirement is 100mg or more and micro minerals or trace elements when less than 100mg is needed daily.
- Macro minerals help to balance the pH of the body, and specific amounts are necessary in the blood and cells to promote acid–base balance. Interactions occur among trace minerals.
Triglycerides
circulate in the blood and are composed of three fatty acids attached to a glycerol.
Fatty Acids
are composed of chains of carbon and hydrogen atoms with an acid group on one end of the chain and a methyl group at the other.
- Fatty acids can be saturated, in which each carbon in the chain has two attached hydrogen atoms
- or unsaturated, in which an unequal number of hydrogen atoms are attached and the carbon atoms attach to each other with a double bond.
Monounsaturated Fatty acids
have one double bond, whereas polyunsaturated fatty acids have two or more double carbon bonds. The various types of fatty acids, referred to in the dietary guidelines have significance for health and the incidence of disease.
Classifying fatty acids as essential or nonessential
- Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans.
- Linolenic acid and arachidonic acid, another type of unsaturated fatty acids, are important for metabolic processes.
- Deficiency occurs when fat intake falls below 10% of daily nutrition.
- Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids.
Digestion
- Mechanical Breakdown that results from chewing, churning, and mixing with fluid and chemical reactions in which food reduces to its simplest form
- begins in the mouth, where chewing mechanically breaks down food. The food mixes with saliva, which contains ptyalin (salivary amylase), an enzyme that acts on cooked starch to begin its conversion to maltose.
- Proteins and fats are broken down physically but remain unchanged chemically because enzymes in the mouth do not react with these nutrients.
Each part of the gastrointestinal (GI) system has an important digestive or absorptive function.
- Enzymes are the protein like substances that act as catalysts to speed up chemical reactions. They are an essential part of the chemistry of digestion.
- Most enzymes have one specific function. Each enzyme works best at a specific pH.
- The mechanical, chemical, and hormonal activities of digestion are interdependent.
- Enzyme activity depends on the mechanical breakdown of food to increase its surface area for chemical action.
- Hormones regulate the flow of digestive secretions needed for enzyme supply. Physical, chemical, and hormonal factors regulate the secretion of digestive juices and the motility of the GI tract.
- Nerve stimulation from the parasympathetic nervous system (e.g., the vagus nerve) increases GI tract action.
C the PM Diner or Basic Principals of Wound Healing
C=Circulation-you must have adequate perfusion
P=Pressure-relieve pressure and friction
M=Medication-review to find medications that delay healing
D=Devitalized tissue-remove it
I=Infection-keep the wound infection free
N=Nutrition-MUST have adequate nutrition to heal
E=Environment-optimize the wound environment/keep moist but control excess drainage
R=Reevaluate dressings and treatment as the wound changes
Nutrition labs to think about for wound healing
- Albumin: serum protein that can reflect visceral protein stores: 3.4-5.0mg/dl
- stays in body about 21 days (liver function)- if below 2.5 severely protein deficient, if 1.7 then you have enough colloidal pressure to get anasarca (total body edema)
- Prealbumin: Also reflects visceral protein stores;18-30mg/dl. A better indicator of acute protein depletion.
- aka transthyretin, transports thyroid hormones, stays in body 3-5 days, check once a week
- Transferrin: Not used as often, can also reflect visceral protein stores; 250-300mg/dl.
- Nitrogen Balance: Malnourished patients are in a state of negative nitrogen balance, thus no nitrogen available for protein synthesis, indicates catabolism and need for more protein.
- Total lymphocyte count(TLC): Immunocompetence is compromised in protein-energy malnutrition; <1800-2000 cells/mm3 could suggest malnutrition.
- HGB/HCT: Anemia; 13-18/39-54, respectively.
Other types of wounds
Acute wounds: - Incisions - Trauma Chronic wounds: - Venous ulcers - Arterial ulcers - Diabetic ulcers
Culturing wounds
- All wounds have some level of bacterial burden, but may not be infected.
- Wound infection is when the microorganism invades the tissue.
- Do NOT culture pus or other drainage.
- Signs: increased pain, drainage, purulence, peri-wound erythema and fever.
Healing wounds
- Primary intention-wounds that have been closed using staples, sutures or skin glue.
- Secondary intention-left open
Occurs with skin ulcers and infected or dehisced incisions
complications for wound healing
- Dehiscence- cough, move, ripping (7-10 days after surgery), about 1/3 abdominal incisions, pink drainage
- Evisceration- call surgeon, elevate head to take some tensions off, sterile dressing with saline and place over, VS, make NPO, establish IV
- Retention sutures- sutures that have a little plastic slip around them not to heal into wound (lots of tension around wound)
drains for wounds
- Penrose drain- wicking fluid that accumulates around incision, do not replace
- Jackson-Pratt or JP drain- check frequently, may pull them out if instructed, premedicate
- Hemovac- vacuum that draws fluid, coiled spring, drain every shift
cleaning wounds
- Do NOT cleanse with substances toxic to fibroblasts: alcohol, hydrogen peroxide, betadine.
- DO cleanse with normal saline or approved commercial wound cleanser.
- Cleaning lowers the surface temperature of the wound.
dressings
- Purpose: Protection from contamination, further injury, abscess formation, Provide compression, Application of medications,
Absorption of drainage/Debridement of necrotic tissue, Promote healing of the wound. - Goal: Keep moist tissue moist and dry tissue dry: Keep the open area moist, but the skin around it dry. Choose something that will control drainage, but not dry out the wound.
- Biocclusive- seals wound off and can still look, does not absorb drainage but can put overtop something that does
- Hydrocolloid- can leave on up to 7 days, acts like a scab (have it at store, called wound healing strips)
- Hygrogel- keeps wound moist
- Foam- absorbs drainage, can layer this
- Alginate- made from seaweed, absorbs huge amounts of drainage
- Wet to dry dressings- never want wound to dry out so it should be wet to moist (takes out all tissue when you remove if dry) cools wound bed down, takes a lot of time
- Impreganated with silver- helps cut down on infections
- XEROFORM™ Petrolatum Gauze.
- 3% Bismuth Tribromophenate
- Vaseline impregnated in gauze
- engineered skin (skin grafts)
- wound VAC (Machine with sponge inside wound, Removes drainage, Improves rate of granulation tissue, Decreases infection, Improves circulation)
- montogomery straps
- Bandage role or Kerlix
- Use skin protective barrier before tape
- Kelex- white roll
- Coban- created by a vet, only thing It sticks to is self
wound debridement
- Surgical or “sharp” (scapel, scissors)
- Autolytic- provides a moist environment where the body “dissolves” slough ( self-digestion, refers to the destruction of a cell through the action of its own enzymes)
- Enzymatic- applied enzymes dissolve devitalized tissue
- Biosurgery- sterile maggots
- Mechanical- least effective (letting dressing rip it out)
Epiglottis
a flap of skin that closes over the trachea as a person swallows to prevent aspiration
Swallowed food enters the
- esophagus, and wavelike muscular contractions (peristalsis) move the food to the base of the esophagus, above the cardiac sphincter
- Pressure from a bolus of food at the cardiac sphincter causes it to relax, allowing the food to enter the fundus, or uppermost portion, of the stomach..
The chief cells in the stomach secrete
pepsinogen
The pyloric glands secrete
Gastrin: a hormone that triggers parietal cells to secrete hydrochloric acid (HCl)
The parietal cells secrete
HCl and intrinsic factor (IF), which is necessary for absorption of vitamin B12 in the ileum. HCl turns pepsinogen into pepsin, a protein-splitting enzyme.
The body produces gastric lipase and amylase to begin
fat and starch digestion, respectively.
A thick layer of mucus protects the
lining of the stomach from autodigestion.
Two substances directly absorbed through the lining of the stomach are?
Alcohol and aspirin
The stomach
acts as a reservoir where food remains for approximately 3 hours, with a range of 1 to 7 hours.
Food leaves the
atrium, or distal stomach, through the pyloric sphincter and enters the duodenum. Food is now an acidic, liquefied mass called chyme.
Bile
- Manufactured in the liver and then concentrated and stored in the gallbladder.
- It acts as a detergent because it emulsifies fat to permit enzyme action while suspending fatty acids in solution.
Pancreatic secretions contain six enzymes
amylase to digest starch; lipase to break down emulsified fats; and trypsin, elastase, chymotrypsin, and carboxypeptidase to break down proteins.
Peristalsis
- continues in the small intestine, mixing the secretions with chyme. The mixture becomes increasingly alkaline, inhibiting the action of the gastric enzymes and promoting the action of the duodenal secretions.
- Epithelial cells in the small intestinal villi secrete enzymes (e.g., sucrase, lactase, maltase, lipase, and peptidase) to facilitate digestion.
Where does the major portion of digestion occur?
in the small intestine, producing glucose, fructose, and galactose from carbohydrates; amino acids and dipeptides from proteins; and fatty acids, glycerides, and glycerol from lipids. Peristalsis usually takes approximately 5 hours to pass food through the small intestine.
Absorption of Nutrients
- Body Absorbs nutrients
- Small intestine primary absorption site
Malnutrition Screening
-Gather information on current condition, assessment whether it will worsen, or if disease process will worsen condition
Tools for Malnutrition Screening
- Subjective global assessment
- Mini nutritional assessment
Screening a patient is a quick method of identifying
malnutrition or risk of malnutrition using sample tools.
What should you include in the a screening for malnutrition?
- Include height, weight, weight change, primary diagnosis, presence of other co-morbidities
- Subjective statements included too
- Identification of risk factors-unintentional weight loss, presence of a modified diet, presence of altered nutritional symptoms(nausea, vomiting, diarrhea, constipation) requires nutritional consultation.
