Exam 3: Wounds/Drains/Nutrition/Hygiene Flashcards
Describe the four stages of a pressure injury.
Stage 1: Nonblanchable redness typically over boney prominance
Stage 2: Partial thickness - shallow open ulcer without slough (may be a blister)
Stage 3: Full-thickness - SQ may be visible, but not deeper tissue. Slough may be present but doesn’t obscure
Stage 4: Full thickness - bone, tendon, or muscle may be exposed. Slough or eschar may be present but doesn’t obscure
Describe an unstageable pressure injury and a deep tissue injury.
Unstageable - full-thickness loss where depth is completed obscured by slough or eschar (typ. either 3 or 4)
Deep tissue - Depth unknown. Discolored, intact skin or blister from pressure or shear (painful, firm, mushy, boggy, different temp)
What are four complications of wound healing? Describe each and know the nurse responsibilities.
Infection
Dehiscense
Evisceration
Hemorrhage
How does nutrition aid in wound healing?
Need protein in the diet to be able to rebuild from a wound
Describe the components of the Braden scale?
Sensory Perception - the ability to respond meaningfully to pressure-related discomfort.
Moisture - Presence and duration of moisture on the skin
Activity - Degree of physical activity that the patient is currently capable of
Mobility - Ability to change and control body position
Nutrition - usual food intake pattern
Friction & Shear - whether or not a pt requires assistance to move puts them at risk of these injuries
What are interventions that are used based on the client’s Braden scale results?
Implement turning schedule
Moisturize skin daily and PRN
Obtain PT consult for activity
level, out of bed, foot drop risk as
indicated
Control moisture
Nutrition consult
Minimize shear on bed and chair
surfaces
Pressure redistribution bed; low
air loss if Braden Moisture
subscale less than 3
Patient/Caregiver Education
What are the signs and symptoms of a wound infection?
Redness, warm, painful, unable to use, streaking, fever
What are priority interventions for an immobile client to prevent a skin injury?
Turn team
Positioning devices
Cleaning incontinence quickly
Lifting devices to avoid friction/shear
What are the components of incontinence management?
Frequent position changes
Using an incontinence cleaner
Applying a moisture barrier ointment
What is the purpose of irrigation and debridement?
Clean out the wound of any debris/foreign body/necrotic tissue and to be able to visualize the wound and its depth/damage
Describe slough tissue
Yellow, stringy substance attached to wound bed
Usually must be removed before wound can heal
Describe eschar tissue
Brown, black tissue
Indicates necrosis
Usually must be removed for healing to occur
Describe granulation tissue
Red, moist, beefy; indicates progression to healing
What are documentation requirements when charting wounds?
Location
Size
Tunneling and undermining
Color of ulcer base
Drainage
Use standard measurements
Primary or secondary intention
Describe the various classifications of drainage seen in a wound drain?
Amount – color – odor – consistency
• Serous – clear, watery plasma
• Purulent – thick, yellow, green, tan or brown (pus)
• Sanguineous – bright red, indicates active bleeding (bloody)
• Sero-sanguineous – pale, red, watery; mixture of serous and
sanguineous
Describe the various types of drains.
Jackson-Pratt (JP) drains: closed drainage system with a bulb that exerts a low pressure to pull fluid out of the wound; can hold 25-50 mL of fluid
Hemovacs: “evacuator unit,” closed drainage system that exerts a low pressure to pull fluid out of the wound; can hold up to 500 mL of fluid
Penrose drain: lies underneath dressing; at time of placement, a pin or clip is placed through the drain to prevent it from slipping further into the wound; wound heals from inside out
Describe nursing care for the various types of drains.
Keep drain patent
Keep peri-wound skin dry
Apply absorbent dressings
Skin prep
Change when dressing is moist
Document wound drainage output (I/O record)
Monitor patient nutrition
Up to 100 grams of protein may be lost daily in wound
drainage
What are some age related changes in older adults that can effect nutrition?
changes in appetite, less absorption through GI, medication interactions, cognitive impairment
What are some subjective questions we ask clients when assessing nutrition?
How many meals a day?
Are you allergic to any foods?
Do any foods cause indigestion, gas, or heartburn for you?
Have you noticed any changes in taste?
Have you had a change in appetite/weight?
Which medications do you take?
What are signs and symptoms of dysphagia?
coughing or choking when eating or drinking.
bringing food back up, sometimes through the nose.
a sensation that food is stuck in your throat or chest.
persistent drooling of saliva.
being unable to chew food properly.
What does a clients Body Mass Index indicate? What are the classifications based on BMI?
BMI is a way to classify weight categories
<18.5 underweight
18.6-25 normal
25 -30 overweight
30-35 obese
35+ morbidly obese
What are the signs and symptoms of malnutrition? (Table 45.4)
fatigue, underweight (or overweight/obese), poor posture, weak, inattentive, irritable, paresthesia, tachy, rough skin, dry lips, swollen mucosal membranes
Describe the nursing care of a client on parenteral nutrition.
IV and tubing changes every 24 hours, always use a pump and a filter, and dedicated lumen
Describe nursing care of client who is NPO.
Nothing PO - not even ice chips
No one eats in the room
What are complications of enteral feeding?
Pulmonary aspiration
Diarrhea
Constipation
Tube occlusion
Tube displacement
Abdominal cramping
Delayed gastric emptying
Serum electrolyte imbalance
Fluid overload
Hyperglycemia
Describe nursing care of a client on enteral feeding.
Check placement, aspiration precautions, and monitor BGLs
What is gastric residual volume?
the amount of liquid drained from a stomach following administration of enteral feed
How often do we change a TPN and PPN bag and tubing?
24 hours
How do we prevent complications from TPN?
Use a filter, use a pump, dedicated lumen only, change bag/tubing,
What if I must stop TPN abruptly? What are my considerations?
Monitor closely for hypoglycemia
What are some questions you should ask your client prior to providing interventional hygiene?
No two people care for their body/clean themselves the same way
Cultural considerations
Talk to pt to figure out what’s right for them
What is the proper technique for cleaning the eyes?
◦ Examine sclera for edema, jaundice, or other abnormalities
◦ Remove contact lenses and cleanse; glasses are preferred in hospital
Why do we provide oral care?
x
Describe the options for providing oral care.
◦ Brushing teeth/dentures w/ toothbrush or sponges
◦ Mouthwash
◦ Chapstick
◦ Flossing
◦ NS or salt & soda rinses Q2o
◦ Suction mouth
◦ Denture care
◦ Suction
What are safety considerations when providing oral care?
Biting and no liquid in unconscious pts mouth
What should we monitor while bathing a client?
Skin?
Describe the process for performing a bed bath
Let the person wash what they are able to
Be mindful of privacy
Follow their lead in terms of conversation and what makes them comfortable
Clean an area and then cover it again for privacy
What are the principles for feeding a client?
May need to feed the patient if they are unable to do so or have a swallowing impairment (dysphagia); determine how much help the pt needs
◦ Provide rest or analgesia b/f meal, if necessary
◦ Turn on lights, remove odors and disturbing sights, place pt in a proper position for eating
◦ Prepare patient by washing hands, face; inserting dentures; brushing teeth
◦ Minimize interuptions
What are some considerations when providing toileting for your client?
Provide privacy
Can patient ambulate? Or wipe independently?
Encourage the patient to do as much as they can on their own, but help out with whatever is needed
Know the different toileting options, select the best one for your patient
Foleys
Bed pans
Toilet
Bedside commodes
What should we continue to evaluate as we provide hygiene care?
Skin- check for abnormalities, new signs of ulcers
Patient’s preferences- ensure their privacy; place in their chart
Evaluate the environment: clean and tidy environment promotes health