EXAM 4 Flashcards
PAIN, SKIN INTEGRITY, WOUND, NUTRITION, POST MORTEM, HIPAA, PHYSIOLOGY, OSTOMY, NG, ENTERNAL TUBE FEEDING, CENTRAL VENOUS WEEKS 10-13
1
Q
ACTURE/TRANSIENT PAIN
A
PROTECTIVE MECHANISM THAT HAS AN IDENTIFIABLE CAUSE, IS OF SHORT DURATION, AND LIMITED TISSUE DAMAGE
2
Q
CHRONIC/PERSISTENT NONCANCER PAIN
A
CONSTANT OR RECURRING PAIN THAT LASTS LONGER THAN 6 MONTHS, SEEMS TO SERVE NO PROTECTIVE PURPOSE AND MAY NOT HAVE AN INDENTIFIABLE CAUSE. IT YIELDS TO GREAT PERSONAL SUFFERING AND CAN BE DEBILITATING THOUGH IT IS NOT LIFE THREATENING
3
Q
CHRONIC EPISODIC PAIN
A
OCCURS OVER TIME IN UNPREDICTABLE EPISODES SUCH AS HEADACHES
4
Q
CANCER PAIN
A
OCCURS DUE TO ACUTE AND CHRONIC NOCICEPTIVE OR NEUROPATHIC REASONS. CANCER PAIN HAS BE FOUND TO BE SORELY UNDERTREATED BY HEALTH CARE PROFESSIONALS
5
Q
INFERRED PATHOLOGICAL PAIN
A
SOMATIC OR VISCERAL PAIN OF NOCICEPTIVE OR NEUROPATHIC NATURE DUE TO INTERNAL ORGAN PATHOLOGY OR DAMAGED NERVES
6
Q
IDIOPATHIC PAIN
A
CHRONIC PAIN IN THE ABSENCE OF AN IDENTIFIABLE CAUSE. THERE IS NO ABILITY TO SEE OR FEEL TISSUE DAMAGE AT THE SITE OF PAIN
7
Q
PHANTOM PAIN
A
PERCEPTIONS RELATED TO LIMB OR ORGAN THAT IS NOT PHYSICALLY PART OF THE BODY
8
Q
WHY PAIN IS BAD
A
CONFUSION
FALLS
IMMOBILITY (PNEUMONIA, SKIN BREAKDOWN, CLOTS)
POOR NUTRITION
DEHYDRATION
9
Q
WHY TREATING PAIN IS GOOD
A
HAPPIER WITH TREATMENT OUTCOMES
REGAIN MOBILITY
RETURN TO NORMAL ACTIVITIES
SHORTER HOSPITAL STAYS
FEWER DOCTOR VISITS
10
Q
SOCIOLOGICAL/CULTURAL FACTORS THAT INFLUENCE PAIN
A
- KNOWLEDGE, BELIEFS, ATTITUDES
- FAMILY/FRIENDS SUPPORT
- HOW PAIN SHOULD BE EXPRESSED- QUIET/STOIC
- PRIOR EXPERIENCES
- PRAYERS/CHAPLAIN/WHY ME- SPIRITUAL
11
Q
PHYSIOLOGICAL FACTORS INFLUENCING PAIN
A
- AGE
- PEDS HAVE DIFFICULTY EXPRESSING PAIN
- NOT A GENDER RESPONSE
- MAY HAVE GENETIC COMPONENT
- OLDER ADULTS MAY HAVE AGITATION, CONFUSION, LACK OF SLEEP, FATIGUE MAY WORSEN PAIN
12
Q
ATTENTION TO VS DISTRATION FROM PAIN
A
ATTENTION TO PAIN MAY HEIGHTEN IT WHILE DISTRACTION MAY EASE IT
13
Q
PSYCHOLOGICAL FACTORS INFLUENCING PAIN
A
ANXIETY
FEAR
COPING STYLE
14
Q
NUMERIC SCAL
A
0 = NO PAIN
10 = SEVERE PAIN
15
Q
FACES PAIN SCALE
A
GOOD FOR PEDS
POINT TO FACE
16
Q
OUCHER PAIN SCALE FOR CHILDREN
A
SHOW FACES, CHILD SHOULD CHOOSE FACE TO MATCH FEELINGS. EVEN CHILDREN LEARN CULTURAL EXPRESSION OF PAIN
17
Q
SYMPATHETIC NERVOUS SYSTEM
INITIAL ACUTE PAIN
AUTONOMIC NERVOUS SYSTEM
A
- FIGHT OR FLIGHT
- INCREASED HR, RR, BP
- PALLOR, DISPHORESIS
- INCREASED GLUCOSE
- PUPILLARY DILATION
- DECREASED GASTRIC MOBILITY
- MUSCLE TENSION
18
Q
PARASYMPATHETIC NERVOUS SYSTEM
CONTINUOUS, SEVERE PAIN
AUTONOMIC NERVOUS SYSTEM
A
- REST AND DIGEST
- DECREASED HR, RR, BP
- PALLOR, MUSCLE TENSION
19
Q
NEUMONIC FOR ASSESSING PAIN
A
PQRSTU
20
Q
P OF PQRSTU
A
Palliative or Provoking factors- what makes pain better or worse?
21
Q
Q OF PQRSTU
A
Quality– How do you describe your pain? Sharp, dull, throbbing, aching
22
Q
R OF PQRSTU
A
Region or Radiation of pain- show where you hurt? Does it spread to other areas?
23
Q
S OF PQRSTU
A
Severity (0-10)
24
Q
T OF PQRSTU
A
Timing- is pain intermittent or constant? When did it start & how long does it last?
25
U OF PQRSTU
U-Effect of pain on UR life and activities?
26
WHAT MUST YOU ALWAYS, ALWAYS DO WITH PAIN
*DOCUMENT, DOCUMENT, DOCUMENT- DOCUMENT your reassessment!
27
DISTRACTION
| Non-Pharm measures
ACTIVITIES
Guided Imagery, Relaxation, Music, Repositioning
28
BIOFEEDBACK
| Non-Pharm measures
person relaxes & decreases RR & HR, Herbals- anti-inflammatory or analgesics
29
HOLISTIC OPTIONS
| NON PHARM MEASURES
ACUPUNCTURE
CHIROPRACTOR
30
Cutaneous Stimulation-
| NON PHARM MEASURES
interfere w electrical energy in pain-Heat, ice, TENS, Massage
31
3 OPTIONS FOR ACUTE PAIN MANAGEMENT
NONOPIOID
ACETAMINOPHEN
ADJUVANT
32
Nonopioid:
| ACUTE PAIN MANAGEMENT
NSAIDs
SE- GI bleeding, renal insufficiency, HTN
Ex. Ibuprofen, ASA
33
ACETAMINOPHEN
| ACUTE PAIN MANAGEMENT
SE- Hepatotoxicity
Often in med combos
4 gm Max/Day
34
ADJUVANT
| ACUTE PAIN MANAGEMENT
Used to treat other conditions
Pair well w/ pain meds
Ex- antidepress., antianxiety, sedatives, corticosteroids
35
WHEN ARE OPIOIDS USED
FOR MODERATE TO SEVERE PAIN
36
WHAT SYSTEM DO OPIOIDS WORK ON
CNS
37
SIDE EFFECTS OF OPIOIDS
N&V
CONSIPATION- LONG LASTING SIDE EFFECT
ITCHING
URINARY RETENTION
ALTERED MENTAL STATUS
38
RESPIRATORY DEPRESSION WITH OPIOIDS
NAIVE PTS
WATCH FOR SEDATION
39
PASERO
OPIOID INDUCED SEDATION SCALE
AWAKE, ALERT TO SOMNOLENT
40
NARCAN
REVERSES OPIOID EFFECTS
MONITOR VS FREQUENTLY AFTER ADMIN BECAUSE IT HAS A SHORTER 1/2 LIFE
41
BASIC MEASUREMENT OF ALL NARCOTICS
MORPHINE
JUST LIKE GRAMS ARE THE BASIC MEASURE IN THE METRIC SYSTEM
42
Patient Controlled Analgesia (PCA)
Drug delivery system that permits patient to self administer opioids with minimal risk of overdose
43
HOW MIGHT PCA BE ADMINISTERED
SQ OR IV
44
WHO CONTROLS PCA
PATIENT PUSHES BUTTON
NOT NURSE
NOT FAMILY
45
TEACHING OF PCA
Patient must be taught to dose sooner rather than later
46
NURSE ROLE IN PCA
Nurse monitors system & assesses pain, monitors for over-sedation, respiratory depression
47
Pharmacological Therapies
TOPICAL ANALGESICS
LOCAL ANESTHESIA
REGIONAL ANESTHESIA
PERINEAL LOCAL ANESTHETIC
EPIDURAL ANALGESIA
48
TOPICAL ANALGESICS
| PHARMACOLOGICAL THERAPIES
CREAMS
OINTMENTS
PATCHES (NSAID PRODUCTS, CAPSAICIN)
49
LOCAL ANESTHESIA
LOCAL INFILTRATION OF AN ANESTHETIC MEDICATION TO INDUCE LOSS OF SENSATION TO A BODY PART
EXAMPLE: LIDODERM PATCH
50
REGIONAL ANESTHESIA
A PARTICULAR REGION OF THE BODY
51
PARINEURAL LOCAL ANESTHETIC INFUSION
BLOCK MOTOR AND SENSORY NERVES
52
EPIDURAL ANALGESIA
REGIONAL
ABDMINISTERED INTO EPIDURAL SPACE
53
WHY CAN'T WE USE NUMERICAL SCALE FOR YOUNGER PEDS
IT IS ABSTRACT FOR THEM. THEY CAN'T UNDERSTAND THE CONCEPT
54
WHO ARE THE EXPERTS WITH PAIN
| TIPS FOR EFFECTIVE PAIN MANAGEMENT
PATIENTS
55
WHO SHOULD YOU ESTABLISH A RELATIONSHIP OF TRUST WITH?
| TIPS FOR EFFECTIVE PAIN MANAGEMENT
PATIENT AND FAMILY
56
WHAT SHOULD WE AVOID LABELING PATIENTS AS
| TIPS FOR EFFECTIVE PAIN MANAGEMENT
DRUG SEEKING
57
HOW SHOULD DOSING BE SET UP FOR EFFECTIVE MANAGEMENT
Around the clock dosing can be more effective than PRN dosing since a steady blood serum is maintained
58
WHICH PAIN INTERVENTIONS SHOULD YOU DOCUMENT
NONPHARM AND PHARM
59
CONSTIPATION WITH PAIN MANAGEMENT
Constipation is a primary symptom that remains in long term opioid administration (Stimulant laxative preferred over stool softener)
60
PHYSICAL DEPENDENCE
| BARRIERS TO USE OF OPIOIDS
need for the drug to have pain relief. Withdrawal symptoms if med stopped abruptly- shaking, chills.
61
ADDICTION
| BARRIERS TO USE OF OPIOIDS
compulsive use or impaired use of a drug despite harmful effects or cravings. Addiction is rare in appropriate short term addiction use.
62
TOLERANCE
| BARRIERS TO USE OF OPIOIDS
need for higher dosage to receive the same pain relief result
63
PAIN BREAK THROUGH
| BARRIERS TO USE OF OPIOIDS
occurs when the amount of drug given is not sufficient for the level of pain experienced. It may be due to an increase in pathology or change in activity level.
64
HOW CAN CARE BE CONTINUED OUTSIDE OF THE HOSPITAL
PAIN CLINICS
PALLIATIVE CARE
HOSPICES
65
HOW DO PAIN CENTERS TREAT PATIENTS
ON AN INPATIENT OF OUTPATIENT BASIS
66
WHAT IS THE GOAL OF PALLIATIVE CARE
TO LEARN HOW TO LIVE LIFE FULLY WITH AN INCURABLE CONDITION
67
WHAT ARE HOSPICE PROGRAMS FOR
END OF LIFE CARE
TYPICALLY 6 MONTH PROGNOSIS OR LESS
68
"I JUST DON'T LIKE TO TAKE MEDS"
THINK ITS BAD- MUST EDUCATE
MUST TAKE AS PRESCRIBED
CULTURAL ISSUES
DON'T LIKE THE WAY IT MAKES THEM FEEL
69
ALLERGY VS ADVERSE REACTION
ALLERGY- CODEIN MAKES THROAT CLOSE UP
ADVERSE ACTION- N&V, ADDICTION, DON'T LIKE FEEL
70
PERCEPTIONS RELATED TO LIMB OF ORGAN THAT IS NOT PHYSICALLY PART OF THE BODY
A. IDIOPATHIC PAIN
B. CANCER PAIN
C. PHANTOM PAIN
D. ACUTE PAIN
C
71
MECHANISM THAT HAS AN IDENTIFIABLE CAUSE, IS OF SHORT DURATION, AND LIMITED TISSUE DAMAGE
A. ACUTE PAIN
B. EPISODIC PAIN
C. CHRONIC PAIN
D. CANCER PAIN
A
72
PAIN CAUSES
A. CONFUSION
B. FALLS
C. IMMOBILITY
D. ALL OF THE ABOVE
D
73
PAIN SCALE USED FOR CHILDREN
A. NUMERICAL
B. ANESTHESIAS SCALE
C. FACES
D. CHILDREN DON'T HAVE PAIN
C
74
WHAT MIGHT A PED PT SAY IF THEY ARE NAUSEATED
MY STOMACH HURTS OR DOESN'T FEEL GOOD
75
NONPHARM MEASURES FOR PAIN
A. MEDITATION
B. MASSAGE
C. ACUPUNCTURE
D. ALL OF THE ABOVE
D
76
HOW TO TIE NUMBERS OF PAIN SCALE TO WHAT THEY CAN UNDERSTAND
0 = NO PAIN
5 = MODERATE PAIN- MIGHT NEED MEDS, MIGHT NOT
10 = WORST PAIN EVER, LIKE STICKING HAND IN FIRE
*DOCUMENT WHAT THEY SAY REGARDLESS
77
WHY DO WE NEED VERBAL DISCRIPTION OF PAIN
WE WANT AS MUCH INFO ABOUT PAIN AS WE CAN
78
FLACC SCALE
NONVERBAL
ICU
ANESTHESIA
GRIMACING, MOANING, GRUNTING
79
MAX DOSE OF ACETAMINOPHEN FOR ADULTS
A. 2 G/D
B. 1 G/D
C. 4 G/D
D. 5 G/D
C
BUT REALLY 3 G/D IS SAFER
80
OPIOIDS ARE FOR MODERATE TO SEVERE PAIN
| TRUE OR FALSE
TRUE
81
DIARRHEA IS A SIDE EFFECT OF OPIOID USE
| TRUE OR FALSE
FALSE
82
WHO CAN PUSH THE PCA BUTTON
A. NURSE
B. FAMILY
C. DOCTOR
D. PATIENT
D
83
END OF LIFE PROGRAMS ARE REFERRED TO AS
A. HOME HEALTH
B. HOSPICE
C. NURSING HOME
D. ASSISTED LIVING
B
84
85
WHEN SHOULD YOU REEVALUATE AFTER GIVING PAIN MEDS
30 MINUTES
86
WHAT HAPPENS IF IT WASN'T DOCUMENTED
IT WASN'T DONE
87
88
WHO WOULDN'T GET NSAIDS
BLEEDING DISORDERS
ON BLOOD THINNERS OR ASPIRIN
89
CONCERNS WITH TYLENOL
COLD MEDS
COMBO MEDS
LIVER ISSUES
90
91
WHAT PAIRS WELL WITH PAIN MEDS
ANTIDEPRESSANTS
ANTIANXIETY
92
USES FOR ANTIDEPRESSANTS
DEPRESSION
PAIN
INSOMNIA
*ASK WHY THEY ARE TAKING THE MED
93
Pressure injury
localized damage to the skin or underlying tissue resulting from prolonged pressure and/or friction to the skin, predominately occurring over the bony prominences
94
NPUAP
NATIONAL PRESSURE ULCER ADVISORY PANEL
95
HOW LONG DOES IT TAKE FOR A PRESSURE INJURY TO BEGIN
WITHIN 2 HOURS WHICH IS WHY WE TURN THEM AT LEAST EVERY 2 HOURS
96
WHAT CAUSES A PRESSURE INJURY
BLOOD FLOW IS LOST LIKE PINCHING A STRAW WHEN VASCULAR IS PINCHED
97
WHAT DOES NPUAP DO
NATIONALLY STANDARDIZE PRESSURE WOUND TERMINOLOGY. DOESN'T MATTER FACILITY, IT'S THE SAME. THEY ALSO STANDARDIZE STAGING, DEFINITIONS, REPORTING METHODS.
98
NOVEMBER 15
NATIONAL STOP PRESSURE INJURY DAY
99
Why do you think it is important to have a committee that standarizes how we assess, document and identify wounds
WE NEED TO KNOW WHAT WE ARE LOOKING AT
100
INSURANCE REIMBURSEMENT
| PRESSURE INJURY
DOESN'T PAY IF THEY DIDN'T COME IN WITH IT. THIS AFFECTS YOUR BOTTOM LINE.
101
HOW CAN SOMEONE DIE FROM A PI
SEPSIS- INFECTION IN BLOOD
102
MEDICAL STAFF
| PI
MORE WORK ON YOU
103
COST TO HEAL
| PI
9.1 BILL PER YEAR IN THE US ON WOUND HEALING
10.20K-151K /WOUND
11.MORE THAN 17000 LAWSUITS PER YEAR
104
WHAT MEDICATION IS USED MOST ON PI
SILVER
Ag
105
WHY SO MANY PI LAWSUITS
PREVENTABLE
EVERY WOUND IS TO A DEGREE
106
When looking in the patient's chart, there was no documentation stating the patient arrived at the hospital with a wound to the left heel.
What ramifications will the hospital have?
FINANCIAL RESPONSIBLE
LAWSUIT
INFECTION
107
When looking in the patient's chart, there was no documentation stating the patient arrived at the hospital with a wound to the left heel.
What will the insurance company pay for?
NO
108
ELDERLY
| AT RISK FOR PI
THIN SKIN
DECREASED HYDRATION, ELASTICITY, CIRCULATION, IMMUNE SYSTEM. MORE SEDENTARY.
109
POOR HEALTH/COMORBIDITIES
| RISK FOR PI
SENSORY ISSUES, NEUROPATHY (PAIN OR NUMBNESS), ALTERED LOC (MEDICATIONS, TBI, ACCIDENT, DEMENTIA), INCONTINENCE (ELDERLY, CHILDREN, BUT COULD BE YOUNGER ADULT), POOR NUTRITION (TEETH PROBLEMS- ELDERLY)
110
IMMOBILITY AND SPINAL INJURY
| RISK FOR PI
FRICTION AND SHEAR OF OTHERS MOVING THEM
111
BABIES
| RISK FOR PI
HEAD- NICU OR NEGLECT
112
BRADEN SCALE
TOOL USED TO PREDICT/PREVENT PI
113
CATEGORIES OF BRADEN SCALE
MOBILITY, NUTRITION, FRICTION, MOISTURE, ACTIVITY
114
MOBILITY
| BRADEN SCALE
BEDFAST, CHAIRFAST, WALKS OCCASIONALLY, WALKS FREQUENTLY
115
NUTRITION
| BRADEN SCALE
POOR, INADEQUATE, ADEQUATE, EXCELLENT
*EAT MORE PROTEIN
116
FRICTION
| BRADEN SCALE
PROBLEM, POTENTIAL PROBLEM, NO PROBLEM
117
MOISTURE
| BRADEN SCALE
CONSTANTLY, VERY MOIST, OCCASSIONALLY MOIST, RARELY
118
ACTIVITY
| BRADEN SCALE
COMPLETELY LIMITED, VERY, SLIGHTLY, NO IMPAIRMENT
118
95-year-old female who eats 20% of each meal, on bed rest and continent of urine
| RISK FACTORS
MOBILITY
POOR NUTRITION
AGE- SKIN INTEGRITY
119
LOWER BRADEN SCORE EQUALS
higher the risk (less than 9 extremely high)
120
24-year-old male who eats 95% of each meal, unable to walk due to paralyzation to left side, on oxygen via nasal cannula, A&O x 1 (self)
LOC
MOBILITY
NC- NOSE/EARS
121
2-week-old infant in NICU receiving treatment for gastrointestinal and cardiac congenital disorders
NUTRITION- SHOULD BE OKAY WITH NGT
MOBILITY
COMORBIDITIES- PERFUSION/CIRCULATION, SURGICAL SITES
122
54-year-old CHF patient receiving chemotherpy, continent of B&B, inability to transfer self, due to increased weakness from chemo treatment
CIRCULATION
WEAKENED IMMUNE SYSTEM
SHEARING/MOBILITY
123
BRADEN SCALE SCORE OVERVIEW
6-23 SCALE: Scale of 1-4 in each category, friction 1-3
124
PREVENTION OF PI
ASSESSMENT- BEHIND EARS, BETWEEN TOES, SKIN FOLDS ARE OFTEN MISSED
2. POSITION/TURN Q2H
3. SUPPORT PILLOWS/MATTRESSES, SEAT CUSHIONS
4. SKIN CARE- CLEAN, DRY, PERICARE IS CRITICAL
5. EXERCISE- UP AND MOVING FOR CIRCULATION
6. IMPROVED NUTRITION- ENCOURAGE- DON'T SIT TRAY DOWN AND LEAVE
7. PROMPT CARE FOR INCONTINENT PATIENTS- CHECK Q2H
125
Signs of Possible PI
Redness that won’t blanch
Darkened areas on skin
Warm skin areas
Purple, blue or shiny skin
126
AT FIRST SIGN OF A PI, WHAT SHOULD YOU DO
RELIEVE PRESSURE FOR 30 MINUTES AND REEVALUATE
127
Commonly Missed Assessment Areas
Nasal area and behind the ears- especially with patient is using O2
Back of the head
Heels
Shoulder blades and shoulders
Tips of toes and ankles
CHECK THE ENTIRE BODY
128
Name three ways to prevent pressure injuries.
1. TURNING Q2H OR MORE
2. ENCOURAGE AMBULATION AND ROM
3. SKIN CARE- CLEAN, DRY
129
What does non-blanchable mean?
DOESN'T TURN WHITE AND BACK RED... NO COLOR CHANGE
130
Name 2 indicators of a possible PI
NON BLANCHABLE
ERYTHEMA
SHINY
131
Name 3 commonly missed areas when assessing for PI's.
BETWEEN TOES
ANKLES
EARS
132
WHY IS STANDARDIZATION OF CRITERIA IMPORTANT FOR STAGING WOUNDS
THEY VARY IN SIZE AND SHAPE
IT'S IMPORTANT FOR HOLISTIC CARE
133
SKIN INTEGRITY
| HOW TO STAGE WOUNDS
INTACT OR OPEN
134
SKIN COLOR
| HOW TO STAGE WOUND
IN COMPARISON TO NORMAL/HEALTHY SKIN
135
DEPTH OF AREA
| HOW TO STAGE WOUNDS
HOW DEEP IS THE WOUND
136
STAGE 1 WOUND
NON- BLANCHING
ERYTHEMA
INTACT SKIN
CHANGES IN SENSATION, TEMP, OR FIRMNESS
NOT PURPLE OR MAROON
*RELIEVE PRESSURE FOR 30 MIN AND REEVALUATE
137
STAGE 2 WOUNDS
PARTIAL LOSS OF EPIDERMIS
EXPOSING DERMIS
WOUND BED VIABLE, PINK, OR RED
BLISTER- OPEN OR CLOSED
SHOULD NOT BE BLEEDING UNLESS YOU ARE WIPING THEM HARD
138
WHAT IS NOT INCLUDED AS A STAGE 2 WOUND
MEDICAL ADHESIVE RELATED SKIN INJURY (MARSI)
DERMATITIS
TRAUMATIC WOUNDS (BURNS, SKIN TEARS, ABRASIONS)
SURGICAL SITE
139
STAGE 3 WOUND
FULL THICKNESS SKIN LOSS
ADIPOSE TISSUE IS PRESENT (WHITE)
EDGES CAN HAVE EPIBOLE
IF SLOUGH AND ESCHAR- ONLY AT SIDES
WATCH FOR UNDERMINING AND TUNNELING
140
IF YOU CAN'T SEE THE BASE OF A WOUND, IS IT STAGE 3
NO
141
EPIBOLE EDGES
ROLLED EDGES
NOT GOOD FOR HEALING TIME
142
SLOUGH
YELLOW AND TAN
143
ESCHAR
BLACK OR BROWN
144
WHAT WILL NOT BE SEEN IN A STAGE 3 WOUND
MUSCLE, TENDON, AND LIGAMENTS
CARTILAGE AND BONE
145
STAGE 4 WOUND
FULL THICKNESS AND TISSUE LOSS
MUSCLE, TENDONS, LIGAMENTS AND OR BONES VISIBLE OR PALPABLE
SLOUGH AND/OR ESCHAR VISIBLE COVERING WOUND
UNDERMINING AND TUNNELING IS COMMON
146
WHAT STAGE IS AN ANKLE PRESSURE WOUND AUTOMATICALLY CLASSIFIED AS
STAGE 4
147
UNSTAGEABLE WOUND
FULL THICKNESS AND TISSUE LOSS WITH SUCHA GREAT AMOUNT OF SLOUGH THAT A DETERMINATION CANNOT BE ACCURATELY MADE WITHOUT DEBRIDEMENT AS TO THE DEPTH
148
UNDERMINING
WOUND CONTINUES UP UNDER THE LIP AROUND THE WOUND
149
Deep Tissue Injury
Bone and muscle have had extensive friction
Blood filled blister
Intact skin with darkened area on non-blanching area
Opens – usually goes to a 3-4 (don’t cover it with any kind of dressing- skin prep it)
Can heal, if it opens it will take lots of money and time to heal
150
SIMPLY PUT-STAGE 1
Non-blanching redness with skin intact
151
SIMPLY PUT STAGE 2
OPEN AREA, NO FAT SHOWING
152
SIMPLY PUT STAGE 3
OPEN AREA WITH FAT SHOWING
153
SIMPLY PUT STAGE 4
OPEN AREA WITH MUSCLE, TENDON, OR BONE SHOWING OR PALPABLE
154
SIMPLY PUT UNSTAGEABLE WOUND
CANNOT SEE THE BOTTOM OF THE OPEN WOUND TO DETERMINE STAGE
155
SIMPLY PUT DEEP TISSUE INJURY
INTACT SKIN WITH DISCOLORATION RELATED TO A BLOOD FILLED BLISTER
156
WHAT IS DRAINAGE
LIQUID EXCRETED FROM A WOUND
LIQUID INSIDE OF WOUND
INDICATOR OF WOUND HEALTH
157
WHY DO WE NEED TO LOOK AT WOUND DRAINAGE
IT'S THE WOUND VS. IT TELLS US HOW HEALTHY OUR WOUND IS
158
SEROUS
| DRAINAGE TYPE
1. CLEAR WATER DRAINAGE
2. THIS IS A GOOD SIGN
3. SUGARS, PROTEINS, AND WBC THAT ARE VITAL TO THE HEALING PROCESS
159
SEROSANGUINEOUS
| DRAINAGE TYPES
1. PINK, WATERY DRAINAGE WITH RED FLUID
2. THICK CONSISTENCY- SYRUP
3. INDICATES GOOD CIRCULATION
4. INDICATIVE OF RECENT DAMAGE TO VESSELS
160
WET TO DRY DRAINAGE
1. WET DRESSING, PUT IT IN THE WOUND, COVER, PULL IT OUT DRY TO DRIBRIDE
2. GENERALLY MEDS 30 MIN PRIOR TO DRESSING CHANGES
161
SANGUINEOUS
| DRAINAGE TYPE
BRIGHT RED
2. GOOD SIGN- BLOOD FLOW
3. WOUND IS ACTIVELY BLEEDING
162
PURULENT
| WOUND DRAINAGE
1. THICK YELLOW, GREEN, OR BROWN COLORED
2. NOT NORMAL HEALING PROCESS
3. INDICATIVE OF INFECTION
4. CONTAINS DEAD BACTERIA
163
WHAT COLOR IS SEROUS DRAINAGE
CLEAR, WATERY PLASMA
164
WHAT COLOR IS PURULENT DRAINAGE
THICK, YELLOW, GREEN, TAN, BROWN
165
WHAT COLOR IS SEROSANGUINEOUS
PALE, RED, WATERY, MISCURE OF SEROUS AND SANGUINEOUS
166
WHAT COLOR IS SANGUINEOUS DRAINAGE
BRIGHT RED, INDICATES ACTIVE BLEEDING
167
What is green and yellow drainage called?
PURULENT
168
What is bright red drainage called?
SANGUINEOUS
169
What does clear drainage contain in a wound?
SUGARS, PROTEINS, AND WBC
170
S/S THAT ARE INDICATIVE OF INFECTION
Feelings of malaise
Low grade fever – or – fever
Fluid drainage
Increased or continual pain
Redness or swelling
Hot incision site
ODOR
171
WHERE SHOULD YOU START WHEN CLEANING A WOUND
START AT THE LEAST CONTAMINATED AREA
172
WHAT DIRECTION DO YOU CLEAN A WOUND
Clean outwards
NEVER pull contamination into the wound
173
WHAT PRESSURE SHOULD YOU USE WHEN CLEANING A WOUND
Don't Use friction- but be gentle
174
WHAT DIRECTION TO IRRIGATE A WOUND
Irrigating-let flow from least contaminated
175
HOW MANY TIMES CAN YOU USE A Q TIP WHEN CLEANING A WOUND
1 SWIPE... THEN IT'S CONTAMINATED
176
Cleaning staples/sutures
Start at the staple area and move outward- one swipe
177
NURSES AND PROVIDERS ARE RESPONSIBLE FOR
| Sterile Dressing Changes
REMOVING APPLYING OR CHANGING ALL DRESSINGS
178
WHO CAN DO DRESSING CHANGES
NURSE/PROVIDER
CANNOT DELEGATE TO PCT/CNA BECAUSE REQUIRE ASSESSMENT
PCT/CNA CAN ASSIST BUT NOT PERFORM ALONE
179
Aseptic Dressing Changes
Also called "clean" technique
Follow all policy procedures for replacing dressings
Tell patient what is happening- step by step
Medicate for pain 30 minutes prior
180
IF A DRESSING IS STUCK, WHAT SHOULD YOU DO
moisten with sterile water or normal saline to loosen
181
Steps to Changing a Dressing
| FIRST STEPS
Hand hygiene
Ensure patient is comfortable
Don gloves
Remove dressing- observe wound, note drainage (amount, color, odor)
Biohazard bag
182
STEPS TO CHANGING A DRESSING
| SECOND STEPS
Doff gloves and hand hygiene
Prepare aseptic area
Open sterile gauze
Saturate with sterile water
183
STEPS TO CHANGING A DRESSING
| LAST STEPS
Clean wound
Observe wound- size, depth, odor and color
Apply dressing
Dispose of materials used
Doff gloves
Hand hygiene
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NEVERS
| WOUND MANAGEMENT
Clean over the same area twice with the same gauze or pad
Wipe towards the wound
Let irrigation fluid run from contaminated to non-contaminated
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GAUZE
| DRESSING TYPE
PACKING OR COVERING
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TRANSPARENT FILM
| DRESSING TYPES
Awkward locations
Provide a moist healing environment
Prevent friction
Act as a second skin
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HYDROCOLLOID
| Types of Dressings
Acts like gelatin- sucks out fluids and forms a gel
Used in granulating (healing)
Not for highly draining wounds
Impermeable – bacteria cannot get in
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HYDROGEL
| Types of Dressings
Provide pain relief
Sometimes used to remove dead skin (Santyl)
Protects from infection
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FOAM DRESSING
| TYPES OF DRESSING
Protective barrier
Used on reddened areas to prevent breakdown
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IMPORTANCE OR READING ORDERS
Be sure to read orders completely and follow orders from wound care
YOU ARE LIABLE IF YOU DON'T DO WHAT THE ORDERS SAY OR DO THINGS NOT IN THE ORDERS
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PREPARING FOR THE DRESSING CHANGE
Read notes on previous dressing change
Gather supplies prior
ASK QUESTIONS!!!!
Understand normal healing signs
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WHY DO WE NEED TO UNDERSTAND NORMAL HEALING SIGNS
Will recognize what is abnormal in the healing process
Report abnormal changes immediately
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DEHISCENCE
SURGICAL WOUND REOPENS
194
EVISCERATION
ORGANS PROTRUDING- YOUR ORGANS FELL OUT
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PRESSURE ULCERS
Pressure sore, decubitus ulcer, or bed sore.
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PATHOGENESIS OF PRESSURE ULCERS
PRESSURE INTENSITY
PRESSURE DURATION
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PRESSURE INTENSITY
TISSUE ISCHEMIA
BLANCHING
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TISSUE ISCHEMIA
If pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time, tissue ischemia occurs. If left untreated, tissue death results.
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BLANCHING
occurs when the normal red tones of skin are absent.
200
PRESSURE DURATION
Low pressures over a prolonged time can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death.
201
Any patient who is (WHAT) is at risk for pressure ulcer development.
experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition
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IMPAIRED SENSORY PERCEPTION
| RISK FACTORS FOR PI
cannot feel their body sensations.
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IMPAIRED MOBILITY
| RISK FACTORS FOR PI
unable to independently change position are at risk/cannot change or shift off of bony prominences.
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ALTERATION IN LOC
| RISK FACTORS FOR PI
UNABLE TO PROTECT THEMSELVES
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SHEAR
| RISK FACTORS FOR PI
the force exerted parallel to skin, resulting from both gravity pushing down on the body and resistance (friction) between the patient and a surface.
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FRICTION
| RISK FACTORS FOR PI
the force of two surfaces moving across one another.
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MOISTURE
| RISK FACTORS FOR PI
causes skin breakdown
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STAGE 1
| Classification of Pressure Ulcers
Intact skin with nonblanchable redness
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STAGE 2
| Classification of Pressure Ulcers
Partial-thickness skin loss involving epidermis, dermis, or both
shallow in depth, moist and painful, and the wound base generally appears red
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STAGE 3
| Classification of Pressure Ulcers
Full-thickness tissue loss with visible fat
extends into the subcutaneous layer, and the depth and tissue type will vary depending on body location
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STAGE 4
| Classification of Pressure Ulcers
Full-thickness tissue loss with exposed bone, muscle, or tendon
extends into the subcutaneous layer, and the depth and tissue type will vary depending on body location
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PRIMARY INTENTION
| Process of Wound Healing
Edges are approximated- “closed” and the risk of infection is lowered. Ex. Surgical incision.
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SECONDARY INTENTION
| Process of Wound Healing
wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. If scarring from secondary intention is severe, loss of tissue function is often permanent.
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Partial-thickness wound repair:
inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers
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FULL THICKNESS WOUND REPAIR
HEMOSTASIS, INFLAMMATORY PROLIFERATIVE AND MATURATION
216
Hemostasis-
| FULL THICKNESS WOUND REPAIR
injured blood vessels constrict, platelets gather to stop bleeding.
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INFLAMMATORY
| FULL THICKNESS WOUND REPAIR
THIS RESPONSE IS BENEFICIAL. REDNESS WARMTH AND THROBBING (LOCALIZED)
218
PROLIFERATIVE
| FULL THICKNESS WOUND REPAIR
filling the wound with granulation tissue (red, moist and composed of new vessels), wound retraction and wound resurfacing
219
MATURATION
| FULL THICKNESS WOUND REPAIR
can take place for more than a year. Consists of collagen scarring.
220
HEMATOMA
1. HEMORRHAGE
2. LOCALIZED COLLECTION OF BLOOD UNDERNEATH THE TISSUES
221
second most common health care–associated infection.
Infection-
222
S/S OF AN INFECTED WOUND
: erythema, increased amount of wound drainage, and change in appearance of the wound drainage (thick, color change, presence of odor), periwound warmth, pain, or edema.
223
Dehiscence- .
partial or total separation of wound layers
“tearing/opening”-sensation
224
Evisceration-
total separation of wound layers.
225
Medicare and Medicaid:
| PI
no additional reimbursement for care related to stage III and stage IV pressure ulcers that occur during the hospitalization
226
RISK ASSESSMENT- BRADEN SCALE
developed based on risk factors in a nursing home population and is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development.
227
Factors Influencing Pressure Ulcer Formation and Wound Healing
NUTRITION
TISSUE PERFUSION
INFECTION
AGE
PSYCHOSOCIAL IMPACT OF WOUNDS
228
PREDICTIVE MEASURES
| PRESSURE ULCERS
BRADEN SCALE
229
NUTRITIONAL STATUS
Malnutrition is a risk factor for pressure ulcer development.
230
PAIN
| PRESSURE ULCERS
maintaining adequate pain control and patient comfort increases the patient’s willingness and ability to increase mobility, which in turn reduces pressure ulcer risk.
231
Drains-
emptying. Note frequency of drainage.
232
DOCUMENTATION OF WOUNDS
Character of wound drainage- note amount, odor, color and consistency.
233
WOUND APPEARANCE
should be assessed on an ongoing basis.
234
WOUNDS IN A STABLE SETTING
provider may choose to change the first surgical dressing and provide the 1st dressing change.
235
Wound closures-
staples, sutures or wound adhesives for surgical incisions.
236
Palpation of wound-
observe for swelling and separation of edges.
237
Wound cultures-
must be collected from fresh drainage.
Gram stains
Biopsy
238
HEALTH PROMOTION
Prevention of pressure ulcers
Topical skin care and incontinence management
Positioning
Support surfaces
239
Wound management
DEBRIDEMENT
EDUCATION
NUTRITIONAL STATUS
PROTEIN STATUS
HEMOGLOBIN
240
DEBRIDEMENT
removal of nonviable, necrotic tissue.
241
PROTEIN STATUS
| ACUTE CARE WOUND MANAGEMENT
A patient can lose as much as 50 g of protein per day from an open, weeping pressure ulcer. Need protein supplementation.
242
HEMOGLOBIN
| ACUTE CARE WOUND MANAGEMENT
low hemoglobin level decreases delivery of oxygen to the tissues and leads to further ischemia.
243
HEMOSTASIS
| FIRST AID FOR WOUNDS
Control bleeding.
Allow puncture wounds to bleed. (to remove dirt and contaminants).
Do not remove a penetrating object. (this helps to control bleeding).
Bandage
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CLEANING
| FIRST AID FOR WOUNDS
1. GENTLE
2. NORMAL SALINE
3. PROTECTION
245
SECURING DRESSINGS
Tape
Ties
Binders
Always date, time & initial!
246
TYPES OF DRESSINGS
Gauze
Transparent film
Hydrocolloid
Hydrogel
Foam
Composite
247
BEFORE A DRESSING CHANGE, WHAT SHOULD YOU KNOW
Know type of dressing, placement of drains, and equipment needed.
248
PREPARING FOR A DRESSING CHANGE
Review previous wound assessment.
Evaluate pain and, if indicated, administer analgesics so peak effects occur during dressing change.
Describe procedure steps to lessen patient anxiety.
Gather all supplies.
Recognize normal signs of healing.
Answer questions about the procedure or wound.
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Packing a wound
Negative-pressure wound therapy- vacuum assisted closure.
250
CLEANING SKIN AND DRAIN SITES
Clean from least contaminated to the surrounding skin.
Use gentle friction.
When irrigating, allow the solution to flow from the least to most contaminated area.
251
Suture care-
Policies vary within institutions as to who is able to remove sutures.
252
Staples-
removed with staple remover
253
A postoperative patient arrives at an ambulatory care center and states, “I am not feeling good.” Upon assessment, you note an elevated temperature. An indication that the wound is infected would be:
A. it has no odor.
B. a culture is negative.
C. the edges reveal the presence of fluid.
D. it shows purulent drainage coming from the incision site.
D
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The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges:
A. are approximated.
B. migrate across the incision.
C. appear slightly pink.
D. slightly overlap each other.
Answer: A
Rationale: A clean surgical incision is an example of a wound with little tissue loss. The surgical incision heals by primary intention. The skin edges are approximated, or closed, and the risk of infection is low.
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UNDERSTANDING PRESSURE INJURY
https://www.youtube.com/watch?v=xNH8DDvjSME
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