EXAM 4 Flashcards
PAIN, SKIN INTEGRITY, WOUND, NUTRITION, POST MORTEM, HIPAA, PHYSIOLOGY, OSTOMY, NG, ENTERNAL TUBE FEEDING, CENTRAL VENOUS WEEKS 10-13
ACTURE/TRANSIENT PAIN
PROTECTIVE MECHANISM THAT HAS AN IDENTIFIABLE CAUSE, IS OF SHORT DURATION, AND LIMITED TISSUE DAMAGE
CHRONIC/PERSISTENT NONCANCER PAIN
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
CHRONIC EPISODIC PAIN
OCCURS OVER TIME IN UNPREDICTABLE EPISODES SUCH AS HEADACHES
CANCER PAIN
OCCURS DUE TO ACUTE AND CHRONIC NOCICEPTIVE OR NEUROPATHIC REASONS. CANCER PAIN HAS BE FOUND TO BE SORELY UNDERTREATED BY HEALTH CARE PROFESSIONALS
INFERRED PATHOLOGICAL PAIN
SOMATIC OR VISCERAL PAIN OF NOCICEPTIVE OR NEUROPATHIC NATURE DUE TO INTERNAL ORGAN PATHOLOGY OR DAMAGED NERVES
IDIOPATHIC PAIN
CHRONIC PAIN IN THE ABSENCE OF AN IDENTIFIABLE CAUSE. THERE IS NO ABILITY TO SEE OR FEEL TISSUE DAMAGE AT THE SITE OF PAIN
PHANTOM PAIN
PERCEPTIONS RELATED TO LIMB OR ORGAN THAT IS NOT PHYSICALLY PART OF THE BODY
WHY PAIN IS BAD
CONFUSION
FALLS
IMMOBILITY (PNEUMONIA, SKIN BREAKDOWN, CLOTS)
POOR NUTRITION
DEHYDRATION
WHY TREATING PAIN IS GOOD
HAPPIER WITH TREATMENT OUTCOMES
REGAIN MOBILITY
RETURN TO NORMAL ACTIVITIES
SHORTER HOSPITAL STAYS
FEWER DOCTOR VISITS
SOCIOLOGICAL/CULTURAL FACTORS THAT INFLUENCE PAIN
- KNOWLEDGE, BELIEFS, ATTITUDES
- FAMILY/FRIENDS SUPPORT
- HOW PAIN SHOULD BE EXPRESSED- QUIET/STOIC
- PRIOR EXPERIENCES
- PRAYERS/CHAPLAIN/WHY ME- SPIRITUAL
PHYSIOLOGICAL FACTORS INFLUENCING PAIN
- 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
ATTENTION TO VS DISTRATION FROM PAIN
ATTENTION TO PAIN MAY HEIGHTEN IT WHILE DISTRACTION MAY EASE IT
PSYCHOLOGICAL FACTORS INFLUENCING PAIN
ANXIETY
FEAR
COPING STYLE
NUMERIC SCAL
0 = NO PAIN
10 = SEVERE PAIN
FACES PAIN SCALE
GOOD FOR PEDS
POINT TO FACE
OUCHER PAIN SCALE FOR CHILDREN
SHOW FACES, CHILD SHOULD CHOOSE FACE TO MATCH FEELINGS. EVEN CHILDREN LEARN CULTURAL EXPRESSION OF PAIN
SYMPATHETIC NERVOUS SYSTEM
INITIAL ACUTE PAIN
AUTONOMIC NERVOUS SYSTEM
- FIGHT OR FLIGHT
- INCREASED HR, RR, BP
- PALLOR, DISPHORESIS
- INCREASED GLUCOSE
- PUPILLARY DILATION
- DECREASED GASTRIC MOBILITY
- MUSCLE TENSION
PARASYMPATHETIC NERVOUS SYSTEM
CONTINUOUS, SEVERE PAIN
AUTONOMIC NERVOUS SYSTEM
- REST AND DIGEST
- DECREASED HR, RR, BP
- PALLOR, MUSCLE TENSION
NEUMONIC FOR ASSESSING PAIN
PQRSTU
P OF PQRSTU
Palliative or Provoking factors- what makes pain better or worse?
Q OF PQRSTU
Quality– How do you describe your pain? Sharp, dull, throbbing, aching
R OF PQRSTU
Region or Radiation of pain- show where you hurt? Does it spread to other areas?
S OF PQRSTU
Severity (0-10)
T OF PQRSTU
Timing- is pain intermittent or constant? When did it start & how long does it last?
U OF PQRSTU
U-Effect of pain on UR life and activities?
WHAT MUST YOU ALWAYS, ALWAYS DO WITH PAIN
*DOCUMENT, DOCUMENT, DOCUMENT- DOCUMENT your reassessment!
DISTRACTION
Non-Pharm measures
ACTIVITIES
Guided Imagery, Relaxation, Music, Repositioning
BIOFEEDBACK
Non-Pharm measures
person relaxes & decreases RR & HR, Herbals- anti-inflammatory or analgesics
HOLISTIC OPTIONS
NON PHARM MEASURES
ACUPUNCTURE
CHIROPRACTOR
Cutaneous Stimulation-
NON PHARM MEASURES
interfere w electrical energy in pain-Heat, ice, TENS, Massage
3 OPTIONS FOR ACUTE PAIN MANAGEMENT
NONOPIOID
ACETAMINOPHEN
ADJUVANT
Nonopioid:
ACUTE PAIN MANAGEMENT
NSAIDs
SE- GI bleeding, renal insufficiency, HTN
Ex. Ibuprofen, ASA
ACETAMINOPHEN
ACUTE PAIN MANAGEMENT
SE- Hepatotoxicity
Often in med combos
4 gm Max/Day
ADJUVANT
ACUTE PAIN MANAGEMENT
Used to treat other conditions
Pair well w/ pain meds
Ex- antidepress., antianxiety, sedatives, corticosteroids
WHEN ARE OPIOIDS USED
FOR MODERATE TO SEVERE PAIN
WHAT SYSTEM DO OPIOIDS WORK ON
CNS
SIDE EFFECTS OF OPIOIDS
N&V
CONSIPATION- LONG LASTING SIDE EFFECT
ITCHING
URINARY RETENTION
ALTERED MENTAL STATUS
RESPIRATORY DEPRESSION WITH OPIOIDS
NAIVE PTS
WATCH FOR SEDATION
PASERO
OPIOID INDUCED SEDATION SCALE
AWAKE, ALERT TO SOMNOLENT
NARCAN
REVERSES OPIOID EFFECTS
MONITOR VS FREQUENTLY AFTER ADMIN BECAUSE IT HAS A SHORTER 1/2 LIFE
BASIC MEASUREMENT OF ALL NARCOTICS
MORPHINE
JUST LIKE GRAMS ARE THE BASIC MEASURE IN THE METRIC SYSTEM
Patient Controlled Analgesia (PCA)
Drug delivery system that permits patient to self administer opioids with minimal risk of overdose
HOW MIGHT PCA BE ADMINISTERED
SQ OR IV
WHO CONTROLS PCA
PATIENT PUSHES BUTTON
NOT NURSE
NOT FAMILY
TEACHING OF PCA
Patient must be taught to dose sooner rather than later
NURSE ROLE IN PCA
Nurse monitors system & assesses pain, monitors for over-sedation, respiratory depression
Pharmacological Therapies
TOPICAL ANALGESICS
LOCAL ANESTHESIA
REGIONAL ANESTHESIA
PERINEAL LOCAL ANESTHETIC
EPIDURAL ANALGESIA
TOPICAL ANALGESICS
PHARMACOLOGICAL THERAPIES
CREAMS
OINTMENTS
PATCHES (NSAID PRODUCTS, CAPSAICIN)
LOCAL ANESTHESIA
LOCAL INFILTRATION OF AN ANESTHETIC MEDICATION TO INDUCE LOSS OF SENSATION TO A BODY PART
EXAMPLE: LIDODERM PATCH
REGIONAL ANESTHESIA
A PARTICULAR REGION OF THE BODY
PARINEURAL LOCAL ANESTHETIC INFUSION
BLOCK MOTOR AND SENSORY NERVES
EPIDURAL ANALGESIA
REGIONAL
ABDMINISTERED INTO EPIDURAL SPACE
WHY CAN’T WE USE NUMERICAL SCALE FOR YOUNGER PEDS
IT IS ABSTRACT FOR THEM. THEY CAN’T UNDERSTAND THE CONCEPT
WHO ARE THE EXPERTS WITH PAIN
TIPS FOR EFFECTIVE PAIN MANAGEMENT
PATIENTS
WHO SHOULD YOU ESTABLISH A RELATIONSHIP OF TRUST WITH?
TIPS FOR EFFECTIVE PAIN MANAGEMENT
PATIENT AND FAMILY
WHAT SHOULD WE AVOID LABELING PATIENTS AS
TIPS FOR EFFECTIVE PAIN MANAGEMENT
DRUG SEEKING
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
WHICH PAIN INTERVENTIONS SHOULD YOU DOCUMENT
NONPHARM AND PHARM
CONSTIPATION WITH PAIN MANAGEMENT
Constipation is a primary symptom that remains in long term opioid administration (Stimulant laxative preferred over stool softener)
PHYSICAL DEPENDENCE
BARRIERS TO USE OF OPIOIDS
need for the drug to have pain relief. Withdrawal symptoms if med stopped abruptly- shaking, chills.
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.
TOLERANCE
BARRIERS TO USE OF OPIOIDS
need for higher dosage to receive the same pain relief result
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.
HOW CAN CARE BE CONTINUED OUTSIDE OF THE HOSPITAL
PAIN CLINICS
PALLIATIVE CARE
HOSPICES
HOW DO PAIN CENTERS TREAT PATIENTS
ON AN INPATIENT OF OUTPATIENT BASIS
WHAT IS THE GOAL OF PALLIATIVE CARE
TO LEARN HOW TO LIVE LIFE FULLY WITH AN INCURABLE CONDITION
WHAT ARE HOSPICE PROGRAMS FOR
END OF LIFE CARE
TYPICALLY 6 MONTH PROGNOSIS OR LESS
“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
ALLERGY VS ADVERSE REACTION
ALLERGY- CODEIN MAKES THROAT CLOSE UP
ADVERSE ACTION- N&V, ADDICTION, DON’T LIKE FEEL
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
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
PAIN CAUSES
A. CONFUSION
B. FALLS
C. IMMOBILITY
D. ALL OF THE ABOVE
D
PAIN SCALE USED FOR CHILDREN
A. NUMERICAL
B. ANESTHESIAS SCALE
C. FACES
D. CHILDREN DON’T HAVE PAIN
C
WHAT MIGHT A PED PT SAY IF THEY ARE NAUSEATED
MY STOMACH HURTS OR DOESN’T FEEL GOOD
NONPHARM MEASURES FOR PAIN
A. MEDITATION
B. MASSAGE
C. ACUPUNCTURE
D. ALL OF THE ABOVE
D
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
WHY DO WE NEED VERBAL DISCRIPTION OF PAIN
WE WANT AS MUCH INFO ABOUT PAIN AS WE CAN
FLACC SCALE
NONVERBAL
ICU
ANESTHESIA
GRIMACING, MOANING, GRUNTING
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
OPIOIDS ARE FOR MODERATE TO SEVERE PAIN
TRUE OR FALSE
TRUE
DIARRHEA IS A SIDE EFFECT OF OPIOID USE
TRUE OR FALSE
FALSE
WHO CAN PUSH THE PCA BUTTON
A. NURSE
B. FAMILY
C. DOCTOR
D. PATIENT
D
END OF LIFE PROGRAMS ARE REFERRED TO AS
A. HOME HEALTH
B. HOSPICE
C. NURSING HOME
D. ASSISTED LIVING
B
WHEN SHOULD YOU REEVALUATE AFTER GIVING PAIN MEDS
30 MINUTES
WHAT HAPPENS IF IT WASN’T DOCUMENTED
IT WASN’T DONE
WHO WOULDN’T GET NSAIDS
BLEEDING DISORDERS
ON BLOOD THINNERS OR ASPIRIN
CONCERNS WITH TYLENOL
COLD MEDS
COMBO MEDS
LIVER ISSUES
WHAT PAIRS WELL WITH PAIN MEDS
ANTIDEPRESSANTS
ANTIANXIETY
USES FOR ANTIDEPRESSANTS
DEPRESSION
PAIN
INSOMNIA
*ASK WHY THEY ARE TAKING THE MED
Pressure injury
localized damage to the skin orunderlying tissue resulting from prolonged pressureand/or friction to the skin, predominately occurring overthe bony prominences
NPUAP
NATIONAL PRESSURE ULCER ADVISORY PANEL
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
WHAT CAUSES A PRESSURE INJURY
BLOOD FLOW IS LOST LIKE PINCHING A STRAW WHEN VASCULAR IS PINCHED
WHAT DOES NPUAP DO
NATIONALLY STANDARDIZE PRESSURE WOUND TERMINOLOGY. DOESN’T MATTER FACILITY, IT’S THE SAME. THEY ALSO STANDARDIZE STAGING, DEFINITIONS, REPORTING METHODS.
NOVEMBER 15
NATIONAL STOP PRESSURE INJURY DAY
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
INSURANCE REIMBURSEMENT
PRESSURE INJURY
DOESN’T PAY IF THEY DIDN’T COME IN WITH IT. THIS AFFECTS YOUR BOTTOM LINE.
HOW CAN SOMEONE DIE FROM A PI
SEPSIS- INFECTION IN BLOOD
MEDICAL STAFF
PI
MORE WORK ON YOU
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
WHAT MEDICATION IS USED MOST ON PI
SILVER
Ag
WHY SO MANY PI LAWSUITS
PREVENTABLE
EVERY WOUND IS TO A DEGREE
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
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
ELDERLY
AT RISK FOR PI
THIN SKIN
DECREASED HYDRATION, ELASTICITY, CIRCULATION, IMMUNE SYSTEM. MORE SEDENTARY.
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)
IMMOBILITY AND SPINAL INJURY
RISK FOR PI
FRICTION AND SHEAR OF OTHERS MOVING THEM
BABIES
RISK FOR PI
HEAD- NICU OR NEGLECT
BRADEN SCALE
TOOL USED TO PREDICT/PREVENT PI
CATEGORIES OF BRADEN SCALE
MOBILITY, NUTRITION, FRICTION, MOISTURE, ACTIVITY
MOBILITY
BRADEN SCALE
BEDFAST, CHAIRFAST, WALKS OCCASIONALLY, WALKS FREQUENTLY
NUTRITION
BRADEN SCALE
POOR, INADEQUATE, ADEQUATE, EXCELLENT
*EAT MORE PROTEIN
FRICTION
BRADEN SCALE
PROBLEM, POTENTIAL PROBLEM, NO PROBLEM
MOISTURE
BRADEN SCALE
CONSTANTLY, VERY MOIST, OCCASSIONALLY MOIST, RARELY
ACTIVITY
BRADEN SCALE
COMPLETELY LIMITED, VERY, SLIGHTLY, NO IMPAIRMENT
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
LOWER BRADEN SCORE EQUALS
higher the risk (less than 9 extremely high)
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
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
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
BRADEN SCALE SCORE OVERVIEW
6-23 SCALE: Scale of 1-4 in each category, friction 1-3
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
Signs of Possible PI
Redness that won’t blanch
Darkened areas on skin
Warm skin areas
Purple, blue or shiny skin
AT FIRST SIGN OF A PI, WHAT SHOULD YOU DO
RELIEVE PRESSURE FOR 30 MINUTES AND REEVALUATE
Commonly Missed Assessment Areas
Nasal area and behind the ears- especially withpatient is using O2
Back of the head
Heels
Shoulder blades and shoulders
Tips of toes and ankles
CHECK THE ENTIRE BODY
Name three ways to prevent pressure injuries.
- TURNING Q2H OR MORE
- ENCOURAGE AMBULATION AND ROM
- SKIN CARE- CLEAN, DRY
What does non-blanchable mean?
DOESN’T TURN WHITE AND BACK RED… NO COLOR CHANGE
Name 2 indicators of a possible PI
NON BLANCHABLE
ERYTHEMA
SHINY
Name 3 commonly missed areaswhen assessingfor PI’s.
BETWEEN TOES
ANKLES
EARS
WHY IS STANDARDIZATION OF CRITERIA IMPORTANT FOR STAGING WOUNDS
THEY VARY IN SIZE AND SHAPE
IT’S IMPORTANT FOR HOLISTIC CARE
SKIN INTEGRITY
HOW TO STAGE WOUNDS
INTACT OR OPEN
SKIN COLOR
HOW TO STAGE WOUND
IN COMPARISON TO NORMAL/HEALTHY SKIN
DEPTH OF AREA
HOW TO STAGE WOUNDS
HOW DEEP IS THE WOUND
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
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
WHAT IS NOT INCLUDED AS A STAGE 2 WOUND
MEDICAL ADHESIVE RELATED SKIN INJURY (MARSI)
DERMATITIS
TRAUMATIC WOUNDS (BURNS, SKIN TEARS, ABRASIONS)
SURGICAL SITE
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
IF YOU CAN’T SEE THE BASE OF A WOUND, IS IT STAGE 3
NO
EPIBOLE EDGES
ROLLED EDGES
NOT GOOD FOR HEALING TIME
SLOUGH
YELLOW AND TAN
ESCHAR
BLACK OR BROWN
WHAT WILL NOT BE SEEN IN A STAGE 3 WOUND
MUSCLE, TENDON, AND LIGAMENTS
CARTILAGE AND BONE
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
WHAT STAGE IS AN ANKLE PRESSURE WOUND AUTOMATICALLY CLASSIFIED AS
STAGE 4
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
UNDERMINING
WOUND CONTINUES UP UNDER THE LIP AROUND THE WOUND
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’tcover it with any kindof dressing- skin prep it)
Can heal, if it opensit willtake lots of money and time toheal
SIMPLY PUT-STAGE 1
Non-blanching redness with skin intact
SIMPLY PUT STAGE 2
OPEN AREA, NO FAT SHOWING
SIMPLY PUT STAGE 3
OPEN AREA WITH FAT SHOWING
SIMPLY PUT STAGE 4
OPEN AREA WITH MUSCLE, TENDON, OR BONE SHOWING OR PALPABLE
SIMPLY PUT UNSTAGEABLE WOUND
CANNOT SEE THE BOTTOM OF THE OPEN WOUND TO DETERMINE STAGE
SIMPLY PUT DEEP TISSUE INJURY
INTACT SKIN WITH DISCOLORATION RELATED TO A BLOOD FILLED BLISTER
WHAT IS DRAINAGE
LIQUID EXCRETED FROM A WOUND
LIQUID INSIDE OF WOUND
INDICATOR OF WOUND HEALTH
WHY DO WE NEED TO LOOK AT WOUND DRAINAGE
IT’S THE WOUND VS. IT TELLS US HOW HEALTHY OUR WOUND IS
SEROUS
DRAINAGE TYPE
- CLEAR WATER DRAINAGE
- THIS IS A GOOD SIGN
- SUGARS, PROTEINS, AND WBC THAT ARE VITAL TO THE HEALING PROCESS
SEROSANGUINEOUS
DRAINAGE TYPES
- PINK, WATERY DRAINAGE WITH RED FLUID
- THICK CONSISTENCY- SYRUP
- INDICATES GOOD CIRCULATION
- INDICATIVE OF RECENT DAMAGE TO VESSELS
WET TO DRY DRAINAGE
- WET DRESSING, PUT IT IN THE WOUND, COVER, PULL IT OUT DRY TO DRIBRIDE
- GENERALLY MEDS 30 MIN PRIOR TO DRESSING CHANGES
SANGUINEOUS
DRAINAGE TYPE
BRIGHT RED
2. GOOD SIGN- BLOOD FLOW
3. WOUND IS ACTIVELY BLEEDING
PURULENT
WOUND DRAINAGE
- THICK YELLOW, GREEN, OR BROWN COLORED
- NOT NORMAL HEALING PROCESS
- INDICATIVE OF INFECTION
- CONTAINS DEAD BACTERIA
WHAT COLOR IS SEROUS DRAINAGE
CLEAR, WATERY PLASMA
WHAT COLOR IS PURULENT DRAINAGE
THICK, YELLOW, GREEN, TAN, BROWN
WHAT COLOR IS SEROSANGUINEOUS
PALE, RED, WATERY, MISCURE OF SEROUS AND SANGUINEOUS
WHAT COLOR IS SANGUINEOUS DRAINAGE
BRIGHT RED, INDICATES ACTIVE BLEEDING
What is green and yellow drainage called?
PURULENT
What is bright red drainage called?
SANGUINEOUS
What does clear drainage contain in a wound?
SUGARS, PROTEINS, AND WBC
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
WHERE SHOULD YOU START WHEN CLEANING A WOUND
START AT THE LEAST CONTAMINATED AREA
WHAT DIRECTION DO YOU CLEAN A WOUND
Clean outwards
NEVER pull contamination into the wound
WHAT PRESSURE SHOULD YOU USE WHEN CLEANING A WOUND
Don’t Use friction- but be gentle
WHAT DIRECTION TO IRRIGATE A WOUND
Irrigating-let flow from least contaminated
HOW MANY TIMES CAN YOU USE A Q TIP WHEN CLEANING A WOUND
1 SWIPE… THEN IT’S CONTAMINATED
Cleaning staples/sutures
Start at the staple area and move outward- one swipe
NURSES AND PROVIDERS ARE RESPONSIBLE FOR
Sterile Dressing Changes
REMOVING APPLYING OR CHANGING ALL DRESSINGS
WHO CAN DO DRESSING CHANGES
NURSE/PROVIDER
CANNOT DELEGATE TO PCT/CNA BECAUSE REQUIRE ASSESSMENT
PCT/CNA CAN ASSIST BUT NOT PERFORM ALONE
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
IF A DRESSING IS STUCK, WHAT SHOULD YOU DO
moisten with sterile water or normal saline to loosen
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
STEPS TO CHANGING A DRESSING
SECOND STEPS
Doff gloves and hand hygiene
Prepare aseptic area
Open sterile gauze
Saturate with sterile water
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
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
GAUZE
DRESSING TYPE
PACKING OR COVERING
TRANSPARENT FILM
DRESSING TYPES
Awkward locations
Provide a moist healing environment
Prevent friction
Act as a second skin
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
HYDROGEL
Types of Dressings
Provide pain relief
Sometimes used to remove dead skin (Santyl)
Protects from infection
FOAM DRESSING
TYPES OF DRESSING
Protective barrier
Used on reddened areas to prevent breakdown
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
PREPARING FOR THE DRESSING CHANGE
Read notes on previous dressing change
Gather supplies prior
ASK QUESTIONS!!!!
Understand normal healing signs
WHY DO WE NEED TO UNDERSTAND NORMAL HEALING SIGNS
Will recognize what is abnormal in the healing process
Report abnormal changes immediately
DEHISCENCE
SURGICAL WOUND REOPENS
EVISCERATION
ORGANS PROTRUDING- YOUR ORGANS FELL OUT
PRESSURE ULCERS
Pressure sore, decubitus ulcer, or bed sore.
PATHOGENESIS OF PRESSURE ULCERS
PRESSURE INTENSITY
PRESSURE DURATION
PRESSURE INTENSITY
TISSUE ISCHEMIA
BLANCHING
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.
BLANCHING
occurs when the normal red tones of skin are absent.
PRESSURE DURATION
Low pressures over a prolonged time can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death.
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
IMPAIRED SENSORY PERCEPTION
RISK FACTORS FOR PI
cannot feel their body sensations.
IMPAIRED MOBILITY
RISK FACTORS FOR PI
unable to independently change position are at risk/cannot change or shift off of bony prominences.
ALTERATION IN LOC
RISK FACTORS FOR PI
UNABLE TO PROTECT THEMSELVES
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.
FRICTION
RISK FACTORS FOR PI
the force of two surfaces moving across one another.
MOISTURE
RISK FACTORS FOR PI
causes skin breakdown
STAGE 1
Classification of Pressure Ulcers
Intact skin with nonblanchable redness
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
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
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
PRIMARY INTENTION
Process of Wound Healing
Edges are approximated- “closed” and the risk of infection is lowered. Ex. Surgical incision.
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.
Partial-thickness wound repair:
inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers
FULL THICKNESS WOUND REPAIR
HEMOSTASIS, INFLAMMATORY PROLIFERATIVE AND MATURATION
Hemostasis-
FULL THICKNESS WOUND REPAIR
injured blood vessels constrict, platelets gather to stop bleeding.
INFLAMMATORY
FULL THICKNESS WOUND REPAIR
THIS RESPONSE IS BENEFICIAL. REDNESS WARMTH AND THROBBING (LOCALIZED)
PROLIFERATIVE
FULL THICKNESS WOUND REPAIR
filling the wound with granulation tissue (red, moist and composed of new vessels), wound retraction and wound resurfacing
MATURATION
FULL THICKNESS WOUND REPAIR
can take place for more than a year. Consists of collagen scarring.
HEMATOMA
- HEMORRHAGE
- LOCALIZED COLLECTION OF BLOOD UNDERNEATH THE TISSUES
second most common health care–associated infection.
Infection-
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.
Dehiscence- .
partial or total separation of wound layers
“tearing/opening”-sensation
Evisceration-
total separation of wound layers.
Medicare and Medicaid:
PI
no additional reimbursement for care related to stage III and stage IV pressure ulcers that occur during the hospitalization
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.
Factors Influencing Pressure Ulcer Formation and Wound Healing
NUTRITION
TISSUE PERFUSION
INFECTION
AGE
PSYCHOSOCIAL IMPACT OF WOUNDS
PREDICTIVE MEASURES
PRESSURE ULCERS
BRADEN SCALE
NUTRITIONAL STATUS
Malnutrition is a risk factor for pressure ulcer development.
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.
Drains-
emptying. Note frequency of drainage.
DOCUMENTATION OF WOUNDS
Character of wound drainage- note amount, odor, color and consistency.
WOUND APPEARANCE
should be assessed on an ongoing basis.
WOUNDS IN A STABLE SETTING
provider may choose to change the first surgical dressing and provide the 1st dressing change.
Wound closures-
staples, sutures or wound adhesives for surgical incisions.
Palpation of wound-
observe for swelling and separation of edges.
Wound cultures-
must be collected from fresh drainage.
Gram stains
Biopsy
HEALTH PROMOTION
Prevention of pressure ulcers
Topical skin care and incontinence management
Positioning
Support surfaces
Wound management
DEBRIDEMENT
EDUCATION
NUTRITIONAL STATUS
PROTEIN STATUS
HEMOGLOBIN
DEBRIDEMENT
removal of nonviable, necrotic tissue.
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.
HEMOGLOBIN
ACUTE CARE WOUND MANAGEMENT
low hemoglobin level decreases delivery of oxygen to the tissues and leads to further ischemia.
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
CLEANING
FIRST AID FOR WOUNDS
- GENTLE
- NORMAL SALINE
- PROTECTION
SECURING DRESSINGS
Tape
Ties
Binders
Always date, time & initial!
TYPES OF DRESSINGS
Gauze
Transparent film
Hydrocolloid
Hydrogel
Foam
Composite
BEFORE A DRESSING CHANGE, WHAT SHOULD YOU KNOW
Know type of dressing, placement of drains, and equipment needed.
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.
Packing a wound
Negative-pressure wound therapy- vacuum assisted closure.
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.
Suture care-
Policies vary within institutions as to who is able to remove sutures.
Staples-
removed with staple remover
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
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.
UNDERSTANDING PRESSURE INJURY
https://www.youtube.com/watch?v=xNH8DDvjSME
