M3 D1 Flashcards
Pressure Injury Staging 1-2
Stage 1
- Epidermis intact
- Non blanchable erythema (3 second press no blanching is big indicator of stage 1)
- Pink/red color
- Darker skin–> purplish/darker
Stage 2
- Partial thickness w/ exposed dermis
- Wound bed is pink/red
- Underlying tissues not visible
- No visible granulation
- Often associated w/ shear and friction
stage 3/4 pressure injury
Stage 3
- Full thickness skin loss
- Exposed adipose tissue
- May have necrotic tissue and epibole
Stage 4
- Full thickness skin and tissue loss
- Underlying bone, tendons, muscles visible
- Necrotic tissue may be present
- Epibole/undermining/tunnelling is common
Unstageable and deep tissue injury pressure wounds
Unstageable–> necrotic tissue
- Full thickness injury
- Slough/eschar tissue covers more than 50%
- Ischemic limb–> NO DEBRIDEMENT, prone to infection
Deep tissue injury–> full thickness
- Skin may be intact or not intact
- Purple, red blood blister
- Temperature changes are the first indication
- May open to a stage 3 or 4, may resolve w/o opening
- sheering often the cause
Peripheral Venous Ulcers and Peripheral Arterial Ulcers
Peripheral Venous Ulcers
- Caused by Venous HTN or chronic venous insufficiency
- Leads to build up of fluid in lower extremities
Peripheral Arterial Ulcers
- Arterial Insufficiency–> most commonly lower extremities
- Poor blood flow leads to ischemia, ulcers and inhibited wound healing
- Smaller and shinier wounds
Venous Ulcer NSG managment and ABPI
Nsg managmemt:
- Vascular surgery
- Physio
- High exudate dressings
- Non-adherent dressings (protect surrounding skin)
- compression stockings
ABPI
- Compares lower extremity arterial pressure
- Measured on all 4 limbs using manual BP cuff and doppler ultrasound machine
- Compression NOT recommended for ABPI <0.5 –> can stop arterial flow
1.0 = normal
0.9 = LEAD
0.6-0.8 = borderline
0.5 = severe ishcemia
0.4 or less = critical ischemia/ limb threateneed
arterial wounds
manifestations, nsg management
Manifestations
- Pale
- Surrounding skin is shiny w/ hair loss
- Little to no exudate
- Eschar/slough
- Painful (Pain worse when foot is elevated as blood has more problems getting toe extremities)
Nsg management
- Vascular surgery
- Orthopedics
- Plastic surgery
- Physio
- Cleansing–> only for healable wounds
- Povidone 10% for non healable
- Do not debride until vascularization is improved
- Leave eschar alone, do not touch, apply anything etc.
Cancer origin
Origin of Cancer
- Likely to be multifactorial
Origins of cancer may be
- Genetic
- Chemical
- Environmental
- Viral or immunological
- From causes not yet identified
development of cancer
stage 1,2,3 metastasis and immune response
Stage 1 – Initiation (carcinogens)
- Viral
- Chemical
- Radiation
- Genetic factors
- Unknown factors
- Hormones
Stage 2 Promotion
- smoking
- obesity
- diet
Stage 3 Progression
- Increased growth rate of tumour
- Invasiveness
- Metastasis
Metastasis process
- begins with rapid growth of primary tumour
- Develops its own blood supply
- Certain segments of primary tumour can detach and invade surrounding tissues or vessels to travel to distant sites.
Immune response
- inadequate as cancer cells arise from normal human cells
3 classification of cancer
site, grading severyity, staging
Anatomical site
1. Carcinoma (epithelial tissue –> lines organs)
2. Sarcoma (bones, soft tissues and muscles)
3. Lymphoma (lympatic system)
Histological analysis (grading severity)
- Grade 1 to 4
- Based on how much they differ from normal cells
Extent of disease (staging)
- 0: Cancer in situ
- I: Tumour limited to tissue of origin; localized tumour growth’
- II: Limited local spread
- III: Extensive local and regional spread
- IV: Metastasis
7 warning signs of cancer
CAUTION
C - Change in bowel or bladder habits
A - A sore that does not heal
U - Unusual bleeding or discharge
T - Thickening or a lump
I - Indigestion or difficulty swallowing
O - Obvious change in wart or mole
N - Nagging cough or hoarseness
cancer diagnostics
tests, tissues obtained how?
Specific diagnostic tests
- Biopsy involves histological examination by a pathologist of a piece of tissue.
Tissue may be obtained by
- Needle or aspiration
- Incisional procedure
- Excisional procedure
procedures
- Alkaline phosphatase blood levels
- Calcitonin
- Carcinoembryonic antigen (CEA)
- Tumor markers
cancer therapies
surery,
Surgery
- may be preventative, diagnostic, curative or palliative)
Chemotherapy
side effects, types of IV acess, what must we monitor
Side effects
- Leukopenia (WBC < 4 x 109/L)
- Neutropenia
- Anemia
- Thrombocytopenia
- Alopecia
- Anorexia
Types of IV access devices used for administration:
- Hickman
- Broviac
- Port-a-cath
WE MUSTTTT
- Monitor for extravasation during infusion and notify the HCP immediately if this occurs.
nutrition and pain management following chemo
Malnutrition risk
- High protein – repair and regenerate cells
- High caloric – energy and minimize weight loss
Risk of infection
- Wash and cook foods thoroughly
Pharmacological interventions
- NSAID
- opioids
- adjuvant pain medications
