mod 8 E- I Flashcards
What can throw off the fit of a prothesis
fluctuation in weight and fluid volume
What is the disease process seen with those that have a prothesis
either slows wound healing or makes the skin susceptible to damage
How many times should you look at the skin and cleanse for prothesis?
2 times
- when taking it off and putting it back on
Cleansed: mild soap and water daily
What should you not do when caring for prothesis?
The area should not be shaved and no lotions or creams unless prescribed by doctor
Rashes
first/ easiest type of skin breakdown to prevent and heal are rashes
Areas suspectable: beneath breast, under arms, and between folds
What is another concern for rashes beside skin on skin contact?
skin on plastic contact
Devices like IV or oxygen tubing
May be due to latex, ex: allergy
protective cloth can eliminate the contact
Friction and Shearing
Often occurs while pt is in bed
occurs when pt body slides down and skin stuck to linens
creates heat and leads to development of blisters
to eliminate: amount of time spent with head of bed should be eliminated
greater than 30 degrees will slide down the bed
Pressure Injuries, decubits uclers, pressure sores, pressure ulcers, bed sore
dangerous medical condition
occurs over the bony prominences areas
Some may heal or may never
Can cause infection
If infection is not taken care of the resident can become septic and die
When did medical stop covering pressure injuries
Oct 2008, due to them being preventable
stage 1 pressure injury
tell the nurse immediately
skin is intact; reddened or discolored and Non blanching (area pressured while turn white)
may be warm and edema
stage 2 pressure injury
skin in open
epidermis and sometimes dermis involved
appears as a shallow crater
must be cleaned and dried as directed
stage 3 pressure injury
epidermis, dermis, and subcutaneous tissue involved
eschar may be present
what can stage 2 and 3 have?
if necrotic tissues or an eschars tissues the wound must be debride
Eschar: necrotic tissues sometimes found in wound bed of a pressure injury
Debriment: chemical or manual removal of eschar
stage 4 pressure injury
epidermis, dermis, and subcutaneous tissue and supporting structures including muscles, tendons, joints, and bones involved
may take months to heal
if does not heal: sustain scaring and deformity and loss of function
Affecting factors for developing pressure injuries?
immobility
inability to perceive pain
an altered level of consciousness
incontinence
poor nutrition
high microclimate
What can incontience create?
it can create a moist environment
skin moisture can macerate the skin
Maceration: appears as a skin that is softened from constant moisture exposure
What from urine and feces creates quick skin break down
alkalinity of the skin
action of enzymes
skin can break down quickly
Nutrition’s importance of developing pressure injuries
Need adequate nutrition and protein
Protein are building blocks creating new tissue
Without proper protein the skin becomes edematous
DeHydration: can make the tissues dry and skin more brittle
Microclimate
close enviornment in which the level of heat and humidity are localized
ex: between the skin and bed
Skin needs a dry and constant temp.
Inspect and cleanliness
need to pull up the folds and look during morning/evening baths
You may apply cornstarch of powder under breasts, arms, and skin folds
What to do when apply powder or corn stratch
turn away from the resident
place a small amount of powder on the palm of the hand and pat it
turn your back while shaking the powder into your hand will prevent the resident from inhaling powder
Shearing and friction prevetnion of 30 degrees angle
elbow and heel protectors
if not available use socks or long-sleeved shirts
try to elevate the heels
place pillows under elbows
Pressure relieving devices
Mattress toppers: must be repositioned every 2 hr due to increase microclimate
alternating pressure pads for wheelchair
residents who have:
- sore on butt
- high risk of skin breakdown
-spend a lot of time in wheelchair
should have a pad
Positining devices
Pillows: easiest and most accessible
wedges pillows: position resident on her side
if pillows or wedge pillows unavailable use:
- bed/bath blankets can be rolled up
reducing microclimate
- does not have too many blankets
- fevers should be reported
- special low air loss mattress help reduce microclimate
friction and shearing devices
friction/shearing prevention devices: can be used when moving a resident upward in bed
2 cna
- obese or fragile skin
on 3 resident is gently slid upward there is no lifting
Urinary retention
- Body does not send the message to the brain/ brain doesn’t receive them or blockage
Inability to empty the bladder either partially or fully
if bladder does not empty it can be damaged or even rupture
Steps taken when there is no bowel elimination
no bowel movement in 3 days: latex or milk of magnesia is given
if it has been 4 days: a suppository is inserteds
5 days: edema is given
Edema
injection of fluid into the rectum
resident holds fluid in rectum as long as possible
over the counter fleet enema
resident must always lay on left side when given edema
suppository
a wax cone that is inserted into the rectum to help the resident have a bowel movement
Incontinent care
incontinences: involuntary leakage or passing of urine from the bladder or feces from rectum
if resident is physically able to sit on toilet help do so
try to run faucet
clean, peri-care, apply barrier cream
types of incontinence products
liner is pad that is inserted into underwear
briefs: worn in place of underwear
barrier cream should be applied to anyone that is incontinence
if no red areas apply to anal area and buttocks
Urostomy
bladder is diseased or removed from trauma
no longer functioning
urostomy: ureters are detached from blader and hen attached to a segment of the bowel
one end then extends outside of the abdominal wall which allows the urine drain outside of the body
1/3 to 1/2 full
Stoma
Is an opening that protrudes form the abdomen
connecting an internal organ to the outside to the body
usually pink or red in color
urine is collected and emptied once bag is 1/3 full and at the end of each shift
ostomies
rectum/colon is disease they may not have a bowl movement via the rectum
colostomy: made from large intestine
ileostomy: made from the small intestine
removal and procedure of ostomies
- empty and clean ostomy bag
bag should be emptied when: - approximately half full
- when resident requests
clean stoma and surrounding area w adult wipes
reusable bag: - rinse and empty bag
- dry bag and reattach
Devices used for elmination- bedpan, commode, urinal, commode hat
bedpan:
- bed bound
- strict bed rest
- cannot sit up on a toilet or commode
- used at night so they do not need to get out of bed
commode:
- cannot walk, can sit on toilet
- empty/ clean with adult/disinfecting wipes
- replace it under toilet seat of commode
- if resident is on intake/output: place commode hat under toilet seat of commode
urinal:
- in replace of graduate to measure urine
- place bed protector underneath
- place washcloth around rim
- tell pt to place on side rails
commode hat:
- used for collecting output or a sample of output
- measuring urine: place hat in front part of commode
- collecting stool: place it in back part of commode
- both: place one in front and back
- no tp in it
Traditional and fracture bedpan
commonly used: fracture more economical/smaller
- assisting a resident w/hip surgery you must only use a fracture pan
digestive tract bleeding
upper bleeding: stomach/beginning of intestine will result in black starry tool
blood in stool is occult (hidden)
lower: may be frank blood (red/obvious)
hemorrhoids:
large distended veins around the anus
- due to constipation
- bleed frank blood
tell the nurse if:
- occult/frank blood
- do not flush toilet
bowel/bladder retaining
- ask pt to wait longer
- nrs would begin/educate program
- cna: encourage/ remind longer waiting times
- help them feel relaxed
height and weight
proper height/weight:
- calc fluid and nurition needs/ med
heights
cannot stand: tape measure can be used
resident facing away, looking straight ahead: back, shoulders, and buttocks against the scale
stand up scale: feet flat on floor, toes pointing forward, shoes kept on
weights
once per week- bath day
hospital: taken daily, @ same time
loss or gained 3 pounds is out of normal limits and should be reported to nrs.
What residents may not perceive pain
comatose, confused, certain disease like disease
breast prosethic
can be fitted 6 weeks after maestomcy
partial or full
partial: only part place inside their brea/specila bra
may be a partial mastectmy or lumpectomy
Artificial limb
sock or gel insert
cushion join during movement
absorbs sweat
no wrinkles
not on: use ACE bandage or special shrink sock to prevent swelling
what is the relationship between incontience and maceration
moist environment it skin will cause skin to macerate
maceration is softened from constant moisture
once macerated can be damaged by friction
External cath
removes urine via cath
single use 8-12 hrs
removed if soiled
replaced every 60 days
Orthosis
Brace, splint, or orthopedic device (aka orthotic)
* Custom made
* Can be made for upper/lower extremities, back, neck, head
* Used by those with an injury, disability, or birth defect
help with ROM exercises
