Module 7 Flashcards
Important structures of the GI Region?
Esophagus
Stomach
Pancreas
Liver
Gallbladder
Small Intestine
Appendix
Large Intestine
Rectum
Function of the Esophagus?
Peristalsis
Function of the Stomach?
mix food with enzymes to continue the process of digestion
Peristalsis
movement/muscle contractions
Function of the Pancreas
Secrete digestive enzymes into the duodenum to break down proteins, fats, and carbs
Where is the pancreas located?
Mid-Epigastric Region, behind the liver
Function of the Liver?
process absorbed nutrients from the small intestine
produce bile that is secreted into the small intestine to help digest fat
Detoxify
Function of the Gall Bladder?
store and concentrate bile
it is within the liver connected to the small intestine for bile release
3 Parts of the Small Intestine
Duodenum –> Jejunum –> Ileum
Function of the Small intestines
Breaks down food with pancreas and liver help
peristalsis
How long is the S intestine?
22 foot long muscular tube
What is the Duodenum largely responsible for?
continuous breaking down process of food
What is the Jejunum and Ileum mainly responsible for?
absorption of nutrients into the bloodstream
What are the contents of the small intestine ? (form)
Semi Solid to Liquid
Once nutrients are absorbed in the small intestine, the contents enter the…
large intestine
Function of the Appendix?
In the lower Right Abdomen
Function unknown - theory is it stores good bacteria for “Rebooting” the digestive system after illness, or that it is a vestigial organ
Function of the Large Intestine
mostly removal of water from contents and formation of stool
Parts of the Large Intestine
Cecum
Ascending (Right) Colon
Transverse (Across) Colon
Descending (Left) Colon
Sigmoid Colon (Storage)
Rectum
It has 6 main parts and is a 6 foot long muscular tube
What is stool consisted of?
mostly food debris and bacteria
What is the function of the bacteria/natural flora in our gut and stool?
Synthesize vitamins
Process waste products and food particles
protect against harmful bacteria
What is the Rectum?
8 inch Chamber connecting colon to the anus
When gas or stool enters, neurological sensors message the brain which decides whether to empty or not - if not, sensation to void temporarily ceases
Things to Ask During An Abdominal Health History?
Appetite/Weight Change
Difficulty Swallowing
Food Intolerance
Abdominal Pain/Discomfort (Visceral, parietal, referred pain)
Medications taken/allergic to
A nutritional assessment
Vomiting, Nausea (looks, when, amount, etc)
Bowel Habits (amount, timing, etc)
Past Abdominal history
COLDSPA
Acronym to remember what to learn about pain/illness
Characteristics, Onset, Location, Duration, Severity, Pattern, Associated Factors (of the pain)
Visceral Pain
Organ pain
Dull, Diffuse Pain
Parietal Pain
Lining Pain
Sharp pain
Referred Pain
pain felt in an area away from the source of it
Important subjective considerations on the Abdominal Health History for Infants/children?
do they breast feed/ what kind of food do they eat?
how often do they eat?
constipation?
abdominal pain/discomfort?
weight issues?
Important subjective considerations on the Abdominal Health History for Adolescents?
do they regularly eat meals
do they exercise
their activity levels
what is their nutrition like
do they have weight issues (ask carefully since they have body image issues)
Important subjective considerations on the Abdominal health History for Pregnant women?
Morning sickness (50-70% have it)
Heartburn (decrease gastroparesis)
constipation
Gastroparesis
disease in which the stomach cannot empty itself of food in a normal fashion / delayed gastric emptying (leads to heartburn in people that are pregnant for example)
Equipment needed for an Abdominal Assessment?
Stethoscope
Measuring Tape (Size of Liver)
Small Pillow/ Rolled up Blanket
Pen Light
Marking Pen
What is the abdominal assessment technique order?
Inspection –> Auscultation –> Percussion –> Palpation
this order is because percussion or palpation can stimulate the abdominal intestinal region leading to false results like noises when there would not have normally been any there
What side of the bed should you stand at during the abdominal assessment?
the right side
Important Pre-Abdominal Assessment points to know.
Stand on the right
Provide privacy
expose the ENTIRE abdomen
Raise the bed for good body mechanics and lower when done
If can be tolerated, lower the head of the bed into a supine position - if they cannot do this go semi-fowlers
have good lighting
relax patient
patient needs to void
ask about painful areas - examine last
watch the patients face
warm stethoscope and hands
have shortened fingernails
distract patient with convo/questions
visualize organ locations
proceed in correct order
explain what you do and why
cultural considerations
Things to observe during inspection of the abdomen?
- Contour (Flat, Round, Scaphoid, Protuberant)
- Symmetry
- Umbilicus (contour, inflammation, hernia, infection - in newborns consider bleeding and infection)
- Skin (striae, scars, bruising, lesion, rash, tattoo, pulsations at eye level, hair distribution)
Term for Bruising
Ecchymosis
Movement seen or Bruits Heard in Epigastric region…
may indicate an aortic aneurism
When inspecting abdominal distension what is important to keep in mind on what may be causing it?
7 F’s:
Flat
Flatus
Fluid
Fetus
Feces
Fetal Growth
Fibroid
Hernia
when organs squeeze through a spot in muscle, tissue, or skin
Important hernia locations (5)
- epigastric
- umbilical
- Inguinal (groin/V-line/pubic bone area)
- Femoral (thigh)
- Incisional (out of incision/evisceration)
When inspecting the abdomen, you are going to view what regions?
The 4 Quadrants (LRQ –> URQ –> ULQ –> LLQ)
Epigastric Region (below xiphoid but above umbilicus)
Periumbilical Region (two finger diameter around umbilicus)
Pelvic Region
What organs are in the RUQ?
Gallbladder
Liver
Duodenum
Pancreas Head
R Adrenal Gland
Portion of R Kidney
Some of Ascending/Transverse Colon
What can pain in the RUQ indicate?
Cardio - MI, Angina
Pulmonary - Pneumonia
GallB - Cholecystitis, Cholelithiasis
Hepatic - Hepatitis, Cancer (CA)
Intestine - Ulcer, Appendicitis
Cholelithiasis
Gallbladder stones
Cholecystitis
Gallbladder inflammation
What organs are in the LUQ?
Spleen
Left Liver Lobe
Stomach
Pancreas Body
Left Adrenal Gland
Portion of Left Kidney
Some of Transverse/Descending Colon
What can pain in the LUQ indicate?
Cardio - MI, Angina
Pulmonary - PE, Pneumonia
Pancreas - Pancreatitis
Spleen - Rupture
Stomach - GERD, Ulcer, Hiatal Hernia
What organs are in the RLQ?
Ovaries/Uterus (When enlarged)
Right Spermatic Cord
Ascending Colon
Lower part of R Kidney
Right Ureter
Appendix !!!!
Bladder when distended/full
What organs are in the LLQ?
Ovaries/Uterus (when enlarged)
Left Spermatic Cord
Descending/Sigmoid Colon
Left Ureter
Bladder when distended/full
What can pain in the RLQ or LLQ indicate?
Ovary/Uterus - Ectopic Preg., Cyst, Pelvic Inflam Disease
Intestines - Perforation, Constipation, Diverticulitis, Hernia
Kidney - Nephrolithiasis, Infection
Appendix (Right) - Appendicitis
Nephrolithiasis
kidney stones
Examples of where Referred Pain can occur?
Shoulder
Scapula
Thighs and Genitals
Lower Back
Umbilical Area
What can referred pain in shoulder indicate?
Ruptured Spleen
Ectopic Pregnancy
Pancreatitis
Perforated Duodenal Ulcer
What can referred pain in the scapula indicate?
Cholecystitis
MI
Angina
Pancreatitis
What can referred pain in the thighs or genitals indicate?
Renal issues
What can referred pain in the lower back indicate?
Pancreatitis
Rectal Lesion
Abdominal Aortic Aneurysm
What can referred pain in the umbilical area indicate?
Small Intestine Issue
Appendix Issue
Colon Issue
9 Abdominal Regions
(R Hypochondriac)(Epigastric)(L Hypochondriac)
(R Lumbar) (Umbilical) (L Lumbar)
(R Iliac) (Hypogastric) (L Iliac)
(used during palpation and percussion of abdomen)
Striae
“Stretch Mark”
Can be Violet or a Pearly White color
occurs when someone gave birth or had a rapid weight change (like: was obese and lost weight fast)
What can cause a protuberant abdomen?
Decreased muscle tone
What does an abdominal mass look like?
An area where the stomach protrudes out
It may indicate a curable/malignant/benign/painful/non-painful/incurable tumor/mass - needs to be tested
Caput Medusae
Issue in the abdomen where superficial blood vessels protrude out due to portal hypertension to appear “snake-like”
Ascites
Fluid trapped in the peritoneal cavities (abdomen)
What often is the cause of ascites of the abdomen?
Some liver issue like cancer, cirrhosis, etc
What area of the abdomen is auscultated first with the warm stethoscope diaphragm?
The Ileocecal Valve
Where is the ileocecal valve ?
in the Right Lower Quadrant (where the cecum of the colon is and where the S and L intestines meet)
How often do healthy bowel sounds occur?
every 5 to 20 seconds - these are called active bowel sounds
Loud and prolonged (borborygmic) bowel sounds are ____
hyperactive
If bowel sounds are occurring every 20-30 seconds due to constipation, beginning of ileus, or decreased motility, they are ____
hypoactive
In order to declare bowel sounds as ABSENT, how long must you auscultate?
a full 3 to 5 minutes
What may cause absent bowel sounds?
Decreased motility due to paralytic ileus, peritonitis, anesthesia (may want to flick abdomen for stimulation) - this is a very serious issue
What are active bowel sounds (sound, why they happen, why we assess them)?
Sporadic, irregular high pitched clicks/gurgles due to peristalsis and we listen to them to assess bowel motility
What other sound should we auscultate when doing the abdominal assessment?
The vascular sounds of the aorta using the bell
this area is the epigastric region / below the xiphoid process and above the umbilicus
What is a problematic sound, and what does it indicate, in the epigastric region?
If you hear a systolic bruit that could indicate abdominal aortic aneurysm
Why do we percuss the abdomen?
To detect fluid, gaseous distention, masses, and asses position and size of various structures
What areas are percussed in an abdominal assessment?
all 4 quadrants or the 9 regions including flank areas of the back (where kidneys are)
What is the predominant sound (indicating air) during abdominal percussion?
Tympany
What can a dull percussion indicate in abdominal assessments?
locations of organs the liver, a distended bladder, pregnant uterus, fluid, feces, or other solid masses
When doing abdominal palpation, what must be done and in what order?
Light Palpation x9 –> Deep Palpation x9 –> Rebound Tenderness
Why do light palpation in an abdominal assessment?
check for surface abnormalities, muscle rigidity, and tenderness
What is the motion of light and deep palpation?
It is a dipping motion with fingers/palm together and flat
the light palp goes about 1-2 cm, while deep goes about 4-6 cm
Deep also uses one hand on top of one another, while Light uses only one hand/fingers
Why do deep palpation in an abdominal assessment?
check organs (liver, spleen, kidneys, aorta) for masses or other issues
If there is tenderness/pain expressed or found in light palpation, then you should …
NOT do deep palpation
Rebound Tenderness
Pressing into the and and releasing quickly to see if pain, grimace, or yelling is elicited
If it is, it is a positive sign of some issue
Blumberg’s Sign
Rebound Tenderness
The abdominal wall is compressed slowly and then rapidly released. If there is pain elicited it is a positive sign (indicates something like peritonitis)
Obturator Test
Patient lies on back with right hip flexed 90 degrees. Examiner holds patients right ankle in right hand. With left hand examiner rotates hip by moving the right knee to and away from the body. Pain elicited is a positive sign (of appendicitis)
Murphy’s Sign
Test where the patient is asked to breath out, followed by placing the hand over the gall bladder (R. MCL) - the patient then breaths in
Normally, the abdominal contents are pushed down as the diaphragm moves up, but if the patient stops breathing and winces to “catch” their breaths it is a POSITIVE sign of a gall bladder issue
Important objective developmental considerations for Infants and Children when doing the abdominal physical assessment?
their first stool (meconium) could still be present in newborns
liver takes up more space than an adult
the abdominal wall is thinner
organs are palpable easier
urinary bladder is higher up than in adults
contour is often protuberant / pot bellt shape
Umbilical Herniation in newborns
Important objective developmental considerations for Pregnant Women when doing the abdominal physical assessment?
Hemorrhoid presence
Bowel Sounds can be diminished
Appendix is displaced up and to the right
Important objective developmental considerations for Elders when doing the abdominal physical assessment?
Increased abdominal fat
Less musculature
Organs may be easier to palpate now
-oscopy
test allowing for a test of the GI system
a tiny camera is inserted into the area and can visualize the area for the physician
What things can an -oscopy procedure due?
Visualize the area
Biopsy mucosa and lesions
Remove Lesions
Cauterize Bleeding
Difference between a Colonoscopy and a Sigmoidoscopy?
Colonoscopy examines the entire colon, but the sigmoidoscopy only examines the lower third (sigmoid colon)
Contrast Medium Study - Barium Swallow/Enema
The patient NPO after midnight and must understand the procedure and consent. the barium is chalky and could cause stomach irritation, and laxatives may be needed to flush barium afterward
The barium swallow, radioactive, can help visualize areas like the esophagus, upper GI, stomach, S intestines
A barium enema can help visualize the large intestine
BS
Barium Swallow
BE
Barium Enema
GI Occult Blood Test
Test checking for blood in the stool - if blue, there is a positive for blood present in stool
Up to 3 dasys before avoid red meat, raw fruit, vegetables, aspirin, and vitamin C to prevent False Pos/Neg
NPO
Non Per Orum - Nothing By Mouth
Type of Intake Diet requiring that nothing (not even ice) be eaten prior to surgeries, GI abnormalities, N&V, L&D, some lab work, and when comatose
Some health histories may require the use of IV fluids
If well nourished, can be tolerated for a short time
Important Considerations for NPO
Keep the mouth moist (do not swallow)
Practice Good Oral Care
They may be grumpy from lack of food/drink
Clear Liquid Diet
Any liquid that is see through at room temp (broth, coffee, carbonated beverages, ice pops, gelatin, clear juice, tea)
1st step post-surgery
poor nutritional value (long term would need IV sub)
“clear Diet, advance as tolerated” means nurses can assess advancement
Clear Liquid Diets allow the nurse to …
assess tolerance to PO intake, and choose advancements in diet
Concerning Signs to Be on the Look Out For during Clear Liquid Diets?
Not Voiding
Full Feeling
Diarrhea
Abdominal pain and distention
What things do we want the patient to experience before advancing past a clear liquid diet?
Want them to feel hungry
Have positive bowel sounds
have them pass flatus (sometimes)
be able to eat half or three-fourths of their tray before advancing
Full Liquid Diet
Includes all of the clear diet plus milk products, frozen deserts/custards/pudding, pasteurized eggs, veggie juices, milk/egg substitutes
This has better nutrition than a clear diet so it can be taken for a few days without supplementation
Soft Diet
“bland diet” or “Low fiber diet”
It is a regular diet to remove food difficult to digest or chew
it meets nutritional satisfactory, but it is very tasteless
What cannot be given in a soft diet?
No High Fiber Food (salad, roughage)
No High Fat Food
No Highly Seasoned Food
Pureed Diet
Foods (meat, veggies, etc) are blended to a liquid form similar to baby food
It is for patients with difficulty chewing, swallowing, facial control/paralysis, or post oral surgery
Has nutritional value since foods are blended with broths, gravies, cream soups, cheese, milk, juices to increase calorie and nutritional value
Problems with the Pureed Diet
A patient could aspirate on the food if they cannot swallow
Mechanical Soft Diet
Diet where food is modified for texture (chopped, ground, pureed) when the patient has difficulty chewing or surgery to the head/neck/mouth
Mashed soft ripened fruits and cooked, mashed, soft veggies are common in this diet
Regular Diet
“House Diet”
Any food is allowed , and patients can generally order what they want depending on the facilities dietary system
Issue is aspiration though once again
NAS
“No Added Salt” or Sodium Restricted Diet
Used for patients with heart disease, hypertension, kidney disease, or ascites
I&O
Intake and Output
We need to measure what patients consume and what they put out
Examples of Intake
By Mouth Foods
IV Fluids
Antibiotics
Examples of Output / 3 Ways Output is Measured
Urine
Sweat
Stool
How is intake and output measured?
Solid intake - percentage taken in
Liquid Intake - mL or cc
Output - cc or mL for liquids ; weight for solids
Important Nursing Considerations on Challenges in Nutrition
Impaired Appetite
Eating Alone
culture
Religion
Serving Times
State of Health
Preferences
Cognitive Level
Cognitive Impairment
Ways to Stimulate an Appetite in a Patient
Offer small and frequent feedings
solicit favorite foods from home when possible
provide a pleasant eating environment
schedule procedures and meds when they are less likely to interfere with appetite
control pain, nausea, depression with meds
offer alternatives for items person will not/ cannot eat
provide good oral hygiene
provide a comfortable position
If a patient cannot chew or swallow at all, how may they eat?
Enteral Feedings
Parenteral Feedings
Enteral Feedings
Feedings administered directly into the stomach via a tube (ex: OG, NG, PEG)
OG Tube stands for …
Oral Gastric Tube
NG Tube stands for …
Naso Gastric Tube
PEG Tube stands for …
Percutaneous Gastrostomy or Jejunostomy Tube
How are enteral feeding tubes named?
based on where they are inserted and then directed
NG Tubes
Put in the nose down to the stomach
for short term use (< 6 weeks)
What is a risk of using an NG tube?
aspiration
What does aspiration look like during enteral feedings?
Increased HR, RR
Anxiety
Auscultated Rhonchi
Vomiting up Solution
Decreased O2 Sat
If rhonchi are still present after coughing, this is an indication of …
aspiration of solution during enteral feedings
Think ____ to help prevent aspiration of NG tube feeding patients
positioning (of the tube and the patient)
What position should the patient be in during NG tube feedings and up to an hour after?
High Fowlers or on their Right Side if Comatose
Points to consider when doing enteral feedings?
Food at room temp (cold can cause cramps/diarrhea)
Aspirate prior to feeding to assess residuals and evaluate last feeding absorption
May have to check placement with X Ray (first check)
Assess bowel sounds prior to feeding (if absent hold it)
Look for dumping syndrome signs
Flush tubing with water to maintain fluid balance and patency of tubes
A piston syringe residual of greater than 150 for enteral feeding means…
you should contact the physician (it should be 100-150)
Enteral Feeding Schedules
Intermittent
Bolus Intermittent
Continuous Feedings
Cyclic Feedings
Preferred Enteral Feeding Schedule
Intermittent
Intermittent Feeding
300-500 mL of enteral formula administered several times a day (preferred method)
Bolus Intermittent Feeding
a bag hanging by gravity or a syringe delivers formula into the stomach - can be fairly quick and therefore may not be tolerated
Continuous Feeding
infusion pump administers feedings at a constant flow 24 hours a day.
Stomach never gets a rest and patient must be at a 30 degree angle at all times
Cyclic Feedings
continuous feedings delivered over less than 24 hours (usually at night)
What is the bumper in an enteral feeding tube?
a balloon that inflated to prevent migration out of the stomach
Tubes need to be ____ so we do not clog smaller tubes
patent
Parenteral Feeding
Deliver nutrients directly into bloodstream - bypassing GI tract
used when patients cannot meet nutritional needs orally or enterally
yellow fluids are often the solution with white as the lipid/fat contents
Solutions present in Parenteral Feeding
Dextrose
Amino Acids
Electrolytes
Vitamins
Trace Elements in Sterile Water
What sort of patients need parenteral feedings?
Comatose
Non functioning GI Tracts
Extensive Burns
Extensive Surgery
Extensive Cancer Treatments
Premature Infants
What is the general duration of parenteral feeding?
less than or equal to 14 days / 2 weeks
2 Types of Parenteral Nutrition Solution?
TPN and PPN
TPN
Total Parenteral Nutrition
Uses a central IV line (like vena cava), since peripheral with this could cause infection or phlebitis
It is highly concentrated, hypertonic nutrient solution
*Neonates can have this administered in peripheral IV (commonly) or central lines - they often get TPN
PPN
Peripheral Parenteral Nutrition
Not as nutrient dense as TPN making it less caustic to veins
Complications of Parenteral Nutrition
Liver Damage (from lipids)
Hyperglycemia (from dextrose)
Sepsis (unclean catheter)
Phlebitis/Infiltration
Central Line Placement Issues (Infection, Catheter Fracture, Clotting)
What is important to keep in mind on frequency of BM?
frequency varies person to person and it is not necessary for everyone to have a daily BM
Common bowel problems?
Diarrhea
Fecal Impaction
Flatulence
Constipation
Bowel Incontinence
What to assess on patient Bowel Elimination?
Color
Odor (C Diff has a distinct smell)
Amount
Consistency
Frequency
Contributing Factors for Altered Bowel Function
Activity Levels
Physiologic Factors
Defecation Habits
Diagnostic Procedures
Anesthesia
Pathologic Conditions
Pain
Medications
How does activity affect bowel function?
immobility and lack of exercise can lead to weakened abdominal and pelvic muscles
Physiologic Factors that can affect bowel function?
Anxiety
Depression
*they have a response on the enteric nervous system
How does anesthesia affect bowel function?
It can slow normal colonic movement by influencing the ileus
Example of a Pathologic Condition that can alter bowel function?
a spinal cord injury
How do medications affect bowel function?
A drug may increase or decrease GI motility and influence appearance of stool
Also, habitual laxative use will inhibit natural defecation reflexes and cause more constipation
Ostomy
Surgically formed opening from the inside of an organ to the outside of the body - the intestinal mucosa is brought to the abdominal wall, and a STOMA is formed by suturing the mucosa to the skin
What is the consistency of ostomy excrement?
depends on its location
Ileostomy content consistency is ..
liquid form since it is from the ileum of the small intestine
Colostomy content consistency is ..
formed, but depends on location:
Ascending colon is both liquid and formed
Transverse colon is more formed than liquid
Descending and Sigmoid should be formed
Why is a colostomy needed?
Bowel is blocked or perforated
Portion of bowel has been removed d/t cancer
Trauma
Is an ostomy permanent or temporary?
both
Temporary allows the bowel to heal and permanent occurs fi rectal cancer or a portion of the GI tract was removed
How many stomas are in a temporary ostomy?
2 because they will eventually be refused by surgery
When assessing a stoma/ostomy, a healthy stoma is …
Bright red or dark, pink and moist
has minimal bleeding
size stabilized after 6-8 weeks
protrude about .5 to 1 inch from the abdominal surface
A pale stoma indicates…
anemia
Dark Purple / Blue Stoma indicates …
ischemia or compromised circulation
Stoma Nursing Interventions
Try to limit odors as much as possible
Keep skin around the peristomal area clean and dry
Measure I&O properly
Educate and explain to help get them through it
Encourage patient to participate in care and look at the ostomy
Enemas
A solution put into the rectum and large intestine to distend the intestines and maybe irritate intestinal mucosa to cause increased peristalsis and expulsion of feces and flatus (lube causes explosive defecation)
Purpose of Enemas
To relieve constipation or fecal impaction
Promote Visualization of intestinal tract during X ray
Prevent the escape of feces during surgery
treat parasites and worm infestations
Types of Enemas
Cleansing
Retention
Carminative
Return-Flow
How to administer an enema?
Sims position on Left Side so the fluid flows down the sigmoid colon on left side –> raise solution to increase flow force slowly –> if there is pain or cramping clamp the tube for 30 s and restart even slower –> instruct client to hold 10-15 minutes unless a bowel movement was the purpose —> have bedpan/commode ready –> document
Nursing Interventions to Promote Bowel Elimination
Goal to Promote Regular Defecation
Provide Privacy
Schedule
Lots of Fluids and fiber
Provide as normal a position as possible when using bedpan
Milk of Magnesia –> Suppositories’ –> Enema
What parts are included in an integumentary assessment?
Skin
Hair and Scalp
Nail
The skin is the ____ organ, and the most ____
largest, neglected
The skin accounts for around ___% of your body weight
15 %
The average person has ___ ____ skin cells
300 million
Your skin hosts around ____ types of bacteria
1000
More than half the dust in your home is…
actually dead skin
The skin renews every …
28 days
Functions of the integumentary system?
Offers Protection (against organisms/weather/etc)
Thermoregulation (subcut. fat allows)
Alerts the Sensory System (pain, heat, etc)
Metabolizes Vitamin D
Affects communication and Identification (people or texture of things)
The integumentary system is deeply entwined in the ____ system
neuro
Epidermis
First Skin Layer
Melanocytes (color)
Provides a Barrier
Thin (5 layers to it)
Acidic pH and has a Lipid Layer to ward off organisms and moisturize/protect
Visible
Why are skin washing products so important to think about in the hospital?
You do not want to wash off the acidic pH of the epidermis and weaken protection
Dermis
“The Working Layer” below epidemis
Hair Follicles, Capillaries, Sweat Glands, Nerve Ends
Most Dense layer of Skin (2 layers to it)
Fibroblasts here release collagen and elastin
Important to immunity, nutrition, skin repair, heat regulation, equilibrium maintenance
Basement Membrane
zone dividing the epidermis and dermis
as this membrane degrades with age, the skin becomes less supple, intact, or elastic
Collagen
Protein released by dermis fibroblasts
helps in the strengthening of the skin
Elastin
protein released by dermis fibroblasts
helps pull skin back into place / provide elasticity
Subcutaneous Tissue
“Hypodermis” / Below Dermis
Layer between skin and structures like bone, muscle, tendon
Acts as an insulator and pressure redistributor
Not every area has / has little subcutaneous tissue
If there is not much subcutaneous tissue in an area, what may occur?
In areas like the ear pinna, bridge of nose, and heel there is little protection and pressure redistribution so skin breakdown can occur more easily here
Perfect Wound Healing Trajectory?
Hemostasis –> Inflammation –> Proliferation –> Tissue Remodeling
Hemostasis
First stage of wound healing
body forms a clot almost immediately
can be influenced by age and blood thinners
Inflammation
Second stage of wound healing
blood vessels have clot, and then WBC immediately come and macrophages eat away at bacteria - rescue and fight
inflammation helps healing without allowing infection
Sometimes suturing or cleaning out the wound occurs here
Proliferation
Third stage of wound healing
body heals from the inside out
epidermal injuries proliferate and heal faster
comorbidities may cause becoming stuck and this and the inflammation stage without progression, and thus needing intervention
Tissue Remodeling
Final and Fourth stage of wound healing where the body keeps closing the wound inside out
What is a big influence on wound healing?
comorbidities
In what direction does the body heal skin?
From Inside Outward
What kind of skin injury heals quickest?
Epidermal
Full Thickness Wound
A wound that goes down into the dermal layer and takes longer to heal than an epidermal injury
A wound is ____ not ____
closed not healed
Healing means it wont occur again its over, but closing means theres still remodeling occurring
Wound Closure
Primary, Secondary, Tertiary Intention
Primary Intention
Wound closure from something like sutures or medical intervention
Secondary Intention
wound closure that occurs by letting normal body processes occur
Tertiary (Delayed Closure) Intention
Dirty wound is allowed to be open and heal naturally for a time with cleaning products used, and eventually it will be surgically closed
ex: Fasciotomy
Factors that can affect wound healing ?
Comorbidities:
Circulation impairment
Hyperglycemia (too much sugar means the wound will not want to close)
Tobacco Use
Poor Nutrition (lack of vitamins, proteins, calories will slow down the process)
Spinal Cord injury
Infections
Dying process (blood is diverted to vital organs so skin is neglected)
Nurses are responsible for taking care of the patient’s (potentially neglected) ____
skin!
How long should a skin assessment take?
5 minutes or less
What is the skin assessment technique order?
Interview, Inspection, Palpation
What doing the skin assessment it is important to know what 2 things?
- Patients and caregivers are best info sources
- Ask questions to get the full picture
Pressure point Areas
Areas that pressure wounds/wounds are more likely to occur
Buttocks > Heels > Elsewhere
Skin Inspection
Check skin for:
Tone based on ethnicity
Pigmentation
Color changes
lesions
rashes
infections
hygiene issues
If you can, it is better to do what during skin assessments?
Do it without gloves
Skin Palpation
Touch the skin:
open or closed?
hot or cold?
erythema? infection?
hydration: cracked, scaly, turgor
Inflammation, edema, rashes
moisture of skin: diaphoretic, oily, dry
What is the next step after skin palpation?
Hair and Scalp Assessment
Hair and Scalp Assessment
Inspect hair and scalp:
presence or absence of hair
infections
infestations with things like lice and nits
dry hair, dry scalp
What is the next step after hair and scalp assessment?
Nail Assessment
Nail Assessment
Inspect Nails:
condition
infections
trimming/grooming ability
color of nailbeds
capillary refill
dry, brittle, cracked, clubbing?
What may clubbed nails be an indicator of?
COPD, sickle cell, cystic fibrosis, anemia
What to look at when assessing a wound?
First: ASSESS WHOLE PATIENT (holistically)
Etiology/location
wound bed color
drainage amount and color (COCA/REEDA)
Odor
size
periwound condition
pain
Wound assessments need you to first assess the whole patient, what does this mean?
Assess them holistically: spiritually, physically, psychologically, etc
Use the science AND THE ART of nursing
REEDA
Wound assessment mnemonic
Red
Ecchymosis
Edema
Drainage
Approximation
COCA
Wound drainage mnemonic
Color
Odor
Consistency
Amount
Drainage Types
Serous
Serosanguinous
Sanguineous
Serous Drainage
Clear stick fluid / light yellow (seen near end of wound healing)
Serosanguinous Drainage
Slightly bloody/pink mixed with some serous drainage near mid to late healing
Sanguineous
Bloody Drainage
Braden Scale
Pressure ulcer risk predictor score with 6 categories
6 Braden Scale Categories
Sensory Perception
Moisture
Activity
Mobility
Friction and Shear
Nutrition
The lower the Braden scale score…
the higher the risk of pressure ulcer (18 or less is high risk)
Slough
light yellow wound area that can probably be cleaned off
Granulation Tissue
red healthy tissue indicative of healing
Eschar
black wound made of necrotic dry tissue that may need debridement or natural sloughing off
Maceration
break down of skin due to too much moisture
How to measure a wound?
Length is cephalocaudal direction in cm
Width is hip to hip direction in cm
Depth is from the deepest part in cm
Tunnels need depth in cm and clock direction
Undermining needs start and stop direction in clock direction
Tunnelling
A deeper wound that “tunnels” under the skin and must be measured in cm and referred to by clock direction
Undermining
Areas where the wound bed are wider than the peri wound and need to be measured according to clock direction
Potential Wound Complications?
In Hospital:
Poor Drainage Management
Wound Healing Stalled
S/S of Infection present in wound or systemic
Wound Pain
In community:
Patient goals change
Patient does not follow care plan
Treatment expensive
No caregiver to help with wound care
Comorbid conditions not well controlled
Ways to Manage Wound complications?
Notify the Provider
Request Specialist Consult
Wound Culture/Blood Work
Antibiotic Therapy when Infected
Teach pain management
Communicate with patient to address concerns
Include patient in plan of care
Social workers may be needed to address financial or caregiver concerns
Dietician consultation
Pressure Ulcers/Injury
“Cubuteous Ulcers” / “Bed Sores” - Now called pressure injuries
A bottoms up skin injury (not surface) rated as a stage I to IV scale, unstageable, or deep tissue pressure injury
Pressure Injuries are ___ ___
bottoms up
Stage I Pressure Injury
Non blanchable area of erythema over a bony prominence (stays red when blanched - wont turn white)
Stage II Pressure Injury
Partial thickness skin loss with the dermis now present visibly
Pink/red wound bed or serous filled blister
fat, granulation, slough, or eschar ARE NOT PRESENT
due to shearing/external forces
Stage III Pressure Injury
Full thickness skin loss, adipose tissue present, nonviable tissue may also be present
Supporting structures ARE NOT PRESENT
may have tunneling or undermining
Epithelial tissue growth may not return to normal color
CAN HAVE granulation, slough, non viable tissue present unlike stage II
Stage IV Pressure Injury
Full thickness skin loss with the supporting structures (bone, tendon, muscle, fascia) present/visible
Unstageable Pressure injury
Full thickness wound that cannot be staged since it is covered by nonviable slough tissue or eschar
must be unroofed to determine
Deep tissue injury
Area of intact or nonintact skin with area of NON BLANCHABLE deep red, maroon, or purple discoloration
may also be a blood filled blister
Venous Ulcers / Lymphedema in regards to Healthcare settings
80% of all lower limb wounds, reoccurs very commonly, and costs 2 billion annually
hard to treat may need lifelong compression
CVI stands for
Chronic Venous Insufficiency (Venous Ulcers)
Etiology of Venous Ulcers
High pressure in lower leg vessels
Decreased venous return
Damage to valves
Vein distention and obstruction
venous stasis (hard to return blood to heart)
S/S of CVI and Venous Wounds
Lower Limb Edema (pulses felt if not)
Dry Scaly Skin
Sensitive Skin
Itchy Skin
Maceration
Hemosiderin Staining
Varicosities
Lipodermatosclerosis (lower leg skin changes)
Wounds located in medial limb (calf), and gaiter area
Irregular Wound Borders
LARGE amount of exudate
Feet are warm/pink
Can be painful
Leg takes on an upside down / bottleneck shape
Hemosiderin Staining
Venous ulceration occurring with a red/purple color
Venous Ulcers/CVI may require…
lifelong compression that is difficult to maintain
Lymphedema etiology
Edema in Lymph:
Trauma to area
Radiation
cancer
vessel infections
Lymphedema is often …
unilateral (because circulation is broke by a disease on one side)
Lipedema
symmetric enlargement of legs due to fat deposits in obesity
Treatment of Lymphedema?
massage and compression for life (but venous ulcers mostly take compression)
Arterial Ulcer
Limited or no arterial blood flow feeding lower limbs leading to ischemia which causes ulceration and bad healing
Etiology of Arterial Ulcers
Major cause - Tobacco Use
Others: Diabetes, Raynaud’s, HTN, Auto Immune Disease
Arterial Ulcer and Ischemia Characteristics
Punched out appearance
defined borders
typically unhealthy wound bed colors (yellow, brown, black)
often infected with minimal drainage
often present on distal toes, ankles, feet
pedal pulses nonpalpable or faint
feet may be dusky or cool to the touch
toe nail fungus often present
lack of hair growth on limbs
necrosis may be present
very painful ulcers
complain of intermittent claudication (walking pain) and pain with leg elevation
Lower Extremity Neuropathic Disease (LEND)
Disease leading to neuropathic ulcers from various conditions, most commonly diabetes
Etiology/Causes of Neuropathic Ulcers
Most Commonly: Diabetes
Other: Kidney disease, traumatic spinal cord/nerve injury, infection, vitamin deficiency, medications, chemotherapy
It is due to perfusion impairment contributing to damage of the nerves to the extremities
Most common type of neuropathic ulcer
Diabetic Foot Ulcers
Sensory neuropathy pathology of Neuropathic Ulceration
Paresthesia
Loss of sensation, recognition, balance
Risk of falls
Paresthesia
loss of the ability to feel
Motor neuropathy pathology of Neuropathic Ulceration
Foot Deformities
Changes in Gait / Autonomic Neuropathy
Sweat Gland Regulation - cracks, fissures in skin occur
Bone changes - osteopenia, fractures
Charcot Foot
Neuropathic Ulcers are typically on what surface?
Plantar surface where a boney issue is underneath (often where someone stepped on something or a shoe rubbed it)
Charcot foot
condition causing the weakening of the foot bones occurring in people with significant nerve damage (neuropathy)
Diabetic foot ulcers increase risk of …
Amputation significantly, which leads to a drastic increase in mortality rate
Surgical Wounds
incisions made purposefully by a professional and are cut precisely, creating clean edges around the wound, and then often closed by primary intention
Why might a surgical wound be left open to heal by tertiary intention?
to allow better granulation tissue formation depending on wound characteristics and the reasoning behind the surgical intervention
Clean Surgical Wound
Non-contaminated surgical wound
Performed in operating room which is a sterile environment
can be left opened or closed
Contaminated Surgical Wound
wound without infection, but at high risk for infection
high microorganism load occurred
Dirty Surgical Wound
Surgical wound done in a dirty/non-sterile area with high risk of infection and infection probably already present
MASD
Moisture Associated Skin Damage
Often forgotten, but needs management
It is the inflammation of the epidermis from exposure to urine, stool, sweat, drainage over time
The skin is saturated, injured, and susceptible to disease/breaking
Can be difficult to treat, and moisture must be managed
Palliative Wound Care
approach of wound care on relieving suffering and improving QOL when curing is difficult/impossible
one of the most challenging areas, with long term wounds difficult to heal
Patient MAY be on end of life care
Palliative Wound Care Goals
What is most concerning to patient?
What are the patient/caregiver willing to do?
What are the comorbid factors/prognosis involved?
We want to know what is most concerning to the patient and caregiver and be on the same page of treatment, be inline with them and not gung-ho about it
What symptoms may be most problematic for a patient in palliative wound care?
Odor
Pain
Drainage Management
Location
Emotional Problems
Kennedy terminal ulcer
Wound requiring palliative care/palliative wound
Sudden onset of a deep purple/maroon color over an area like the sacrococcygeal/ischium
It is butterfly/pear shaped with irregular borders and progresses rapidly
it often indicates the patient as being near death
Gangrenous Ulcers and Weepy Edema
Palliative Care Wounds
Often indicate the patient is at end of life
Gangrenous appears as crusty and blackened on lower limbs, and weepy edema has pitting edema with fluid leaking out
Malignant Lesions
“Fungating Lesions”
Type of Palliative care wound
It is cancer that breaks through the skin
Offensive odor
Very Painful
Drainage is excessive because it is very vascularized and bleeds easily
Common in hospitce populations
What is important to critical thinking when dealing with malignant lesions?
- We need a dressing that wont stick or cause more damage/bleeding
- We need to understand the patients problem and get creative in covering them up so they can be part of the community in their final time
Overall, when managing wounds it is important to do what?
GO BACK TO THE ASSESSMENT AND GOALS
everyone should be on the same page during treatment
Dehisced
wound surgically created that has opened back up
Evisceration
when bowel comes out of a wound that has opened up on the anterior/abdomen - it is a surgical emergency since pinching can occur leading to loss of blood flow and necrosis followed by sepsis and death
Herniation
bowel comes through the muscle layer, but not all the way out like in evisceration
