Powerpoints and Notes Flashcards
Describe the function of the skin. (6)
Provide protection for underlying tissues
Control body temperature
Provide sensory perception of pain, touch, cold and heat
Assist in the maintenance of the fluid and electrolyte balance
Use sunlight to synthesize vitamin D, which is necessary to Ca and Ph metabolism
Major component in self and body image
What are normal characteristics of skin?
Intact with no abrasions
Feels warm when palpated
Turgor is elastic and firm
Usually smooth and soft
Color varies from part to part
What is moisture in the skin related to and what is the normal state of skin?
Moisture in the skin is directly related to the degree of hydration and the condition of the outer lipid of the skin.
Moisture refers to the wetness and oiliness.
Skin folds like axilla are normally moist
Skin is normally smooth and dry.
What is temperature dependent on?
Temperature within the body depends on the amount of blood circulating through the dermis.
What are reasons for temperature changes within the body?
Temperature changes occur at the site of infection, sites of inflammation, stage 1 pressure sores, and coldness r/t decreased circulation.
Describe turgor.
Turgor represents the skin’s elasticity and is an indication of hydration.
Turgor decreases with age
Decrease in turgor predisposes the client to skin breakdown.
What are factors that affect skin integrity?
Genetics and heredity
Age
Chronic Illnesses
Medications
Poor nutrition
What are pressure ulcers?
________ __________ are defined as any lesion caused by unrelieved pressure that results in damage to underlying tissue
What are pressure ulcers also known as?
Decubitus ulcers or pressure sores.
Describe the etiology of pressure ulcers.
Pressure ulcers are due to localized ischemia (a deficiency in the blood supply)
The tissue is caught between two hard surfaces, usually the surface of the bed and the bony skeleton. Prolonged unrelieved pressure damages small blood vessels.
Usually occur over bony prominences, after skin has been compressed it will appear as if the blood has been squeezed out of it.
Describe reactive hyperemia.
When pressure is relieved, the skin takes on a bright red flush, which is the body’s mechanism for preventing pressure ulcers. The flush is due to vasodilation.
What two other factors frequently act in conjunction with pressure to produce ulcers?
Friction: the force acting parallel to the skin.
example-pulling pt up in bed. Use drawsheet so it won’t slide skin.
Shearing: a combination of friction and pressure
example- sliding down in bed. Support patient, lower head of bed, provide pillows
What are risk factors of developing pressure ulcers?
Immobility and Inactivity
Inadequate Nutrition
Hypoproteinemia (abnormally low protein in the blood)
Fecal and Urinary incontinence (will become worse if laying in urine)
Decreased mental status: Pt may not know that they have to move.
Diminished sensation: might not feel the pressure. Decreased circulation/sensation in paralysis, stroke, nerve damage, diabetes
Excessive Body Heat
Advanced age
What is the Braden Risk Scale and what factors are measured?
The Braden Risk Scale is a method used to predict pressure ulcer risk.
Factors included are sensory perception, moisture, activity, mobility, nutrition, friction/shear
Describe stage 1 and 2 of pressure ulcer development and state the difference between them.
Stage 1: nonblanchable erythema signaling potential ulceration
Stage 2: Partial thickness skin loss (abrasion, blister)
Difference: blister or abrasion in stage 2
Describe 3 and 4 of pressure ulcer development and state the difference between them.
Stage 3: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia.
Stage 4: Full thickness skin loss with tissue necrosis of damage to muscle, bone, or supporting structure.
Difference: Stage 3 does not affect bone.
What are nursing interventions that can prevent or promote healing of pressure ulcers?
Assess risk factors
Assess hygiene and skin care
Keep area clean and dry
Use a protective skin barrier if needed
Reposition every two hours and check for reactive hyperemia or blanching
Provide adequate nutrition, monitor nutrition and weigh patient
Follow doctors orders for treatment plan
What are the phases of wound healing?
Inflammatory phase, Proliferative phase, Remodeling phase.
Describe the inflammatory phase.
Inflammatory phase:
- immediate to 2-5 days - Hemostasis-vasoconstriction - Inflammation-vasodilation, phagocytosis
Describe the proliferative phase.
Proliferative phase:
- 2 days to 3 weeks - granulation- fibroblasts lay bed of collagen - contraction- wound edges pull together to reduce defect - epithelialization
Describe the remodeling phase.
Remodeling phase:
- 3 weeks to 2 years - new collagen forms - scar tissue is only 80 percent as strong as original tissue.
During a physical assessment of a pressure ulcer, what are we assessing and documenting?
- Location of the lesion-be as specific as possible
- Size of the lesion in centimeters-length, width, and depth
- Stage of ulcer
- Color of the wound bed and location of necrosis
- Undermining- look for skin that overhangs the wound edges.
- Conditions of the margins (macerated? mushy? look at outside borders.)
- Integrity of the surrounding skin
- Clinical signs of infection (redness, warmth, swelling, pain, odor, color and exudate) serous, purulent, sanguineous.
What are further factors that nurses need to document when assessing pressure ulcers?
Presence of undermining or sinus tracts
Amount of time the lesion has been known to exist
Note any past treatments and any change in products
Current treatment-document the type of irrigation, products, and secondary dressing used.
What changes to the skin occur due to age?
Reduction in skin turgor
Reduced thickness and vascularity of dermis
Degeneration of elastin fibers
Thinning and graying of hair on scalp, pubic and axilla areas
Thickening of hair in nose and ears
Slower growth of fingernails, more brittle nails
Reduction in number of sweat glands
What are measures to prevent pressure ulcers?
Provide nutrition- fluid intake, protein, vitamins, weight, lab data
Maintaining skin hygiene- mild cleansing agents, avoid hot water, moisturizers, skin protection
Avoiding Skin trauma- semi fowlers position, lifting devices, reposition every 2 hrs, smooth firm surfaces
Providing supportive devices-matress, beds, wedges, pillows
How do we care for patients with stage 1 or 2 pressure ulcers?
Prevent further breakdown
Apply decubitus mattress
Apply transparent film dressing (tegaderm) or hydrocolloid dressing (duoderm)
What are ways to manage stage 3 and stage 4 pressure ulcers?
Wounds may be cleansed wih normal saline if indicated
May cover with dry gauze
Obtain doctors orders or protocols established for pressure ulcers
What are different types of wound dressings?
Transparent film- Tegaderm Hydrocolloids - Duoderm Hydrogels Polyurethane Foams Alginates-Kaltostat Vacuum-assisted closure (VAC)- use of suction equip. to apply negative pressure to wound
What are factors that affect wound healing?
Diabetes Infection Drugs Nutrition Tissue Necrosis Hypoxia Excessive tension Another wound Low temperature
Describe the etiology for feeling pain.
Receptor nerve cells in and beneath your skin sense heat, cold, light, touch, pressure, and pain
When there is an injury-these tiny cells send messages along nerves into your spinal cord and then up to your brain.
What happens to the body in response to pain?
1st the sympathetic nervous system responds (fight or flight response)
Increase BP and Pulse, reflexive movements
Over time (minutes or hours) pulse and BP return to baseline despite persistence of pain
Vital signs adapt but pain fibers do not
Describe acute, chronic, referred, and radiating pain.
Acute-may have sudden or slow onset, it is protective, patient seeks help
Chronic- lasts 6 months or longer and often limits normal functioning
Referred- felt in a part of the body that is considerably removed from the tissues causing the pain
Radiating- is perceived at the source of the pain and extends to nearby tissues
Describe intractable, phantom, and neuropathic pain.
Intractable- pain that is highly resistant to relief
Phantom- painful sensation perceived in a missing body part, or in a body part paralyzed from a spinal cord injury. Can last for a long time and you still treat the patient for the pain they are feeling.
Neuropathic- results as a disturbance of the peripheral or central nervous system that results in pain, which may or may not be associated with an ongoing tissue damaging process. It is described as sharp and shooting.
Describe pain reaction, pain threshold, and pain tolerance.
Pain reaction- includes the autonomic nervous system and behavioral responses to pain.
Pain threshold- the amount of pain stimulation a person requires in order to feel pain. High threshold means you can tolerate pain well. Everyone’s threshold is unique.
Pain tolerance- the amount and duration of pain that an individual is willing to endure
What are factors that affect our pain experience?
Ethnic and cultural values
-Some tolerate making noise while in pain, others do not.
Developmental stage
Environment and Support Persons
Past pain experiences
-Can cause greater anxiety than necessary
Anxiety and Stress
-Can make pain worse
What questions do we ask while assessing pain?
Take a thorough history about the patient’s pain
Ask about:
- location - intensity - quality - pattern
Further questions:
- Pain to touch? - Is Pt walking with/without difficulty? - What activity were you doing before the pain started? - What makes the pain go away? - What helped last time with this pain? Was it medication?
When we assess pain, what are all the factors to take into consideration?
Precipitating factors
Alleviating factors
Associated symptoms
Effects on ADL’s
-Can they walk? Go to the shower? Bathe themselves?
Past pain experiences
Meaning of pain
Coping resources
Affective responses
What implementation is included for pain management?
Acknowledge patient’s pain
Assist support persons
Reduce misconceptions
Reduce fears and anxiety
What are nonpharmacologic ways to manage pain?
Physical interventions
-Repositioning pt.
Cutaneous stimulations
- Massage - Heat and cold - Accupressure
What are ways to administer nonpharmacologic practices?
Immobilization
TENS- Transcutaneous electrical nerve stimulation
Distraction- Tv, talking to them, family/visitors, relaxation channels on tv.
Hypnosis
What are analgesics?
Drugs which relieve pain without causing loss of consciousness.
What factors affect the selection of an appropriate analgesic?
- The severity of pain
- Duraiton of action
- Desired duration of therapy (how quickly will it go into effect and how long will it last)
- Ability to cause drug interactions
- Hypersensitivity of the patient
- Available routes of administration
Describe opioid analgesics.
Opium’s major component is morphine
-Morphine can cause respiratory depression, constipation
It is controlled substance used to treat moderate to severe pain
Opioids relieve pain by binding to opiate receptors and activating endogenous pain suppression in the CNS.
What are common side effects of opiates?
All opiates result in some initial drowsiness when first administer, but with regular administration, thi side effect tends to decrease.
May cause nausea, vomiting, constipation
Respiratory depression is common side effect to monitor
Dependence can result
What is the most popular analgesic antipyretic used?
Aspirin is the most popular, most widely used of this group, used for mild to moderate pain. High doses can cause an anti-inflammatory effect.
Some adverse effects are GI hemorrhage, Tinnitus, and Reyes Syndrome.
Describe acetaminophen.
Acetaminophen decreases pain and fever, but not inflammation.
Side effects include hepatotoxicity and nephrotoxicity and more.
Cough/cold medicines usually already have Tylenol
so overdose is unfortunately common.
Describe NSAIDS.
NSAIDS:
- drugs such as Ibuprofen (Advil, Motrin)
- Have anti-inflammatory, analgesic, and antipyretic effect.
- They relieve pain by acting on peripheral nerve endings at the injury site and decreasing the level of inflammation mediators generated at the site of injury.
What are examples of multi-purpose adjunctive medications?
Steroids: used in metastatic bone pain, mood elevation, and increased appetite. Also useful to relieve pain associated with liver metastasis and other visceral pain syndromes.
Capsaicin: diabetic neuropathy, posherpetic neuralgia, arthritis, Kaposi’s sarcoma lesions.
Vanlafaxine: SNRI: proved to be effective in diabetic neuropathy and treating depression.
Describe some treatments for neuropathic pain.
-Topical lidocaine/Lidoderm
-Capsaicin
Tricyclics antidepressants
-Anticonvulsants
Describe some treatments of muscle and visceral pain.
Baclofen-muscle spasms
Ditropan-bladder spasms, visceral pain
What does WHO stand for and how many steps are included in the analgesic ladder?
WHO= World Health Organization and there are three steps included in this ladder model
Describe what is included within the three steps on the analgesia ladder.
Step 1-Mild pain
-Tylenol, ASA (Aspirin), NSAIDS
Step 2-Mild to Moderate pain
- Combo drugs like Vicodin, Lortab, Percocet, Tylenol #3, Ultram - Hydrocodone, Codeine
Step 3- Moderate to Severe pain
-Morphine, Methadone, Dilaudid, Fentanyl, Oxycontin.
When administering pain medications, what are nursing interventions that are important to remember?
Assessment and planning must precede treatment
Use a pain scale before and after administration of medication
Question location, duration, intensity, and character of pain and other factors discussed
Monitor signs and symptoms of pain
(verbal statements, facial grimace, perspiration, nausea, anxiety, restlessness, vital sign changes, guarding)
Reassess patient’s pain within 30 minutes of giving med and then in 2 hrs.
Which is included in our documentation about a patient’s pain?
What patient describes (in own words if possible)
-“My head hurts, can I have my pain medication?”
The pain scale from 1-10: 4/10
Nursing assessment (be specific)
-Pt c/o headache that increases in bright room...etc.
Describe rest. What does it imply/not imply?
Rest implies calmness, relaxation without emotional stress, and freedom from anxiety.
Rest does not always imply inactivity
-Some people find some activities such as walking in fresh air restful
Describe the physiology of sleep.
Thought to be controlled by the centers located in the lower part of the brain.
The RAS (reticular activating system) is thought to control the sleep-wake cycles to some degree.
Describe NREM sleep. How many stages are included within NREM sleep?
NREM:
- Most sleep during the night is NREM sleep.
- It is a deep, restful sleep and brings a decrease in some physiological functions.
- Accounts for about 75-80% of sleep during the night
Four stages total
Describe stage 1 of NREM sleep.
Stage 1 of NREM sleep:
- Profound restlessness - Usually lasts only a few minutes - Floating sensation - Eyes roll from side to side
What happens in stage 2 of NREM sleep?
During stage 2 of NREM sleep:
- Lightly asleep - Easily aroused - Constitutes 40-45% of total sleep time
Describe stage 3 of NREM sleep.
Stage 3 of NREM sleep:
- Less easily aroused - Medium-depth sleep - Blood pressure lowers - Body temperature lowers - Muscles totally relaxed
*This is the stage where sleep helps restore physiologic factors
What happens in stage 4 of NREM sleep?
During stage 4 of NREM sleep:
- Deepest sleep stage - Rarely moves - Muscles completely relaxed - Difficult to arouse - Occurs 30-40 minutes following onset of sleep
Describe REM sleep.
REM sleep:
- About 25% of the sleep of a young adult
- Usually recurs about every 90 minutes and lasts 5-30 minutes.
- REM sleep is not as restful as NREM sleep
- Most dreams take place during REM sleep
- Active dreaming occurs and dreams are remembered
- The sleeper may be difficult to arouse or may wake spontaneously
- Muscle tone is depressed
- Heart rate and respiratory rate are often irregular
What is the order of stages within our sleep cycle?
NREM Stage 1
NREM Stage 2
NREM Stage 3
-Stages 1-3 last about 20-30 minutes
NREM Stage 4
-Stage 4 lasts about 30 minutes
NREM Stage 3
NREM Stage 2
REM Sleep
-REM lasts about 10 minutes
NREM Stage 2
-Another cycle is repeated excluding stage 1What are factors that affect our sleep?
Age
-Elderly don’t often sleep as long…up during the night…etc.
Environment
Fatigue
Life Style
Psychologic Stress
Alcohol and Stimulants
Diet
Smoking
Motivation
Illness
What are medications that affect sleep?
Alcohol Amphetamines Antidepressants Beta-blockers Bronchodilators Caffeine Decongestants Narcotics (stop the sleep cycle Steroids
What are some comfort measures that are used to promote sleep?
Administer analgesics or sedatives about 30 minutes before bedtime
Encourage clients to wear loose-fitting nightwear
Remove any irritants against the client’s skin such as moist or wrinkled sheets or drainage tubing
Position and support body parts to protect pressure points and aid muscle relaxation
Offer a massage just before bedtime
Provide caps and socks for older clients and those prone to cold
Administer necessary hygiene measures
Keep bed linen clean and dry
Provide a comfortable mattress
Encourage client to void before going to sleep
What is pain?
Pain-An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Before continuing to treat an ulcer, what are necessary steps you should take?
The nurse needs to look at it, describe it, measure it, etc. BEFORE continuing to treat the ulcer and dress it.
Define purulent, sanguineous, and serous.
Purulent: Containing discharge or production of pus
Sanguineous: Of, containing, relating to, or associated with blood
Serous: Thin and watery (can be clear)
What is a good way to remember whether to apply wet or dry dressings?
If wound is wet then you want to dry it
If wound is dry then you want to wet it
What is a sinus tract and how do we measure it?
A _______ ________ is a depression or cavity formed by a bending or curving.
Can be measured with a sterile Qtip
If a patient is not doing a lot of moving, then what kind of beds can be used?
Clinatron beds: Excellent yet expensive and doctor has to order it
Air mattresses: Effective and much cheaper
Describe hydrocolloids.
Hydrocolloids keep wounds moist, don’t get changed daily, sticks well, and depending on the doctor’s orders they can stay on for several days.
Describe wound vacs.
- Excellent for wounds that have a lot of drainage. –The tube goes into the wound bed with the dressing on top, where it then works as a suction, with negative pressure, to drain the wound.
- Can change dressing every 3-4 days
Define eschar and slough
Eschar: A dry scab or slough formed on the skin as a result of a burn or by the action of a corrosive or caustic substance.
Slough: A layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation.
What is an example of radiating pain?
Sciatic pain
What is a PCA pump and how does it work?
PCA stands for a patient controlled analgesic pump, which is a method of pain control that gives patients the power to control their pain.
This pump is prescribed by a doctor and is connected directly to a patient’s intravenous (IV) line.
Describe the normal, average, bradycardia, and tachycardia guidelines for heart rate.
Normal: 60-100 bpm
Average: 60-80 bpm
Bradycardia: Under 60 bpm (can be normal in athletes)
Tachycaria: Over 100 bpm
What are examples of blood vessels and what are the functions?
Examples of blood vessels:
Arteries, arterioles, capillaries, veins, venules
Function:
Transport 02 and nutrients
What are the components included in blood?
Platelets Plasma RBC's Hgb (hemoglobin) Hct (hematocrit) WBC's
Describe the rule associated with oxygenated/deoxygenated blood for arteries and veins. What is the exception to this rule?
Arteries carry oxygenated blood
Veins carry deoxygenated blood
Exception to the rule:
Pulmonary arteries carry deoxygenated blood and pulmonary veins carry oxygenated blood.
Describe the path of blood within the heart.
Blood from back portion of body goes into the inferior vena cava.
Blood from anterior portion of body goes into superior vena cava.
Both go into right atrium, tricuspid valve, right ventricle, pulmonary valve, pulmonary arteries, lungs, pulmonary veins, left atrium, mitral/bicuspid valve, left ventricle, aortic valve, aorta.
Keeping in mind that normal ranges change dependent on the institution, what are considerable lab value ranges for RBC’s, Hgb’s, Hct’s, and WBC’s?
RBC:
- Female: 3.6-5 - Male: 4.2-5.4
Hgb (Hb):
- Female: 12-16 g/dl - Male: 14-17.4 g/dl
Hct:
- Female: 36-48% - Male: 42-52%
WBC:
- Adult: 4.5-10.5 - Black adult: 3.2-10
Describe RBC’s.
RBC’s are major components of circulation
They carry oxygen & iron throughout the body
Describe Hct.
Hematocrit is the percentage of RBC’s combined with plasma.
Hct should be 3x the value of Hgb.
Useful for assessing hydration status and fluid status.
Hct values will be higher during dehydration due to combination of plasma.
Hct will drop with blood loss or with too much fluid in the body.
Bone marrow suppression will cause a drop in Hct.
What are the effects of aging on the circulatory system?
Arteriosclerotic plaques narrow the arterial walls
By 80 years of age, cardiac output will have decreased by 1/2. (1% drop each year after age 25)
Heart takes longer to respond to stress or exertion
Arteries lose the ability to stretch
Vein walls thin due to loss of subcutaneous tissue (will lead to bruising very easily)
Describe cardiac output.
___________ ____________ is the amount of blood ejected by the heart with each ventricular contraction.
Roughly 4-8 Liters each minute
What are the benefits of exercise?
Improved cardiovascular fitness
Greater lean body mass and lesser body fat
Improved strength and muscular endurance
Improved flexibility
Increased ability to use O2
Quicker recovery after hard work.
