TEST 1 Flashcards
NURSING OR MEDICINE?
Determines responses to health problems, level of wellness, and need for assistance
NURSING
NURSING OR MEDICINE?
Provides physical care, emotional care, teaching, guidance, and counselling
NURSING
NURSING OR MEDICINE?
Interventions aimed at prevention and assisting the client to meet his or her own needs
NURSING
NURSING OR MEDICINE?
Determines etiology of illness or injury
MEDICINE
NURSING OR MEDICINE?
Provides medical treatments and surgery
MEDICINE
NURSING OR MEDICINE?
Interventions aimed at preventing and curing injury or illness
MEDICINE
WHAT NURSING ROLE?
- compassionate, understanding, caring, empathetic
- offer skilled care to those recuperating from illness or injury
- alleviation of suffering through the diagnosis and treatment of human response
- prevention of illness and injury
- support patients at critical times
CAREGIVER
WHAT NURSING ROLE?
- daily care
- comprehensive care: complete care looking at potential complications
- collaborative care: working with other health professions
- requires critical thinking
CAREGIVER
WHAT NURSING ROLE?
- informed, communicative, patient, empathetic
- teach patients so that they can make informed decisions
- protection, promotion, and optimization of health and abilities
- and help them navigate the increasingly complex health care system
EDUCATOR
WHAT NURSING ROLE?
- requires effective communicative, assertion skills
- advocate for patients’ rights
- advocacy in the care of individuals, families, communities, and populations
- and help them navigate the increasingly complex health care system
- advocate for selves & peers
ADVOCATE
WHAT NURSING ROLE?
- requires good delegator, diplomatic, problem-solving skills
- policy development
LEADER OR MANAGER
WHAT NURSING ROLE?
nursing practice is dynamic and responds to increasing knowledge generated through research, reflection, and scientific discovery.
RESEARCHER
WHAT IS THE NURSING PROCESS?
ADPIE
ASSESS DIAGNOSE PLAN IMPLEMENT EVALUATE
WHAT PART OF THE NURSING PROCESS?
involves collecting subjective and objective information about the client
ASSESS
WHAT PART OF THE NURSING PROCESS?
analyzing the assessment data, drawing conclusions from the information, and labelling the human response
DIAGNOSE
WHAT PART OF THE NURSING PROCESS?
consists of setting goals and expected outcomes with the client and, when feasible, the client’s family and determining strategies for accomplishing the goals
PLANNING
WHAT PART OF THE NURSING PROCESS?
involves the use of nursing interventions to activate the plan. The nurse also promotes self-care and family involvement, where appropriate.
IMPLEMENT
WHAT PART OF THE NURSING PROCESS?
an extremely important part of the nursing process that is too often not addressed sufficiently
EVALUATE
WHAT PART OF THE NURSING PROCESS?
the nurse first determines if the identified outcomes have been met
EVALUATE
The NANDA list of accepted ________ _________ has been organized using a modification of Gordon’s (2006) functional health patterns. This framework is useful to analyze data to formulate actual nursing diagnoses, as well as nursing diagnoses for which the client is at risk.
nursing diagnoses
In the nursing diagnose, clinically relevant cues are clustered into functional ___________ ____________
health patterns
The two main purposes of NANDA are:
- to develop a diagnostic classification system (taxonomy)
2. to gather, identify, and standardize nursing diagnoses
ACUTE OR CHRONIC?
- is typically characterized by a sudden onset, with signs and symptoms related to the disease process itself.
- signs are typically objective manifestations of a condition, whereas symptoms refer to the subjective reports of the client.
- illness ends in a relatively short time, sometimes in recovery and sometimes in death
ACUTE
The simultaneous occurrence of several chronic medical conditions in the same person.
Multimorbidity
Having multiple chronic medical conditions is associated with many negative outcomes: clients have decreased quality of life, psychological distress, longer hospital stays, more postoperative complications, a higher cost of care, and higher mortality.
Multimorbidity
an increase in the seriousness of a disease or disorder as marked by greater intensity in the signs or symptoms of the patient being treated.
Exacerbation
What factors can contribute to and individual’s susceptibility to chronic illness
The key determinants of health are also critical considerations in the development of chronic illness.
What factors can contribute to and individual’s susceptibility to chronic illness
- Lifestyle factors such as substance use and misuse and high-risk activities can be harmful to a person’s long-term health.
- influence of social, economic, and environmental factors on the decisions people make about their health.
Modifiable OR non-modifiable risk factors to chronic illness?
age, sex, and genetic makeup
NONMODIFIABLE
Modifiable OR non-modifiable risk factors to chronic illness?
Cultural and environmental risk factors, such as air pollution, may play a significant role in the development of chronic illness, and may be modifiable in some cases.
MODIFIABLE
Objective manifestations of a condition
SIGN
The subjective reports of the client
SYMPTOM
PREOPERATIVE NURSING ACTIONS
- final preoperative teaching, assessment, and communication of pertinent findings, and ensuring that all preoperative preparation orders have been completed and that records and reports are present and complete to accompany the client to the OR.
- verify the presence of a signed operative consent, laboratory data, a history and PE report, a record of any consultations, baseline vital signs, and nurses’ notes.
if the anxiety level is extremely high, cognition, decision making, and coping abilities are ___________.
diminished
HOW CAN The nurse decrease some PREOPERATIVE anxiety for the client?
by providing information about what can be expected
WHAT SHOULD THE NURSE DO IF A PATIENT’S PREOPERATIVE ANXIETY IS EXCESSIVE?
The surgeon should be informed
Discharge planning considerations during the preoperative period
Consideration of family support is important with the older adult. With the increase in outpatient surgical procedures and shorter postoperative hospitalization, family support is an important consideration in the continuity of care for the older client.
information required during the preoperative interview
- Determine the psychological status of the client in order to reinforce coping strategies for undergoing the proposed surgery.
- Determine physiological factors related and unrelated to the surgical procedure that may contribute to operative risk factors.
- Establish baseline data for comparison in the intraoperative and postoperative periods.
- Identify prescription medications and over-the-counter drugs and herbs that have been taken by the client that may affect the surgical outcome.
- Ensure that the results of all preoperative laboratory and diagnostic tests are documented and communicated to appropriate personnel.
- Identify cultural and ethnic factors that may affect the surgical experience.
- Determine if the client has received adequate information from the surgeon to make an informed decision to have surgery, and ensure that the consent form is signed.
- Identify any pyschosocial needs of the client, and assess the client’s ability to cope with stressors and change to lifestyle. Ensure that the client has supports in place for the postoperative period.
Preoperative nursing assessment
- Determine the client’s psychological and physiological factors that may contribute to operative risk factors
- Establish baseline data
- Identify and document the surgical site
- Identify prescription and over-the-counter (OTC) drugs and herbal products
- Confirm laboratory results
- Note cultural and ethnic factors that may affect the surgical experience
- Validate that the consent form has been signed and witnessed
Common fears associated with surgery include:
the potential for death, permanent disability resulting from surgery, pain, change in body image, or results of a diagnostic procedure.
Before nonemergency surgery can be legally performed, the client must sign a voluntary and informed consent in the presence of a witness.
INFORMED CONSENT
an active, shared decision-making process between the provider and the recipient of care
that protects the client, the surgeon, and the hospital and its employees.
INFORMED CONSENT
3 conditions must be met for consent to be valid.
- must be adequate disclosure of the diagnosis; the nature and purpose of the proposed treatment; the risks and consequences of the proposed treatment; the probability of a successful outcome; the availability, the benefits, and the risks of alternative treatments; and the prognosis if treatment is not instituted.
- the client must demonstrate clear understanding and comprehension of the information being provided. Because preoperative drugs may cloud a client’s comprehension, the operative consent must be signed before any preoperative medication is given.
- the recipient of care must give consent voluntarily. The client must not be persuaded or coerced in any way to undergo the procedure
3 exceptional circumstances for obtaining consent in an emergency situation include:
- when the client exhibits a life- or health-threatening episode,
- when treatment cannot be delayed without endangering the life or health of the client, and
- when the client is unable to consent for the procedure because of circumstances beyond his or her control.
Preoperative teaching involves 3 types of information:
sensory, process, and procedural.
CONSIDERATIONS FOR PREOPERATIVE TEACHING: Different clients, with varying cultures, backgrounds, and experiences, may want ___________ types of information.
different
CONSIDERATIONS FOR PREOPERATIVE TEACHING: DOCUMENTATION
All teaching should be documented in the client’s medical record.
CONSIDERATIONS FOR PREOPERATIVE TEACHING: 3 POST-OPERATIVE EXERCISES
- DB&C
- REPOSITIONING
- LEG ROM
CONSIDERATIONS FOR PREOPERATIVE TEACHING:
3 CONSIDERATIONS FOR NUTRITION
- Most surgeries require NPO after midnight
- Increase diet slowly
- Nausea is common
CONSIDERATIONS FOR PREOPERATIVE TEACHING: AMBULATION
EARLY AMBULATION IS IMPORTANT AND HELPS PREVENT DVT
CONSIDERATIONS FOR PREOPERATIVE TEACHING: MEDICATION
Stop taking prescribed medications, OTC medications, and herbal remedies as suggested by the physician, anaesthesiologist, or surgeon
Types of control measures and purpose of those measures in the OR
- Filters and controlled airflow in the ventilating systems provide dust control
- Positive air pressure in the rooms prevents air from entering the OR from the halls and corridors
- The functional design facilitates the practice of aseptic technique by the OR team
- The temperature is controlled to remain between 20°C and 24°C & humidity is regulated at 30 to 60% to facilitate client comfort under the surgical drapes, team comfort during the procedure, and an environment that is unfavourable to bacterial incubation and growth
- There should also be proper ventilation in each room to provide both physical comfort and for proper air exchange, which helps remove toxic fumes and anaesthetic gas fumes
- The privacy of the client is achieved by restricting access by unnecessary hospital personnel and to visitors.
OR aseptic considerations
- Supplies should be opened as close as possible to the surgery start time.
- Each package should be checked for wrapper integrity and changed chemical indicators (both external and internal).
- The contents of any package with questionable wrappers or indicators should be considered unsterile.
- Fabric, plastic, or items wrapped in paper or plastic that are dropped on the floor should be considered unsterile.
- All materials that enter the sterile field must be sterile.
- If a sterile item comes in contact with an unsterile item, it is contaminated.
- If an item is contaminated before passing it to the scrub nurse, it should immediately be discarded.
- Sterile team members must wear only sterile gowns and gloves. Once dressed for the procedure, they should recognize that the only parts of the gown considered sterile are the front from chest to table level and the sleeves to two inches above the elbow.
- A wide margin of safety must be maintained between the sterile and the unsterile fields.
- Tables are considered sterile only at tabletop level; items extending beneath this level are considered contaminated.
- The edges of a sterile package are considered contaminated once the package has been opened.
- Bacteria travel on airborne particles and will enter the sterile field with excessive air movements and currents.
- Bacteria travel by capillary action through moist fabrics, and contamination occurs.
- Bacteria harbour on the client’s and the team members’ hair, skin, and respiratory tracts and must be confined by appropriate attire.
Identification process for OR:
Asking the client to state:
- her or his name
- the surgeon’s name
- the operative procedure and location.
A rare metabolic disease characterized by hyperthermia with rigidity of skeletal muscles that can result in death.
Malignant hyperthermia
The choice of discharge site is based on:
- client acuity,
- access to follow-up care,
- potential for postoperative complications.
specifically an arterial oxygen tension (PaO2) of less than 60 mm Hg, is characterized by a variety of nonspecific clinical signs and symptoms, ranging from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia.
- Hypoxemia,
- The most common cause of postoperative hypoxemia is _____________, which occurs as a result of retained secretions or decreased respiratory excursion.
atelectasis
- Appropriate postoperative positions for recovery:
- the unconscious client is positioned in a lateral “recovery” position (keeps the airway open and reduces the risk of aspiration if vomiting occurs)
- Once conscious, the client is usually returned to a supine position with the head of the bed elevated (maximizes expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm)
Interventions for hypotension
The most common cause of hypotension in the PACU is unreplaced fluid and blood loss; thus, treatment is directed toward restoring circulating volume. If there is no response to fluid administration, cardiac dysfunction should be presumed to be the cause of hypotension
Intervention for hypotension must be ____________ to prevent the devastating complications of cardiac ischemia or infarction, cerebral ischemia, renal ischemia, and bowel infarction.
timely
Initial nursing actions (2) upon receiving postoperative client on surgical floor from the PACU:
- Assess vitals
- Review post-op orders
Priority care in the postanaesthesia care unit (PACU) includes monitoring and management of:
4 things
- respiratory and circulatory function,
- pain,
- temperature,
- the surgical site.
Nursing interventions to promote intestinal motility
Abdominal distension may be prevented or minimized by early and frequent ambulation, which stimulates intestinal motility
The use of unfractionated heparin (UH) or low–molecular weight heparin (LMWH) is a prophylactic measure to prevent:
venous thrombosis and pulmonary embolism
4 Nursing interventions for absence of voiding
- normal positioning of the client—sitting for women and standing for men
- Providing reassurance
- use of techniques such as running water, drinking water, or pouring warm water over the perineum may also be of assistance
- encouraging ambulation
Interventions (in proper order) if postoperative bleeding is assessed at the incision site:
- Reinforce
- replace blood loss
- Perform clotting screen and platelet count, ensure good intravenous (IV) access.
- inserting a central venous pressure (CVP) catheter.
- Give protamine if heparin has been used.
- Order cross-matched blood.
- If the clotting screen is abnormal, give fresh frozen plasma (FFP) or platelet concentrates. 8. Consider surgical re-exploration at all times.
CAUSES OF DVT:
- inactivity,
- body position,
- pressure
RISKS OF DVT
VENOUS STASIS
DECREASED PERFUSION
DVT IS ESPECIALLY COMMON IN WHAT POPULATIONS
older adults and obese or immobilized individuals, clients with a history of DVT have a greater risk for pulmonary embolism.
WHY IS DVT LIFE-THREATENING?
because it may lead to pulmonary embolism.
WHAT ARE THE WARNING SIGNS OF PULMONARY EMBOLISM?
any client complaining of tachypnea, dyspnea, and tachycardia, particularly when the client is already receiving oxygen therapy
MANIFESTATIONS OF PULMONARY EMBOLISM
chest pain, hypotension, hemoptysis, dysrhythmias, or heart failure.
If a piece of a _____________ becomes dislodged and travels to the ___________, it can cause a pulmonary infarction of a size proportionate to the vessel in which it lodges.
clot
lung
syndrome characterized by decreased tissue perfusion and impaired cellular metabolism
Shock
SHOCK results in an imbalance between the __________ of and the ___________ for oxygen and nutrients.
supply
demand
When a cell experiences a state of _____________, the demand for oxygen and nutrients exceeds the supply.
hypoperfusion
WHICH STAGE OF SHOCK?
occurs at a cellular level is usually not clinically apparent
IntitIal stage
WHICH STAGE OF SHOCK?
clinically apparent and involves neural, hormonal, and biochemical compensatory mechanisms in an attempt to overcome the increasing consequences of anaerobic metabolism and to maintain homeostasis.
Compensatory stage
WHICH STAGE OF SHOCK?
begins as compensatory mechanisms fail
PROGRESSIVE STAGE
4 STAGES OF SHOCK:
- INITIAL
- COMPENSATORY
- PROGRESSIVE
- REFRACTORY
WHICH STAGE OF SHOCK? decreased perfusion from peripheral vasoconstriction and decreased CO exacerbate anaerobic metabolism
REFRACTORY
WHICH STAGE OF SHOCK? In this final stage, recovery is unlikely.
REFRACTORY
WHICH STAGE OF SHOCK? the client will demonstrate profound hypotension and hypoxemia, and organ failure.
REFRACTORY
WHICH STAGE OF SHOCK? aggressive interventions are necessary to prevent the development of MODS.
PROGRESSIVE STAGE
TYPE OF SHOCK occurs when there is a loss of intravascular fluid volume.
HYPOVOLEMIC SHOCK
TYPE OF SHOCK
results when fluid is lost through hemorrhage, gastrointestinal (GI) loss (e.g., vomiting, diarrhea), fistula drainage, diabetes insipidus, hyperglycemia, or diuresis.
ABSOLUTE HYPOVOLEMIC SHOCK
TYPE OF SHOCK
results when fluid volume moves out of the vascular space into extravascular space (e.g., interstitial or intracavitary space) and this is called third spacing.
RELATIVE HYPOVOLEMIC
PHYSIOLOGICAL CONSEQUENCES OF HYPOVOLEMIC SHOCK
decrease in venous return, preload, stroke volume, and CO resulting in decreased tissue perfusion and impaired cellular metabolism.
CLINICAL MANIFESTATIONS OF HYPOVOLEMIA
increase in heart rate, CO, and respiratory rate and depth; and a decrease in stroke volume, PAOP, and urine output.
CLINICAL MANIFESTATIONS OF HYPOVOLEMIA depend on the ____________ of injury or insult, age, and general state of health and may include anxiety;
extent
Common laboratory readings during progressive stage
Increased lactic acid: Usually increases once significant hypoperfusion and impaired oxygen utilization at the cellular level have occurred; by-product of anaerobic metabolism
Increased Liver enzyme: Elevations indicate liver cell destruction in progressive stage of shock
Interventions for anaphylactic shock
Maintaining a patent airway is important
Nebulized bronchodilators are highly effective.
Aerosolized epinephrine can also be used to treat laryngeal edema.
Endotracheal intubation or cricothyroidotomy may be necessary to secure and maintain a patent airway
Common fluids used in fluid resuscitation
isotonic crystalloids, such as normal saline, are used in the initial resuscitation of shock.
Lactated Ringer’s solution should be used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate, and thus the serum lactate levels would increase.
In some cases, hypertonic saline may be administered to expand plasma volume
Colloids are effective volume expanders because the size of their molecules keeps them in the vascular space for a longer time.
Septic shock manifestations
- inflammation
- coagulation increase fibranolysis
- Respiratory failure
- fever
- tachycardic
- hyperventaltion
- hypoxemia
- low blood pressure urine output decreases
- confusion
- agitation
Goal of care for cardiogenic shock
to restore blood flow to the myocardium by restoring the balance between oxygen supply and demand.
Definitive measures to restore blood flow include thrombolytic therapy, angioplasty with stenting, emergency revascularization, and valve replacement
WHAT IS MODS
multiple organ dysfunction syndrome
failure of two or more organ systems in an acutely ill client such that homeostasis cannot be maintained without intervention
MODS
WHAT IS SIRS
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME
Nursing assessment for MODS
(1) prevention and treatment of infection,
(2) maintenance of tissue oxygenation,
(3) nutritional and metabolic support,
4) appropriate support of individual failing organs.
Dosage adjustment based on assessment of the adequacy of analgesic effect versus the side effects produced
TITRATION
What is your part in assessing appropriate pain sedation?
One widely used system is the analgesic ladder proposed by the World Health Organization (WHO)
The WHO treatment plan emphasizes that different drugs are used depending on the severity of pain, using a three-step ladder approach.
Step 1 drugs are used for mild pain, step 2 for mild to moderate pain, and step 3 for moderate to severe pain.
If pain persists or increases, drugs from the next higher step are used to control the pain.
The steps are not meant to be sequential if someone has moderate to severe pain: for this person, the analgesics given would be the stronger analgesics listed in steps 2 and 3.
How do you decide if pain is an issue?
- IF THE CLIENT SAYS IT IS
2. IF THE CLIENT’S HEALING IS BEING COMPROMISED BECAUSE OF PAIN
2 goals of a nursing pain assessment
(1) to describe the client’s multidimensional pain experience for the purpose of identifying and implementing appropriate pain management techniques
(2) to identify the client’s goal for therapy and resources for self-management.
Why is it important for postoperative patients, or even patients with pain to use pain sedation appropriately?
In the acutely ill client, unrelieved pain can result in increased morbidity as a result of respiratory dysfunction, increased heart rate and cardiac workload, increased muscular contraction and spasm, decreased gastrointestinal (GI) motility and transit, and increased catabolism.
It is dangerous and can lead to many physical and psychological complications.
UNRELIEVED PAIN
Rates of disease.
MORBIDITY
In the acutely ill client, unrelieved pain can result in increased ___________ as a result of respiratory dysfunction, increased heart rate and cardiac workload, increased muscular contraction and spasm, decreased gastrointestinal (GI) motility and transit, and increased catabolism
morbidity
________________ refers to the rates of disease in a population, whereas _____________refers to the rates of deaths.
Morbidity
mortality
Rates of death.
MORTALITY
_____________ involves the activation of descending pathways that exert inhibitory or facilitatory effects on the transmission of pain.
Modulation
Depending on the type and degree of ______________, the nociceptive stimuli may or may not be perceived as pain.
modulation
_____________ of pain signals can occur at the level of the periphery, the spinal cord, the brainstem, and the cerebral cortex.
Modulation
______________ is a structured technique that uses the client’s own imagination to develop sensory images that divert focus away from the pain sensation and emphasize other sensory experiences and pleasant memories.
Imagery
Like other distraction techniques, guided imagery provides a _________ _____________ for the pain
mental substitute
_____________ ____________ is a structured technique that enables a client to achieve a state of heightened awareness and focused concentration that can be used to alter the client’s pain perception
Hypnotic therapy
Concerns regarding tolerance, dependence, and addiction are common _____________ to effective pain management as these phenomena are often misunderstood.
barriers
Tolerance and physical dependence are not indicators of ______________. Rather, they are normal _____________ responses to chronic exposure to certain drugs, including opioids.
addiction
physiological
TRUE OR FALSE? Addiction is common in clients taking opioids for pain relief.
FALSE
Treatment of pain in the elderly client is ________________.
complicated
Older adults metabolize drugs more ____________ than younger persons and thus are at _____________ risk for higher blood levels and adverse effects
slowly
greater
The use of NSAIDs in elderly clients is associated with a high frequency of serious _____ ______________
GI bleeding
Health care providers for older clients should _________ drugs slowly and ________ carefully for side effects.
titrate
monitor
4 CONSIDERATIONS ABOUT PAIN & THE ELDERLY
- older clients often believe that pain is a normal, inevitable part of aging
- may also believe that nothing can be done to relieve the pain.
- may not report pain for fear of being a “burden” or a “bad client.”
- fear of constipation
- goals of a nursing pain assessment
1) to describe the client’s multidimensional pain experience for the purpose of identifying and implementing appropriate pain management techniques
(2) to identify the client’s goal for therapy and resources for self-management.
A comprehensive assessment of pain includes describing:
the onset, duration, characteristics, pattern, location, intensity, quality, and associated symptoms such as anxiety and depression.
Sensory Component (PAIN ABBREVIATION)
P - pattern of pain: pain onset (when it starts) and duration (how long it lasts)
A - area of pain: assists in identifying possible causes of the pain and in determining treatment
I - intensity of pain: assessing the severity, or intensity, of pain provides a reliable measurement that is used in determining the type of treatment, as well as evaluating the effectiveness of therapy
N - nature of pain: the pain nature refers to the quality or characteristics of the pain
Comprehensive pain assessment includes evaluation of all pain dimensions and should be completed at ____________to a facility or service and repeated at ___________ ____________ in order to ____________response to treatment.
admission
regular intervals
evaluate
__________ _____________ to inflammation includes the manifestations of redness, heat, pain, swelling, and loss of function.
local response
____________ _____________ of inflammation include leukocytosis with a shift to the left, malaise, nausea and anorexia, increased pulse and respiratory rate, and fever.
systemic manifestations
5 S&S of inflammation
- Redness
- Heat
- Pain
- Swelling
- Loss of function
the clinical signs of infection
- purulent exudate
- odour
- erythema
- warmth,
- tenderness
- edema
- pain
- fever
- elevated white cell count
The inflammatory response is a sequential reaction to __________ _____________.
cell injury
3 STEPS TO INFLAMMATORY PROCESS
- neutralizes and dilutes the inflammatory agent,
- removes necrotic materials,
- establishes an environment suitable for healing and repair.
The inflammatory response can be divided into 4 CATEGORIES
- a vascular response,
- a cellular response,
- formation of exudate,
- healing.
The need for increased WBCs stimulated by ______________ causes the bone marrow to release more neutrophils into the circulation.
chemotaxis
______________ are the primary phagocytic cells involved in an acute inflammatory response.
Neutrophils
If the demand for neutrophils continues, the bone marrow releases immature forms of neutrophils ( _____________ ) into circulation, causing what is known as a shift to the left.
bands
most important aspect of fever management should be determining its ______________
cause
fever in the immunosuppressed client should be treated ___________ and antibiotic therapy begun because infections can rapidly progress to ____________.
rapidly
septicemia
2 chronic illness that may impede healing:
Diabetes mellitus
Anemia
3 purposes of wound management include
(1) cleaning a wound to remove any dirt and debris from the wound bed,
(2) treating infection to prepare the wound for healing, and
(3) protecting a clean wound from trauma so that it can heal normally.
A dressing material that keeps the wound surface clean and slightly moist is optimal to promote epithelialization.
Red wound dressing
A type of dressing used as an absorption dressing (e.g., calcium alginate, foam, hydrophilic fibres, hypertonic gauze), which absorbs exudate and cleanses the wound surface.
Yellow wound
Semiocclusive or occlusive dressings may be used to promote softening of dry eschar by autolysis. These types of dressings are used in open wounds with necrotic debris and no infection.
Black wound
WHICH WOUND?
Characteristics: Traumatic or surgical wound, possible presence of serosanguineous drainage, pink to bright or dark red healing or chronic wounds with granulating tissue
Purpose of treatment:
Healing Protection and gentle, atraumatic cleansing, fill wound defects, control bacteria, maintain moisture.
RED
WHICH WOUND?
Characteristic: Presence of slough or soft necrotic tissue; liquid to semiliquid slough with exudate ranging from creamy ivory to yellow-green
Purpose of treatment
Healing: Wound cleansing to remove nonviable tissue and absorb excess drainage, debridement, bacteria control, fill wound defects, provide moisture balance
Nonhealing:
Remove loose nonviable tissue, control odour, fill wound defects, control bacteria, promote confort
YELLOW
WHICH WOUND?
Characteristics: Black, grey, or brown adherent necrotic tissue; possible presence of pus
Purpose of treatment
Healing: Debridement of eschar and nonviable tissue, control odour, control bacteria
Nonhealing: Maintain wound, do not debride intact eschar, control odour, control bacteria, promote comfort
BLACK WOUND
_____________ drugs: Impair phagocytosis by WBCs, inhibit proliferation and function, depress formation of granulation tissue, inhibit wound contraction
Corticosteroid
