Test 2 Flashcards
What is the first line of defense against infection?
Intact skin
What does regular bathing remove?
perspiration, bacteria, and oil from the skin
What does regular bathing do?
Increases circulation, maintaines muscle and joint mobility, promotes relaxation, provides a sense of well-being and comfort, time for assessment and interaction
What is self-care?
The ability to independently perform functions of: bathing, dressing, feeding, and toileting.
What does self-care independence enhance?
health and emotional well-being, dignity
Washing principles
Wash from clean to dirty, maintain privacy and dignity, incorporate patient preferences and values. Distal to proximal motion increases venous return
Evidence Based Practice: Basin Bath
Basin bath is associated with increase in infection areas
Evidence Based Practice: Peri-Care
Peri-Care is often omitted; associated with UTI
EVP: what do you do with an unconscious pt for oral care?
Turn them to their side
Oral Care
Helps maintain strong and healthy teeth and gums, prevent tooth loss, increase saliva, taste, comfort, prevent pneumonia
Types of baths
tub, shower, sit-down shower. bed bath (partial/complete), bag bath or towel bath, partial bath (sink bath)
What are some things to consider when bathing the patient?
consider energy, ability of pt, choose bath type that enhances independence while providing benefits. Provide supplies, assist as needed
In what situation would you give a partial bath?
If patient was already bath for the day but was incontinent
Foot Care
Disease state, ROM, and perfusion affect needs and abilities related to foot care
Foot Care assessment and patient aducation
Assess for temperature, circulation, sensation, and wounds. Educate- daily VSE (visual surveillance of extremities), good shoes, report changes
*Pat pts feet when towel drying, don’t rub
Shaving
Shave in direction of hair growth. Electric shaver if in anticoagulant treatment
Glasses & contacts/ Hearing aids
clean glasses daily/ check battery, clean per policy, replace
Feeding: Dysphagia
Difficulty swallowing. Assess patients for dysphagia before feeding. Watch them closely and have assistive devices. Thickened liquids are easier to swallow. Separate flavors, don’t mix them
Toileting
Assess level and type of assistance needed. Assist to bathroom. Provide privacy while maintaining safety, provide hand hygiene for patient, assess need for assistance with peri-care
When are linens changed?
In conjunction with bathing
What is a pressure ulcer?
A localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination w/shear and/or friction
Stage 1 pressure ulcer
Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage 2 pressure ulcer
Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, with slough
Stage 3 pressure ulcer
Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed.
Stage 4 pressure ulcer
Full-thickness tissue loss with exposed bone, tendon, or muscle.
Unstageable
Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. True depth of wound cannot be assessed until slough/eschar is removed
Risks for pressure ulcers
Immobility (unable to move independently), Impaired Perception (numbness, paralysis), Altered LOC (confused-perceive pain/pressure but cant communicate/relieve pressure, coma: no perception plus immobility
Shearing
Skeleton, muscle slide one way, skin stays or moves the other way
Friction
Top layers of skin, sliding across coarse linens, seats, position changes w/o lifts
Wound Healing: Primary Intention (surgical wound)
Clean edges, approximated (closed), low risk of infection, quick healing, fine scar
Secondary Intention
Trauma, ulcer, dehisced wound. Open- wound healing, filled by scar tissue, granulation over time-deep scar. Slow healing= increased risk for infection
Wound Dressings
Protection (against contamination, pain from air), Homeostasis (pressure, clot, edges), Increased Healing (absorb drainage, debride depending on type), Moist environment
Which dressing?
Depends on wound assessment, purpose. Purpose is to provide the right environment to enhance and promote wound healing
What do dressings do?
Moist healing environment stimulates cell proliferation and encourages epithelial cells to migrate. Provide barrier against bacteria and absorb fluid. Decrease or eliminate pain
Assessment of wound care
Is the wound copiously draining? Is it dry? Does it need added moisture? Does it need debridement? Is it infected?
Dehiscence
Wound has opened up. Most often 4-5 days post op
Types of dressings and uses
Gauze- draining wounds, necrotic wounds, those requiring debridement or packing, wounds with tunnels, tracts, or dead space, surgical incisions, burns, dermal ulcers, and pressure ulcers. Some gauze may be integrated with antimicrobial (IV sites, and full thickness wounds are examples)
Transparent films
Lets oxygen pass through to the wound and moisture vapor escape. Not always absorbent
When would transparent films be used?
Partial-thickness wounds, stage 1 and 2 pressure ulcers, superficial burns, donor sites, as a secondary dressing
Foam
Nonadherent and nonocclusive. Hydrophillic, polyurethane, or film coated gel
When would foam be indicated?
Stage 2 and 4 pressure ulcers, partial and full thickness wounds with minimal to heavy drainage, surgical wounds, dermal ulcers, under compression wraps
Composite dressings
Combinations of two or more different products in one. Bacterial barrier, absorptive layer, foam, hydrocolloid, or hydrogel. Semi-adherent or nonadherent
When are composite dressings indicated?
Partial and full-thickness wounds, minimally to heavily draining wounds, dermal ulcers, and surgical incisions
Heat and Cold therapy: Heat
Increases blood flow- vasodilation. Increases oxygen and nutrients to infected area
Heat and Cold therapy: Cold
Vasoconstriction- decreases blood flow.
Wound Care
Least to most contaminated
What is increased to promote healing?
Increase protein, increase vitamin C, increase calories for healing
What does the integumentary system consist of?
Skin, hair, nails
Skin
The largest organ of the body
How does the skin protect?
Regulates body temperature, maintains fluid and electrolyte balance, can repel micoorganisms, can alarm the body that something is wrong, many sense receptors to allow the use of touch
Epidermis
Lacks its own blood supply (Avascular), Keratin makes the outer layer (Stratum corneum) waterproof
Vitamin D
Is activated in the epidermis by UV light, then distributed to the intestines where it promotes the uptake of calcium
Melanocytes
Give color to the skin. Person of color has bigger melanocytes, not more. Patches of melanin make freckles, birth marks and age spots
Hair
Hair follicles are located in the dermis, but are extended from epidermal layer. Hair growth occurs in cycles. Hair color is genetically determined by the persons melanin production. Permaneant baldness (female and male) is genetic
Nail Assessment
Assess for color, shape, thickness, texture and any lesions
Nail Color
Depends on nail thickness, # of RBCs, arterial blood flow and pigment deposits
Nail thickness and shape
Nail thickness increases with aging. Shape: check for clubbing, splitting, separation or increased thickness. Blanch the nail beds
Skin Assessment
History (ask about OTCs, herbal meds, allergies, nutritional status, current health problems), color, vascularity and moisture
Skin: Bacterial Infections- folliculitis, furuncle, cellulitis
Folliculitis- isolated pustules, may have hair growing from it. Furuncle- pus filled lesions. Cellutlitis- darker with red tone
Skin: Viral Infections- Herpes Simplex and Zoster
Simplex- patches, vesicles evolve to postules, which rupture, weep and crust
Zoster- Similar to simplex but present in a iine, along a cranial or spinal nerve
Skin: Fungal Infections-Candidiases
Skinfolds, reddened, macular, oral: whitish plaques
Wound Healing: First Intention
A laceration or incisonal wound, edges are brought together with skin approximated and held in place. Closing the wound immediately helps the connective tissue repair
Wound Healing: Second Intention
Deeper injuries with tissue loss (pressure ulcer) have a cavity open wound that has to heal from gradual filling up the wound with connective tissue
Wound Healing- Third Intention
Delaying closing the wound, waiting for infection or erythema to decrease and then closing it by primary intention.
Wound Exudate: Serosanguinous exudate
Blood tinged fluid consisting of serum and RBCs
Wound Exudate: Purulent exudate
Creamy yellow, beige or green pus, usually have an odor
Contact Dermatitis
An acute or chronic rash caused by direct contact of an irritant or allergen
Atopic Dermatitis
Chronic rash that occurs with respiratory allergies and atopic skin disease
Psoriasis
Lifelong, no cure, may be genetic. An auto immune reaction, scaling disorder with dermal inflammation underneath
Benign Tumors: Cysts
Firm, flesh colored nodules, moves and indents on palpation
Benign Tumors: Nevus
Well defined borders, uniform in color
Benign Tumors: Seborrheic Keratosis
Most common in older people. Brown, tan or black, rough wartlike texture
Benign Tumors: Keloids
Overgrowth of a scar with excessive collagen. More common in AA
Skin Cancer: Squamous Cell Carcinoma
Cancer of the epidermis
Skin Cancer: Basal Cell Carcinoma
Come from the basal cell layer of the epidermis
Skin Cancer: Melanoma
Pigmented cancer cells that come from the melanin producing epidermal cells. Highly metastatic
Environmental Safety
A safe environment includes- meeting basic needs, reducing physical hazards, reducing transmission of pathogens, maintaining sanitation, and controlling pollution
Incident Report
Required for any accident/injury in healthcare setting. Not part of a medical record. Includes: what happened, patient assessment, interventions provided
Restraint Use
Must have a physician order (may apply in emergency, then get order), Order must be rewritten every 24 hours, Restraint policies are specific to health care setting, documentation every 2 hours
Sub Q angle, Intradermal angle, Intramuscular angle
45, 15, 90
Therapeutic effect
Expected or predictable
Side effect
Predictable and often unavoidable
Adverse effect
Unintended, undesirable, and often unpredictable severe response
Toxic effect
Medication accumulates in the blood stream
Isisyncratic reaction
over or under to a medication
Allergic Reaction
Unpredictable response to a medication
Medication Interactions: Synergistic Effects
A synergistic effect occurs when the combined effect of two medications is greater than the effect of the medications given separately
