week 5 content Flashcards
Types of burns
__________
- Flame
- Flash
- Scald
- Contact with hot objects
____________
- Acid
- Alkaline
_______________
- oral/nasal injury
- esophageal injury
- direct parenchymal (functional part) of lung injury
___________
- conversion of electrical energy into heat
_________
- transfer of radiant energy to the body (radiation therapy for cancer)
_____________
- frost bite
- most common in children and OA r/t reduced ability to generate heat
Thermal – most common
cehmical
Inhalation
Electrical
Radiation
Extreme temperature
classification of burn injury:
severity determined by
(4)
- depth of burn
- extent of burn – based on % calculation of total body surface area
- location of burn
- age of patient, medical hx, any circumstances or complicating factors
depth of burn
1. superficial partial thickness = least damaging (1st degree)
2. deep partial thickness = medium damaging (2nd degree)
3. full thickness = most damaging (3rd degree)
- epidermis
- epidermis
- dermis
- epidermis
- dermis
- fat
- muscle
- bone
what do these tell you about the burn?
- lund-browder chart – more accurate b/c it considers patients age in proportion to relative body area size
- rule of nines chart
extent of burns
primary goal in burn emergency
(5)
- stop the burning by removing the source
- ABC’s
- Assessment of burns
- Transfer to burn center as needed
- Stabilization
3 phases of burn management
- Emergent/resuscitative phase
- Acute phase
- Rehabilitation phase
Emergent/resuscitative phase
how long
(up to 72 hours from event where burn occurred)
______________ phase
Time needed to resolve the immediate, life-threatening problems resulting from the burn injury
Emergent/resuscitative phase
Main concern in Emergent/resuscitative phase (2)
Main concern
- Hypovolemic shock – r/t fluid shift
- Edema formation - r/t capillary membrane – there’s no longer a semi-permeable membrane and fluid shifts
Patho of Emergent/resuscitative phase
- Massive F&E shift – r/t ___________
- Hypovolemic shock
main concern?
massive increase in permeability of capillaries
hypovolemic shock
Manifestations of Emergent/resuscitative phase
- Shock due to ________
- Pain - how does it vary by severity?
- which primary skin lesion?
hypovolemia
- full thickness burns (3rd) = less pain due to nerve damage
- Vesicle - blisters
3 main complications of Emergent/resuscitative phase
1. ____________ system
- __________system
3._________ system
cardiovascular
pulmonary
urinary
complications of Emergent/resuscitative phase
1. cardiovascular system
- shock + increased viscosity = ___ risk
- circumferential burns and edema = impaired ________
- treatment for circulation complication =
VTE
circulation
escharotomy (open eschar which allows perfusion and increased circulation)
complications of Emergent/resuscitative phase
2. if burn is inhaled…
which system is a concern for complications?
upper, lower, or both?
pulmonary system
upper and lower airway injury is a concern
complications of Emergent/resuscitative phase
3. why are we worried about the urinary system?
acute renal failure
d/t decrease blood flow to kidneys (w/ shock)
and excessive myoglobin and hemoglobin released
which can block renal tubules
nursing care Emergent/resuscitative phase
prioritize: airway and fluid therapy
- aggressive fluid resuscitation with 2 large bore IVs or Central Venous Access Device (CVAD)
- crystalloids (LR), colloids (albumin), or both?
- what will the fluids do?
- formulas based on location and extent of burns determine amount of fluids to give
- airway #1
- fluid therapy #2
crystalloids (LR), colloids (albumin), or both = increases intravascular volume, increases CO, decreases shock
wound care Emergent/resuscitative phase
1. necrotic tissue removed with ______?
2. escharotomies (open eschar) and fasciotomies (open fascia) performed to help with _________?
3. physically or mentally demanding on pt?
4. permanent or temporary skin coverage = goal?
5. with exposed wounds
PPE = ?
6. Sterile or clean gloves to apply ointments/dressings?
7. Keep room warm or cold?
1.debridement
2.circulation
3.both
4.permanent
5. hats, masks, gloves, gown
6. sterile
7. warm
Drug therapy Emergent/resuscitative phase
- ________ for analgesic and sedative – ATC, IV
- ________ immunization
- _______ antimicrobial agents
* Silver sulfadiazine (Silvadene) - Systemic or local only if concerns regarding sepsis – leading cause of death with burns?
- ___ prophylaxis – r/t increased viscosity
- Nutritional therapy enteral or parenteral feedings?
Opioids
Tetanus
Topical
systemic
VTE
enteral - use gut if working
Silver sulfadiazine (Silvadene)
Drug therapy Emergent/resuscitative phase
Topical antimicrobial agents
Systemic only if concerns regarding sepsis – leading cause of death with burns
Acute phase
how long
(3 weeks – months)
Acute phase
Begins = with mobilizations of _______ and subsequent__________
Ends = when partial thickness wounds are ______and full thickness burns are ________
Begins = with mobilizations of ECF and subsequent diuresis
Ends = when partial thickness wounds are healed and full thickness burns are covered by skin grafts
Acute phase
Partial thickness
- _______ formation: A crust or scab forms over the burned area, layer of dead tissue.
- Removal and re-epithelialization: The eschar can often be removed by medical professionals, allowing__________. This process is known as re-epithelialization
Partial thickness
- Eschar formation: A crust or scab forms over the burned area, layer of dead tissue.
- Removal and re-epithelialization: The eschar can often be removed by medical professionals, allowing new skin cells (epithelial cells) to grow and cover the wound. This process is known as re-epithelialization
Acute phase
Full thickness
T/F
- faster eschar separation compared to partial thickness?
- surgical debridement and skin grafting is common
F - slower because the damage extends deeper
T
_____________ phase
Goals
- working towards resuming functional role in society
- rehabilitate from any reconstructive surgery that may be needed
rehabilitation
rehabilitation phase
avoid ___________ and hypertrophic __________ by
- ROM
- Pressure garments – help keep scars flat
contractures
scarring
HIV is considered AIDS when 1 of 2 things occur (and Usually these occur at the same time)
_______
OR
_______
- CD4 count <200
OR - Developed specific opportunistic infection occurs (cancers, pneumocystis jirovecii, Kaposi’s sarcoma, wasting syndrome, pervasive candidiasis)
how many stages of HIV
3
HIV
stage 1
stage 1.5
Stage 1 = early/acute infection
- Rapid replication
- Undetectable with labs
- Asymptomatic
- Infectious
Stage 1.5 = seroconversion
- Detectable (antibodies)
- Flu like symptoms for several weeks
- Highly infectious!!
HIV
stage 2
stage 2.5
stage 2 = clinical latency/chronic
- Virus levels have stabilized
- Body is fighting infection
- Asymptomatic or mild symptoms
- With treatment = can be in this phase for decades
- Without treatment = can be in this phase for 3-12 years
Stage 2.5 = rapid virus production
- Antiviral fight is becoming less effective
- Viral load increases
- CD4 and T cell count decreases
HIV
stage 3
Stage 3 = AIDS
- Symptomatic HIV infection
which HIV stage?
- Rapid replication
- Undetectable with labs
- Asymptomatic
- Infectious
Stage 1 = early/acute infection
which HIV stage?
- Detectable (antibodies)
- Flu like symptoms for several weeks
- Highly infectious!!
Stage 1.5 = seroconversion
which HIV stage?
- Virus levels have stabilized
- Body is fighting infection
- Asymptomatic or mild symptoms
- With treatment = can be in this phase for decades
- Without treatment = can be in this phase for 3-12 years
stage 2 = clinical latency/chronic
which HIV stage?
- Antiviral fight is becoming less effective
- Viral load increases
- CD4 and T cell count decreases
Stage 2.5 = rapid virus production
which HIV stage?
- Symptomatic HIV infection
- CD4 count <200
- Developed specific opportunistic infection occurs (cancers, pneumocystis jirovecii, Kaposi’s sarcoma, wasting syndrome, pervasive candidiasis)
Stage 3 = AIDS
HIV Risky behaviors
SATA
- Men sex with men
- swimming with infected person
- Injection drug use
- Heterosexual contact
- Mother to child – perinatal
- Blood transfusion
- sharing food
- Men sex with men
X- swimming with infected person - Injection drug use
- Heterosexual contact
- Mother to child – perinatal
- Blood transfusion
X- sharing food
Transmission HIV
SATA
semen
vaginal secretions
Parenteral blood
pregnancy
birth
breastfeeding
all
- improve adherence outcome to ART
SATA - ensure pt is motivated
- social support
- make sure they can afford it
- negotiate treatment plan
- simple regimen
- anticipate s/e
- establish trust
- ensure pt is motivated
- social support
X* make sure they can afford it - negotiate treatment plan
- simple regimen
- anticipate s/e
- establish trust
Education for AIDS patient
SATA
r/t immunosuppression
- Avoid crowded areas
- Avoid traveling to countries with poor sanitation
- Avoid raw food or undercooked food
- Avoid cleaning litter boxes
- Keep home clean
- Don’t allow sick people to visit
- Don’t continue relationships with HIV infected people
Continue ART
Monitor CD4 and viral load
r/t immunosuppression
- Avoid crowded areas
- Avoid traveling to countries with poor sanitation
- Avoid raw food or undercooked food
- Avoid cleaning litter boxes
- Keep home clean
- Don’t allow sick people to visit
X- Avoid relationships with HIV infected people
Continue ART
Monitor CD4 and viral load
HIV Assessment
- Checking for cognitive changes – _____________
- _______ manifestations are common and associated with decreasing CD4 counts
- Types of infections - SATA
- Fungal
- Viral
- Bacterial
- Cancerous
AIDS dementia complex
Oral
all
HIV Prevention
- Avoid risk factors
- Talk about sensitive subjects
- Decrease risks r/t drug use – needle exchange program
- teach how to clean needles with soap
- Decrease risk of perinatal transmission
- Encourage routine HIV testing
- Decreasing work risk with Universal precautions
- universal precautions
- Post exposure prophylaxis
- Pre exposure prophylaxis
HIV Prevention
- Avoid risk factors
- Talk about sensitive subjects
- Decrease risks r/t drug use – needle exchange program
X- teach how to clean needles with soap
- Decrease risk of perinatal transmission
- Encourage routine HIV testing
- Decreasing work risk with Universal precautions
- universal precautions
- Post exposure prophylaxis
- Pre exposure prophylaxis
Universal precautions
potentially infectious HIV
SATA
- Blood
- CSF
- Synovial fluid
- Pleural fluid
- Amniotic fluid
- coughing
- Blood
- CSF
- Synovial fluid
- Pleural fluid
- Amniotic fluid
X- coughing
HIV Health care exposure
Exposure includes
SATA
- Need stick
- Cut with sharp object
- Mucous membrane contact
- Non-intact skin contact
- airborne droplets
- Need stick
- Cut with sharp object
- Mucous membrane contact
- Non-intact skin contact
X- airborne droplets
Post or pre exposure prophylaxis?
Recommendations based on risk of acquiring HIV
- Nature and severity of exposure
- HIV status of exposure source
Post exposure prophylaxis
Post exposure prophylaxis
Regimen ?
Follow up testing for HIV ?
- Combination therapy
- Start drug therapy ASAP – 1-2 hours ideal, max 72 hours
- 6 weeks
- 12 weeks
- 6 months
Pre or post exposure prophylaxis?
Daily med to lower chance of getting HIV
- Highly effective if used as prescribed
Preexposure prophylaxis
Preexposure prophylaxis
Doesn’t protect against other STIs?
Who qualifies? SATA
1. Anal or vaginal sex in last 6 months and Sexual partner has HIV with unknown viral load
2. Anal or vaginal sex in last 6 months and Sexual partner has HIV with known viral load
3. Anal or vaginal sex in last 6 months and uses condom consistently
4. Anal or vaginal sex in last 6 months and Have been diagnosed with STD in the last 6 months
5. men who have had sex with men in last 6 months
6. People who inject drugs
7. People who inject drugs and Injection partner had HIV
8. People who inject drugs and they share equipment to inject drugs
true - continue condom use
X 3. - Haven’t used condom consistently
X 5. men who have had sex with men in last 6 months AND…
X 6. People who inject drugs AND …
Anal or vaginal sex in last 6 months and
- Sexual partner has HIV – unknown or known viral load…OR
- Haven’t used condom consistently… OR
- Have been diagnosed with STD in the last 6 months
People who inject drugs and
- Injection partner had HIV… OR
- They share equipment to inject drugs
Routine screening - at least once
yearly screening - annual screen every year
based on risk factors
- Healthy adults, without risk factors, ages 13-75
- pregnant women, without risk factors, ages 13-75
- Men sex with men
- Injection drug use
- Exchange sex for money/drugs
- Sex partners have HIV, are bisexual, or injection drug users
- Sex partner has unknown HIV status
Routine screening
- Healthy adults, including pregnant women, without risk factors, ages 13-75
Yearly screening
- High risk
- Men sex with men
- Injection drug use
- Exchange sex for money/drugs
- Sex partners have HIV, are bisexual, or injection drug users
- Sex partner has unknown HIV status
HIV screening implications SATA
- Consent
- verify allergies - iodine
- Confidentiality
- Counseling
- Referral to care – if positive for HIV
- Consent
X- verify allergies - iodine - Confidentiality
- Counseling
- Referral to care – if positive for HIV
which generate of ELISA – enzyme linked immunosorbent assay, HIV testing is preferred? and why?
New tests – combination HIV antibody AND antigen tests (“4th generation”) = PREFERRED
- Specificity and sensitivity
- Identifies early/acute phase infections in most patients
- Rapid tests available
what is the Western blot used for?
HIV confirmatory follow up test
Viral load test – HIV RNA
- Quantitative or Qualitative – used as screening to identify HIV infect individuals. Ex: blood donors
- Quantitative or Qualitative – used to manage/monitor those who are infected, can also be used to diagnose
Viral load test – HIV RNA
- Qualitative – used as screening to identify HIV infect individuals. Ex: blood donors
- Quantitative – used to manage/monitor those who are infected, can also be used to diagnose
positive HIV results
1. requires how many tests positive?
2. what type of test(s)
2
- 1st ELISA or combination assay
- 2nd confirmatory assay
Negative HIV results
1. requires how many tests negative?
2. what type?
- Requires 1 test
- ELISA or combination assay
what does HIV indeterminate results mean?
how many tests required?
what type of tests?
Indeterminate
- Requires 2 test
- 1st ELISA or combination assay results in positive
- 2nd confirmatory test results in indeterminate or negative
whats the HIV window period and why is it dangerous?
Time between
- Potential exposure
AND
- When the test will give an accurate POSITIVE result
dangerous bc = If the person is infected with HIV, during this window period they will be
- Very infectious
- but testing negative!!
May not developed antibodies until 4 or more weeks
Monitoring HIV progression
CD4 count
- High or low = good ?
- Normal = ___ - ___
- <____ = AIDS
Viral load
- High or low = good ?
- Ideal <___
Monitoring HIV progression
CD4 count
- High = good
- Normal = 500-1400
- <200 = AIDS
Viral load
- Low = good
- Ideal <50
Best indicator for how healthy immune system is with HIV
Best indicator of how active HIV is on patient’s body
CD4 count or viral load?
CD4 count
viral load
CD4 count or viral load?
Monitors for
- Progression of AIDS
- Risk for opportunistic infection
- Helps determine when it’s time for prophylactic treatment
- Response to ART
CD4 count
viral load also Helps monitor response to ART
When someone with HIV has a CD4 count <200
- They are now vulnerable to ______ and _______
specific opportunistic infections and rare cancers
Check CD4 count and viral load q ___-___ month
3-4
Plasma HIV RNA (_________) quantifies viral burden (the number of HIV viruses circulating in the blood)
viral load
Goal of __________= Inability to detect HIV in blood plasma
For HIV positive person, Does an undetectable viral load indicate clearance of HIV from body?
check baseline viral load before starting ART?
viral load
no
yes - check twice
Why are these other labs worth checking with HIV patient
1. WBC – especially lymphocytes and neutrophils
2. Platelets
3. H&H
4. LFT’s
5. Test for resistance to ______
- – to keep an eye on their immune system
- Lymphocytes – T cells
- Both lymphocytes and neutrophils fight infections - – to monitor bleeding risks
- – b/c blood cells are affected with HIV
- b/c HIV pts often get hepatitis too
- Early detection of co-infection with HBV or HCV - ART drugs
Primary skin lesions
initial manifestations of a skin condition. They arise directly from the skin itself.
- ________ – flat discolored spot
* Ex: freckle, petechiae, flat mole
- _______ – small solid bump
* Ex: wart, elevated moles
- ________
* Elevated
* Solid
* Ex: psoriasis
- _________– pus/purulent filled blister
* Ex: acne, impetigo
- ________ – serous filled blister
* Ex: varicella/chicken pox, herpes zoster/shingles, 2nd degree burns
- ________
* firm
* edematous
* irregular shape
* lasts only a few hours
* ex: insect bite, angioedema
Macule
Papule
Plaque
Pustule
Vesicle
wheal
secondary skin lesions
develop as a result of primary skin lesions or other underlying conditions.
- _________– thinning skin
* Ex: aged skin, striae
- ________ – epidermis is missing, exposed dermis
* Ex: Abrasion, scratch
- _______ – crack/break from epidermis to dermis, dry or moist
* Ex: eczema
- _______- A flaky, dry patch of skin
* Ex: sunburn reaction
- ______ – abnormal formation of connective tissue that replace normal skin
* Ex: surgical incision, healed wound
- _______ – loss of epidermis and dermis, crater like.
* Ex: pressure ulcer
Atrophy
Excoriation
Fissure
Scale
Scar
Ulcer
what skin color change?
- Increased deoxygenated hgb, r/t hypoxia, late sign of low O2 levels
- Cause – heart or lung disease, cold environment
- Nail beds, lips, base of tongue, skin
cyanosis
what skin color change?
- Reduced hgb or blood flow
- Cause – anemia, shock
- Face, line of demarctation on conjunctiva, nail beds, palms of hands, skin, lips
pallor
what skin color change?
- Increased bilirubin
- Cause – liver disease, RBC breakdown
- Sclera, mucous membrane, skin
jaundice
what skin color change?
- Dilation, increased blood flow
- Cause – fever, trauma, blushing, alcohol
- Face, sacrum, shoulders, elbows, heels
Erythema
what skin color change?
- Increased melanin
- Cause – suntan, pregnancy
- Skin exposed to sun, areola, nipples
Tan
Skin cancer
Risk factors
SATA
- Fair skin, blonde or red hair, blue eyes
- hobby trail running
- works as a lifeguard
- Living near equator or high altitude
- Family hx of skin cancer
- Indoor tanning
- smoking
- Fair skin, blonde or red hair, blue eyes
- hobby trail running - - Hx outdoor activities or occupation
- works as a lifeguard - - Hx outdoor activities or occupation
- Living near equator or high altitude
- Family hx of skin cancer
- Indoor tanning
X - smoking
A type of skin cancer, most common, generally less aggressive
Usually r/t sun exposure
Nonmelanoma skin cancers or Malignant melanoma skin cancers?
Nonmelanoma skin cancers
Basal cell carcinoma
Squamous cell carcinoma
Nonmelanoma skin cancers or Malignant melanoma skin cancers?
Nonmelanoma skin cancers
- Locally invasive cancer from _____ cells
- Erythematous, pearly, sharply defined, elevated plaque, depression in middle
Basal cell carcinoma or Squamous cell carcinoma
Basal cell carcinoma
- Keratinizing epidermal cells
- Can be aggressive
- Thin, scaly erythematous plaque
Basal cell carcinoma or Squamous cell carcinoma
Squamous cell carcinoma
A type of skin cancer, most dangerous, can spread rapidly
Usually r/t moles - ABCDE
- Tumors come from melanocytes
- Genetics and environment contribute to development
- Treatment depends on depth of lesion
- Poor prognosis without early diagnosis and treatment - May metastasize to any organ
Nonmelanoma skin cancers or Malignant melanoma skin cancers?
Malignant melanoma skin cancers
Nursing care for skin cancer
SATA
- Get suspicious lesions checked
- Biopsy most likely route for all lesions
- Skin integrity
- smoking cessation
- Coping with dx
- Teaching r/t post biopsy
- Annual check ups
- Get suspicious lesions checked
- Biopsy most likely route for all lesions
- Skin integrity
X- smoking cessation - Coping with dx
- Teaching r/t post biopsy
- Annual check ups
________ infections
Impetigo
Cellulitis
Bacterial
Risk factors for bacterial or viral infection?
- Excessive moisture
- Obesity
- Atopic dermatitis
- Systemic corticosteroid or abx use
- Chronic disease – DMT2
bacterial
bacterial infections
T/F
Staph or strep are usually responsible
drainage is not infectious
Requires good skin hygiene and infection control practices
T
F - If exudate present – drainage is infectious
T
Inflammation of SQ tissue
Cellulitis
s/s of impetigo or cellulitis?
- Hot skin area
- Tender skin area
- Erythematous area with diffuse borders
- Chills, malaise, fever – r/t inflammatory response
cellulitis
cellulitis treatment
Localized
- Moist or dry heat?
- Immobilization or ambulation?
- elevate or ROM?
Systemic
- are Abx indicated?
- Severe = hospitalization
- Untreated = could progress to _______
Treatment
Localized
- Moist heat
- Immobilization and elevation – decrease swelling
Systemic
- Abx
- Severe = hospitalization
- Untreated = could progress to gangrene
____________ infections
* Herpes simplex
* Herpes zoster – shingles
* HPV
* Warts
viral
Herpes zoster – “_______”
- Activation of varicella zoster virus
- Incidence ___creases with age
- Contagious if had/not had virus?
- Burning pain and neuralgia along dermatone (chronic pain along a nerve)
- is there a vaccine?
- what does it prevent
* One time dose for adults > or < 60
Herpes zoster – shingles
- Activation of varicella zoster virus
- Incidence increases with age
- Contagious if not had virus
- Burning pain and neuralgia along dermatone (chronic pain along a nerve)
- Vaccine – zostavas – to prevent shingles
* One time dose for adults >60
virus
Warts in genitals or on body
Preventable with vaccine?
HPV
yes
_________infections
Candidiasis
Tinea corporis
Tinea cruris
Tinea pedis
Fungal
Candidiasis =
Tinea corporis =
Tinea cruris =
Tinea pedis =
Mouth, vagina, skin
ringworm
jock itch
athletes foot
fungal infections
- Harmless or life threatening?
- Skin, hair, ____ more susceptible to fungal infection
- Treatment =
Harmless, embarrassing
Skin, hair, nails more susceptible to fungal infection
Treatment – topical anti-fungal cream
Allergic skin problems
Irritant or allergic dermatitis
Benign =
Life threatening =
contact dermatitis
Stephen johnson syndrome and toxic epidermal necrolysis (TEN)
which Allergic skin problems?
- Immune response usually to a severe adverse reaction to meds or infection
- Acute destruction of epithelium of the skin and mucous membranes
- life threatening medical emergency
Stephen johnson syndrome and toxic epidermal necrolysis (TEN)
s/s
* fever
* cough
* h/a
* myalgia
* nausea
* 1-3 days later skin and mucus membrane findings
Stephen johnson syndrome and toxic epidermal necrolysis (TEN)
Benign skin problems
- Choronic autoimmune
- 15-35 years old
- Genetics
- lesions red and scaling
- Knees, elbows, hands, lower back
- Painful
- Develop into arthritis
- Body image concerns
Psoriasis
Plaque psoriasis – most common,
Factors that affect wound healing
- older or younger?
- Loss of skin turgor
- Skin fragility – systemic steroids, OA
- Decreased circulation and oxygenation like with PVD - poor wound healing
- Slower tissue regeneration
- Decreased absorption of nutrients
- Decrease in collagen
- Impaired immune function
- Dehydration
- Overall wellness
- Decreased WBC count
- Infection
- Medications – chemo, anti-inflammatory, steroids long term
- Low hgb levels
- Obesity
- Smoking
- Chronic disease
- Malnutrition
Factors that affect wound healing
- Age
- Loss of skin turgor
- Skin fragility – systemic steroids, OA
- Decreased circulation and oxygenation like with PVD - poor wound healing
- Slower tissue regeneration
- Decreased absorption of nutrients
- Decrease in collagen
- Impaired immune function
- Dehydration
- Overall wellness
- Decreased WBC count
- Infection
- Medications – chemo, anti-inflammatory, steroids long term
- Low hgb levels
- Obesity
- Smoking
- Chronic disease
- Malnutrition
Wound assessment
Appearance
- Red =
- Yellow =
- Black =
Wound assessment
Appearance
- Red – health regeneration
- Yellow – purulent
- Black – eschar which hinders healing
Wound assessment
(7)
Appearance
Length, width and depth
Closed wounds
Note drains/tubes present
Pain around incision
Closed wounds
- With primary intention – skin edges should be _________
- If it is __________, it is not well approximated
- Staples, sutures, tissue adhesives are doing what?
well approximated
pulling apart
holding skin edges together
Charting
- 1st measure
- 2nd measure
- 3rd measure
- 4th __________ in respect to a clock with 12 being the patients head – when cotton tipped applicator is placed in wound there is movement
- 5th ___________ in respect to a clock with 12 being the patients head – when cotton tipped applicator is placed in wound there is a lip around the wound
Charting
- 1st measure head to toe in cm
- 2nd measure side to side in cm
- 3rd measure depth in cm
- 4th tunneling in respect to a clock with 12 being the patients head – when cotton tipped applicator is placed in wound there is movement
- 5th undermining in respect to a clock with 12 being the patients head – when cotton tipped applicator is placed in wound there is a lip around the wound
Ex: full thickness, red wound, 7x5x3 cm, 3 cm tunnel at 7oclock and 2cm undermining from 3oclock to 5oclock.
Wound drainage is
Normal or abnormal result of the healing process?
- Accumulates during the inflammatory and proliferative phases of healing
can be both
Wound drainage Document (5)
- Amount
- Odor
- Consistency
- Color
- Can be in drainage or on dressing
- Integrity of surrounding skin
Wound drainage
Cleaning
- Observe for ______ or __________ of surrounding skin
how do we measure wound drainage?
1 g = __ ml of drainage
Or document measure as (4) things
irritation or breakdown
weight
1ml
scant, moderate, large, copious
Wound drainage
color
- Contains serum
- watery, clear or slightly yellow
- ex: inside blisters
serum
Wound drainage
color
- contains serum and red blood cells
- thick, red
- bright red – active bleed
- dark red – older bleed
sanguineous
Wound drainage
color
- contains serum and blood
- watery, pale pink
serosanguinous
Wound drainage
color
- contains WBC, tissue debris, and bacteria
- thick
- yellow, tan, green, brown – depends on organisms present
purulent
what type/color drainage would an infected wound be?
purulent drainage - yellow, tan, green, brown – depends on organisms present
what type/color drainage should a healthy new wound be?
serosanguinous drainage
- watery, pale pink
what type/color drainage should a healthy deep or highly vascular wound be?
-sanguineous drainage
bright red – active bleed
- dark red – older bleed
what type/color drainage should a healthy clean wound be?
serous drainage - - watery, clear or slightly yellow
nursing care for wounds
* monitor ________ and _________ levels
high/low protein
carbs
vitamins
high/moderate fat
albumin and prealbumin
- high protein, carbs, vitamins, moderate fat
ex: pt is very malnourished and has an open wound
nurse must prioritize:
impaired wound infection or imbalance nutrition ?
imbalance nutrition
b/c if pt is malnourished, all the sterile technique in the world is not going to help that wound heal
wounds will not heal without adequate nutrition
wound dressing
_________ – used to mechanically debride a wound until granulation tissue starts to form
- self adhesive, transparent – _________
– occlusive dressing that swells in presence of exudate
- wet to dry
tegaderm
- hydrocolloid, duoderm
wound dressing
________ - is a type of medical dressing that creates a barrier between the wound and the environment.
_________ – mostly water, gels after contact with exudate, promotes autolytic debridement (using the body’s natural enzymes to break down dead tissue), rehydrates and fills dead space
- occlusive dressing
- Hydrogel
wound dressing
_________ – nonadherent dressing that conforms to wounds shape and absorbs exudate
________ – powders, pastes, granules, gels, pasts
- Alginates
- Collagen
wound dressing
- Hydrogel – mostly water, gels after contact with exudate, promotes autolytic debridement (using the body’s natural enzymes to break down dead tissue), rehydrates and fills dead space
T/F
1. May need 2ndary occlusive dressing
2. For infected wound
3. For deep wound wound
4. For necrotic tissue
5. For wounds that are draining a lot
6. Provides moist wound bed and can reduce pain
7. can Prevent skin breakdown in high pressure area
all true except
5 - not for wounds that are draining alot
- Use of foam strips into the wound bed with occlusive dressing
- Creates negative pressure to occur once the tubing is connected
- Helps with tissue generation, decrease swelling, enhance healing in moist protective environment
Vacuum assisted closure systems – wound vacs
wound Complications
- Adhesions
- Contractions – skin is pulled together
- Hemorrhage
- Dehiscence
- Evisceration
- Fistula formation – holes occur where they can connect and they shouldn’t be connecting
- Infection
- Excessive granulation tissue
- Keloid formation
all true
wound complications
24 – 48 hours post-surgery/injury = Greatest risk is _________
2-11 days post injury/surgery = Greatest risk is _________
hemorrhage
infection
wound hemorrhage
Possible causes
T/F
* Clot dislodgment
* Slipped suture
* Blood vessel damage
* poor aseptic technique
- Clot dislodgment
- Slipped suture
- Blood vessel damage
X* poor aseptic technique
Internal bleeding may look like
- Swelling
- Fever
- chills
- Odor
- Distention
- Sanguineous drainage – red
- Initially subtle change in vitals
- Swelling
X- Fever
X- chills
X- Odor - Distention
- Sanguineous drainage – red
- Initially subtle change in vitals
__________ – local area of blood collection that appears as red or blue bruise
- Hematoma
Wound hemorrhage – can be an emergency
(3)
- Apply pressure dressing
- Notify HCP
- Monitor vitals
Partial or total rupture/separation of a sutured wound
Usually with a separation of underlying skin layers
Dehiscence
protrusion of internal organs through a surgical incision or wound
Evisceration
post surgery patient
- the nurse notes Significant increase in flow of serosanguinous – pale pink fluid on the wound dressing
- patient reports Immediate hx of sneezing
- Pt reports a sudden change in feeling at wound area
what does the nurse suspect?
Evisceration
- Significant increase in flow of serosanguinous – pale pink fluid on the wound dressing
- Immediate hx of sudden straining – getting up, bearing down, cough, sneeze
- Pt reports a sudden change or pop in wound area
- Visualization of the viscera
Risk factors for Evisceration
- Chronic disease
- OA
- Obesity
- Invasive abdominal cancer
- Vomiting
- Excessive straining – cough, sneeze
- Dehydration and malnutrition
- Ineffective suturing
- Abdominal surgery
- Infection
- Anything that increases pressure at wound site
- poor aseptic technique
Risk factors for Evisceration
- Chronic disease
- OA
- Obesity
- Invasive abdominal cancer
- Vomiting
- Excessive straining – cough, sneeze
- Dehydration and malnutrition
- Ineffective suturing
- Abdominal surgery
- Infection
- Anything that increases pressure at wound site
X- poor aseptic technique
Dehiscence/evisceration nursing care
- Notify ____
- Stay with patient
- Cover wound and any protruding organs with _____ soaked with _____
- Do not _____
- Position pt ____ with _____ bent
- ____ environment
- NPO
- Notify HCP ASAP – surgical intervention required
- Stay with patient
- Cover wound and any protruding organs with sterile towels/dressing soaked with sterile normal saline
- Do not reinsert organs
- Position pt supine with hips and knees bent
- Calm environment
- NPO
Risk factors for which wound complication?
- OA
- Immune suppression
- Impaired circulation/oxygenation
- Wound condition and nature
- Malnutrition
- Chronic disease
- Poor wound care
infection
pt is 7 days post injury/surgery
- Pain
- Redness
- edema
- green drainage - what type of drainage?
- Fever chills
- Odor
- Increase pulse and RR
- Increase WBC
nurse suspects what?
s/s – 2-11 days post injury/surgery
- Pain
- Redness, edema, purulent drainage – gross color
- Fever chills
- Odor
- Increase pulse and RR
- Increase WBC
Nursing care for hemorrhage or infection?
- Sterile/aseptic technique with dressing changes
- Optimal nutrition
- Adequate rest
- Admin abx after culture and sensitivity results
infection
