NUR 204 Health and Wellness Exam 2 Study Guide.pdf - Wound Care., Exams of Health sciences

Download NUR 204 Health and Wellness Exam 2 Study Guide.pdf - Wound Care. and more Exams Health sciences in PDF only on Docsity! Health and Wellness Exam 2 Study Guide.pdf - Wound Care.. Wound Care Factors/ Conditions that may affect Wound Healing: - Vascular Disease - Diabetes - Nutrition (increase in protein is needed for the formation of collagen also increase Vitamin A,C and E - Medications - Excessive Moisture - External Forces (pressure, shear, and friction) - Age Wound Classification Based on:  The Cause (pressure ulcer, diabetic ulcer)  Skin Integrity (open or closed wound)  Wound Depth (partial thickness, superficial)  Amount of Contamination (clean, contaminated, infected)  Healing Process (acute, chronic) A wound can heal through either primary intention or secondary intention, in secondary intention the wound must heal from the bottom and sides of the wound until it’s filled with new tissue. Phases of Wound Healing Inflammatory: lasts up to 3 days coagulation occurs and the wound is cleaned by the body Proliferative: usually lasts a couple weeks, formulation of the granulation tissue forms new skin Maturation: takes up to 1 year scar tissue may develop giving strength to the wound *scar tissue is not as strong as regular skin Complications of Wound Healing Include: - Dehiscence - Evisceration - Fistula formation *if a wound is healing properly, a 1 cm wide range area next to the incision should be able to be palpated also known as “the healing ridge” *symptoms of dehiscence and evisceration include a popping sensation and increase in drainage, nurse should encourage the patient to use a splint or binder to prevent this when coughing or during movement *fistulas puts patient at risk for fluid loss and electrolyte imbalance Pressure Injuries can be caused by: - Intensity of pressure - Duration of pressure - Mechanical devices (nose cannula that may irritate the skin behind the ears or under the nose) Health and Wellness Exam 2 Study Guide.pdf - Wound Care.. - Friction/ shearing - Sensory loss - Moisture/ Nutrition Stages of Pressure Injuries Stage 1: skin is still intact but the skin is erythematous and non blanchable, for a dark skinned patient, the site may be painful and differ in firmness or temperature Stage 2: partial thickness is lost with an exposed dermis, blisters may form Stage 3: full thickness of skin is lost but there is no bone present, there may be tunneling or undermining present Stage 4: Exposure of bone, tendon, or connective tissue is present osteomyelitis may occur and sloughing Unstageable: obscured full thickness and tissue loss but it can’t be measured due to necrotic tissue Deep Tissue Pressure Injury: Nonblanchable deep injury that may cause discoloration under intact skin *wounds don’t heal backwards, a healed wound would be considered a healed Stage 4 *wound measurement is the best way to assess a healing wound  Blood tests can identify chronic diseases that may be leading to the delay of wound healing  Biopsy of the wound helps rule out infection  A score lower than 18 on the braden scale puts the patient at risk for a pressure injury Wound Assessment Includes Noting:  Location of the wound  Size and Color  Presence of Drainage  Condition of the Wound edge  Characteristics of the Wound bed  Patient’s response to the wound *a sterile cotton tipped applicator is used to measure a wound then measure the width and length of the edges of the wound *wound should be “beefy red” and the area should be moist Wound Interventions: 1. Wound Cleansing/Irrigation  0.9% normal saline solution is commonly used, tap water can also be used if its drinkable  Irrigation solution should be room temp or warmed  Irrigation is used to remove debris or bacteria and apply heat and medication 2. Debridement  Removal of necrotic tissue 3. Dressings  Keep the wound free from contamination  Absorb drainage and prevent infection Health and Wellness Exam 2 Study Guide.pdf - Wound Care.. - Diabetes - Allergies/ Intolerances - Obesity - Malnutrition *as BMI levels rise, so does blood pressure and cholesterol levels Anorexia- loss of appetite in patients experiencing illness or side effects from medications, treatments or chemotherapy  24 hour recall and a food diary are used to obtain information about a patients dietary habits  The Mini Nutritional Assessment is a screening tool for malnutrition in older adults BMI Calculations Healthy Weight: 18.5- 24.9 Overweight: 25.0-29.9 Obese Class I: 30.0- 34.9 Obese Class II: 35.0-39 Obese Class III: >40 Signs of Nutritional Imbalance: - Alteration in vital signs - Poor skin turgor/wound healing - Concave abdomen/ ascites - Change in muscle mass - Changes in blood glucose levels, serum albumin, and creatine - Hair color is dull/ skin is dry/ oral mucosa is darker red than normal *prealbumin level tests help to determine current nutritional status *albumin levels help identify the supply of protein in the body for an extended period of time Lab Studies that Assess Nutritional Status Prealbumin- measures amount of protein in the organs, a low value may indicate malnutrition Albumin- checks the amount of protein from an extended period of time Transferrin- measuring iron levels Hemoglobin/Hematocrit- identify the number of circulating erythrocytes and ability to provide oxygen and iron to the cells, less iron means less oxygen Blood Urea Nitrogen/Creatnine- gives a comprehensive metabolic profile of the patient and evaluate kidney function BMI= Weight (kg)/ Height (m) OR Weight (lbs)/ height (in squared) x 703 Health and Wellness Exam 2 Study Guide.pdf - Wound Care.. 1 fl oz=30 ml Interventions to Stimulate the Appetite: - Good Oral Hygiene - Favorite foods and the formation of a meal plan - Minimal environmental odors *decrease in food intake is often accompanied by decrease in fluid intake  Place patient in Fowlers position during eating and Semi fowlers for up to an hour after eating Enteral Feeding Tubes  Provides short term nutritional support for patients who can’t swallow, refuse to eat, or need additional nutrients  Nasogastric tube is placed through the nose and into the stomach (short term)  Peg tubes are surgically places in the upper left quadrant of the abdomen (long term)  Medications are added to the feeding tube by dissolving in 15 to 30 ml of sterile water  Flush before and after medication administration with 15 ml of sterile water  If nose becomes irritated, consider switching nares *X- ray is golden standard for checking tube placement, aspirating GI contents and measuring the pH is another acceptable method TPN is used for patients who don’t have a functioning GI tract or for patients who are unable to absorb essential nutrients *tubing must be changed every 24 hours, dressing changed every 48 hours, and check glucose levels every 6 hours along with input/output *monitor weight, complete blood count, electrolytes and BUN for patients on TPN Short term feedings  Nasogastric  Nasoenteric Long term feedings  Gastostomy  PEG  Jejunostomy Sensory and Cognition  Brain is divided into four main lobes: frontal, parietal, temporal and occipital  Damages to the temporal lobe may affect the ability to smell  Damage to the occipital lobe may affect vision  The 5 senses are detected by the tactile receptors in the dermis and subcutaneous tissues  Sensory receptors for gustation are located on the tongue, roof of the mouth, and throat Health and Wellness Exam 2 Study Guide.pdf - Wound Care..  Sound is interpreted in middle ear *Issues with the labyrinthitis in the middle ear, fluid, or infection may cause loss of balance or equilibrium Cognitive Alterations  Delirium, depression, dementia Ways to care for a patient who is confused/ delerium - Wear a name tag - Address the person by name - Reassure them/ reorient them - Have calendar in the room *a patient with dementia may not benefit from family visits due to risk of overstimulation Cerebrovascular Accidents (3 Types) 1. Ischemic Stroke caused by a narrowing of the vessel or clot 2. Ischemic stroke caused by an embolism causing no blood flow 3. Hemorrhagic stroke caused by bleeding in the brain due to an aneurysm  If there is damage on the left side of the brain, the right side may result in loss of motor and sensory function and vice versa *aphasia is a first indicator that a person may have had a stroke and can be shown in three ways: Expressive aphasia- damages to the motor speech and writing, the patient is able to understand language but are unable to respond Receptive aphasia- damage to the temporal that makes them unable to understand written or spoken language Global aphasia- a manifestation of both expressive and receptive  Meningitis may lead to temporary aphasia  Meniere's Disease may lead to vertigo *if a patient can’t hear, stand in front of them so they can develop the habit of reading lips Myopia- near sightedness, person cannot see far away Presbyopia- age related loss of near vision *for legally blind patients to promote autonomy, help them visualize by telling them where things are using a clock method  Peripheral neurotherapy is common for patients with diabetes or renal disease, for this reason diabetics should not walk around barefoot Risk Factors for Sensory Deprivation  Private room  Sudden decrease from fast to slow environment Health and Wellness Exam 2 Study Guide.pdf - Wound Care..  Must come from the mucus not the saliva  Provide oral care before and after  Used to test for TB *throat culture is considered sterile Radiography Noncontrast studies – X rays, Mammograms Contrast studies- identify more detailed study of organs *nurse should check for allergies and kidney function before a contrast study *for a direct view of GI perform endoscopy *endoscopy helps discover ulcers or reflux lining in the GI tract *biopsy helps discover cancer using a tissue sample For clients with Urinary Alterations use:  X rays of kidney, ureters, bladder (KUB)  Intravenous pyelography  Renal ultrasonography  Cystoscopy For Clients with Cardiopulmonary Alterations:  ECG  Angiography  Lung scan  Laryngoscopy/ bronchoscopy CT Scan  Noninvasive x ray  Shows three dimensional image of the organ MRI Scan  Noninvasive scanning with no radiation  Can't be done on clients with metal devices  No piercings  Provides better contrast between normal and abnormal tissue than a CT scan PET Scan- chemicals are ingested to produce color coded images that can be analyzed, a form of nuclear imaging that distinguishes “hot and cold spots” Health and Wellness Exam 2 Study Guide.pdf - Wound Care..  Requires informed consent that should be retrieved by the nurse and vital signs should be monitored throughout all invasive procedures Assessment/Interventions  Check ID band before procedure  Allergies  Consent  Medications  Preparations (no eating, etc) *post procedure, the nurse monitors vital signs, checks dressings, and asses for complications as well as administer fluids if necessary *drop in BP and increase in HR indicates hemorrhage *kids should be well informed on the procedure and use therapeutic play to make them more comfortable *older adults easily experience electrolyte imbalance easily