Wound Healing and Scrub Nurse Role in the OR: An Overview, Exams of Nursing

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NURSING THEORY N12 EXAM 2 CABRILLO COLLEGE PERIOPERATIVE NURSING, CONSENT, SURGERY, WOUND CARE, PACU, PATIENT EDUCATION - Urgency: Elective, urgent (necessary for pt health, prevention of additional problems), emergent (immediately to save life/function of body part) What are the different classifications of surgery? - - Serious : Major (extensive reconstruction/alteration; increased risk), to minor (minimal alteration, correction of deformities, decreased risk) - Purpose: Diagnostic, ablative, palliative, reconstructive/restorative, procurement for transplant, constructive, cosmetic What are some surgical risk factors - - Smoker - Age (very young/very old) - Mal-nutrition - Obesity - Obstructive Sleep Apnea (OSA) - Immunosuppression - Fluid/electrolyte imbalance - Postoperative nausea/vomiting (PONV) - Venous Thromboembolism (VTE) What does glycemic control have to do with infection? - Poor glucose control increases risk for wound infection/mortality Pressure ulcer prevention aids - - Positioning - Pressure-relieving surfaces What is the importance of warfarin (coumadin) in surgery? - Warfarin is a blood thinning medication and must be ceased 24-48 hrs pre-op - -> increased intracellular Ca ion conc; increased CO2levels; metabolic/respiratory acidosis; increased O2 consumption; prod of heat; activation of sympathetic nervous sistem; High serum K levels; mulitple organ dysfunct/failure What are early signs/symptoms of malignant hyperthermia? Later signs/symptoms? - - elevated temperature - tachypnea - tachycardia/arrhythmias - hyperkalemia/hypercalcemia - hypercarbia - muscular rigidity - Elevated temperature - myoglobinuria - multiple organ failure What are the phases of postoperative care? - - Phase I : immediate postop recovery - Phase II: recovery - Phase III: convalescence What happens in phase I of postoperative care? - - Notification/arrival - Hand off: OR to PACU - Pt monitoring/assessment: Modified aldrete score; modified postanesthesia recovery score (PARS); DASAIM discharge assessment tool - Discharge & Hand-off: PACU to acute care What happens in phase II of postperative care? - - Recovery in ambulatory surgery - Postanesthesia Recovery Score (PARS) What happens in phase III of postperative care? - - Nursing process ADPIE - Assessment: - Diagnose any discrepancies - Planning - Implementation - Evaluate What would you assess post operatively (phase III) - ASSESS: - through pts eyes - airway & respiration - circulation - temp control - fluid/electrolyte balance - neurological functions - skin integrity/condition of wound - metabolism - genitourinary function - gastrointestinal function - comfort What kind of planning should happen post operatively (phase III) - PLANNING - Goals & Outcomes (continue into home setting; established during the preop phase that are still relevant) - Setting priorities (Reestablish priorities as status of pts probs change/evolve) - Teamwork/Collaboration (Goal: return pt to best poss. level of health/functioning, w/smooth transition to home, rehab, or long-term care) What kind of implementation would you consider in phase III of postoperative care? - IMPLEMENTATION - Acute Care - Maintain respiratory function - Prevent circulatory complications (thrombus formation): leg exercises; OOB - Achieving rest/comfort - Temperature regulation - Maintain neurological function - Maintain fluid/electrolyte balance - Promote normal GI funct & adequate nutrition - Promote urinary elimination - Skin & wound care - Maintain/enhance self-concept - Restorative & Continuing Care - Prep for discharge - Provide pt ed - Help pt adhere to exercise program(s) - Make referrals to home care PRN How would you evaluate in phase III of post operative care - Thru pts eyes: Have expectations been met? Pt outcomes - Evaluate for pain relief - Evaluate pt self-care measures Signs and symptoms of fluid imbalance - - Dehydration - Dizziness - Confusion - Electrolyte imbalance -> irregular heartbeat; fast heart rate; fatigue/lethargy; convulsions/seizures; nausea/vomiting; diarrhea/constipation - Altered elimination Signs & symptoms of hemorrhage - - BP drop < 90/60 - Increased HR >100 - Cool, clammy skin - Weak distal pulse - Decreased capillary refill - Diminished orientation/LOC - Severe headache - Nausea a vomiting common - Onset rapid, deterioration rapid Symptoms of Hypoxia - - Skin color changes (blue or bright red) - Tachycardia/Arrhythmias - Increased respiratory rate - Open-mouthed / dyspenic breathing - Shortness of breath - Slowing Heart Rate - Cold extremities What does collagen synthesis do during the proliferative phase of wound healing? Nutritional requirement? - Collagen synthesis created by fibroblasts: - provides strength & structure - Stress on wound influences scar tissue - Requires Vitamin C & B, oxygen, amino acids & zing (Wounds healing by 1º intention should have a healing ridge in 5-7 days; if no ridge: danger of dehiscence) What occurs during angiogenesis (during the proliferative phase of wound healing)? - - Development of new capillaries - Macrophages secrete angiogenesis factor -> formation of red granules (young, budding capillaries) What occurs during epithelialization (during the proliferative phase of wound healing)? - Epithelial cells migrate toward ea. other over the granulation tissue showing healing ridge around the wound edges Explain the Maturation phase of wound healing When does it start? What happens? - - Starts 3rd wk -> 2 yrs - Migrarengtion of fibroblasts decreases scar appearance/size - Collagen scar continues to reorganize and gain strength - Lighter than normal pigment - 3 wks: 20% strength - 6 wks: 50% strength - Max Strength: 70-80% What are the different intentions of healing? - - 1º - 2º - 3º Explain what healing by primary intention is Wound types? Wound edges appear ? Risk of infection? How long does healing take? - - Lacerations, surgical incisions - Wound edges approximated/intact (sutures, staples, glue, steri strips) - Erythema about suture line - Risk of infection is low - Healing occurs quickly - Drainage stops by day 3 - Epithelialization by day 4 - Inflammation present to day 5 - Healing ridge by day 9 Explain healing by Secondary intention Types of wounds? Wound edges are ? How long does healing take? Healing occurs by....? Needs....? Chance of infection? Heals (finishes) WITH ? (due to - - Healing that relies on the body's own mechanisms - Stasis ulcers, decubitus, ulcers, burns - Wound edges = far apart - Very slow healing - Healing by granulation from bottom up and sides inward - Need to protect wound bed: often packed w/gauze or drainage system (ie wound vac); frequent care to remove drainage/debris - Greater chance of infection - Heals w/scar tissue: severe scar tissue may -> permanent loss of tiss funct; broad scar due to large granulation area Describe Granulation Tissue - - Connective tissue: abundant blood supply - Appears dark pink - red - Beefy appearance - Epithelialization Explain the process of healing by Tertiary intention - - Wound is open until bacteria & debris are removed - Wound is sutured together - Example: an infected abdominal wound dehisces, the wound is left open and irrigated Q12H, wet to dry dressing applied to protect & debride wound, antibiotics are admin'd. 5 days later: wound appears clean, WBCs decrease, wound is then closed. What are examples of different types of exudate - - Serous: clear, watery plasma - Purulent: pus-y, thick, yellow, green, tan, brown - Serosanguinous: pale pink, red, watery, mix of clear & red fluid - Sanguinous: Bright -> dark red. Blood. Indicates active bleeding What is Eschar? Where do you find eschar? What does it prevent? - (pronounced "eskar") - Dead, black, dry tissue - Found on or in the wound - Prevents epithelialization What is yellow slough - (pronounced "sluff") - Yellow in color - Fibrin, dead tissue, and exudate accumulation - Need to differentiate from fatty tissue What conditions allow wounds to heal their best? - - Clean (free from necrotic tissue, bacteria, yeast, fungi) - Moist (not wet; occlusive dressing) - Have normal arterial & venous blood supply (no constrictive dressings, no swelling. Has good circulation) - Tissues are hydrated - Pt has good nutrition for healing - Healing wound is protected Describe a Clean wound (Appearance, drainage, systemic effects) - Appearance: - Erythema, some swelling, wound edges = approximated if healing by 1º intention - healing ridge @ 5-7 days - wound bed = pink, red, or dark red What is Blanchable erythema? - If an impending pressure ulcer is relieved in time: period of hyperemia--erythema w/no lasting tissue damage: known as blanchable - Shearing effect: blood flow is blocked; anaerobic metabolism in tissue cells eventually -> decreased cellular integrity -> cell death -> anoxic necrosis of surrounding tissues (tissue death) erythema of intact skin What is the Braden Scale? - Scale with 6 determinants to assess risk of pressure ulcer(s) * The lower the score, the higher the risk (Considers: Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction & Shear) Most common areas for pressure ulcers - - Coccyx - Heel - Ischial tuberosity (buttocks) - Lateral Malleolus (ankle) - Sacrum - Greater trochanter (hip) ("CHILS G") How many stages of classification of pressure ulcers are there? - 4 (I, II, III, IV) Describe a stage I pressure ulcer Treatment? Healing time? - Non-blanchable erythema of intact skin; erythema not gone in 30 mins Apply transparent dressing or topical tx (per facility policy). Keep pressure off of area 1-2 wks Describe a stage II pressure ulcer Treatment? Healing time? - Partial loss of skin involving dermis/epidermis; erythema, blistering, induration, pink, moist wound bed, painful Wound irrigation Transparent dressing *if not infected (see stage III treatment if infected) 2-4 mos Describe a stage III pressure ulcer Treatment? Healing time? - Full-thickness skin loss, Damage or necrosis of subcutaneous tissue May extend to underlying fascia Undermining may be present Wound irrigation Keep wound clear of debris, infection, exudate Moist wound bed Dressing products as indicated 4 mo -> 1 yr Describe a stage IV pressure ulcer Treatment? Healing time? - Full-thickness skin loss Extensive destruction of tissue to muscle, bone, or supporting structures Debridement, wound irrigation Antibiotics, packing, moist wound bed Skin grafting months -> yrs Nursing interventions for pressure ulcers - - Assess comfort level, pain meds, positioning - DO NOT place bed bound pt on trochanter (30º side lying position) - Turn pt Q2H & PRN - ROM exercises - Use pressure decreasing products/mattresses (min. 4" thick foam mattress; air/rotation bed) - Hydrate pt! 1500-3000cc/day if no fluid restrictions - Maximize nutrition What are some of the purposes for patient education? It includes... - To help individuals, families, communities achieve optimal levels of health Pt ed includes... - Maintenance and promotion of health & illness prevention - Restoration of health - Coping with impaired function What are The Joint Commissions "Speak Up" tips? - - Speak up if you have questions/concerns - Pay attention to the care you get - Educate yourself about your illness - Ask a trusted family member/friend to be your advocate - Know which meds you take and why - Use a health care organization that's been carefully evaluated - Participate in ALL decisions about your treatment "SPEAK UP" What are the domains of learning? - - Cognitive - Affective - Psychomotor (CAP) Explain the COGNITIVE domain of learning - - Cognitive: includes all intellectual behaviors & requires thinking Explain the AFFECTIVE domain of learning - - Affective: Deals w/expression of feelings, and development of attitudes, opinions or values