Exam 2 - fundalmentals PDF

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Wound care ● Skin function ○ Protect, psychosocial, sensation, Vit. D production, immunologic, absorption, elimination ● Factors affecting skin ○ unbroken/ healthy skin/ mucus membrane help defend against harmful agent ○ Resistance to injury depends on age, underlying tissue condition, illness ■ Hydrated and nourished skin can resist injury well!! ■ Good circulation maintains cells life. ■ Fluid loss during illness = dehydration = flabby/loose skin; seen in elderly ■ Excess perspiration during illness predispose to skin breakdown ■ Jaudice: yellow and itchy ■ eczema and psoriasis: need special care ○ Child less 2 years: skin is thinner and weaker than adults ○ Infant- skin is easily injured and prone to infection. But children skin become resistance to injury and infection ○ Elderly: maturation of epidermal cell is prolonged = thin and easily injuried skin ■ Circulation and collagen is imparied = increase risk to tissue damage from pressure ○ Obese and very thin = suspectible to skin injury ● Types of wound ○ Intentional or unintentional ○ Open or closed ○ Acute or chronic ○ Partial thickness, full thickness,complex ● contusion is caused by a blunt instrument and may result in bruising or hematoma. ● abrasion is the rubbing or scraping of epidermal layers of skin. ● laceration is the tearing of skin and tissue with a blunt or irregular instrument. ● Avulsion is the tearing of a structure from normal anatomic position. ● Principle of help in wound healing ○ Intact skin is the 1st line defense against microorganism ○ Wash hands ○ Adequate blood supply ○ Proper nutrition ○ Wound free of foreign materials = proper healing ■ Extent of damage and state of health affect healing ● Phase wound ○ Hemostasis- involves blood vessels constrict and blood clotting begins. ■ Occurs immediately after initial injury ■ Involved blood vessels constrict and blood clotting begins. ■ Exudate is formed, causing swelling and pain. ■ Increased perfusion results in heat and redness.

■ Platelets stimulate other cells to migrate to the injury to participate in other phases of hea ○ inflammatory phase - white blood cells move to the wound. ■ Follows hemostasis and lasts about 4 to 6 days ■ White blood cells move to the wound. ■ Macrophages enter the wound area and remain for an extended period. ■ They ingest debris and release growth factors that attract fibroblasts to fill in the wound. ■ The patient has a generalized body response. ○ proliferation phase- granulation tissue is formed to fill the wound. ■ Begins within 2 to 3 days of injury and may last up to 2 to 3 weeks ■ New tissue is built to fill the wound ■ space through the action of fibroblasts. ■ Capillaries grow across the wound. ■ A thin layer of epithelial cells forms across the wound. ■ Granulation tissue forms a foundation for scar tissue development. ○ maturation phase- collagen is remodeled, forming a scar. ■ Final stage of healing; begins about 3 weeks to 6 months after injury ■ Collagen is remodeled. ■ New collagen tissue is deposited. ■ Scar becomes a flat, thin, white line. ● Process of healing ○ Primary intention■ minimal tissue loss ■ Edges well approximated (surgical incision closed w/sutures) ○ Secondary Intention ■ Tissue loss ■ Edges wide- not approximated (pressure ulcer) ■ Heals by granulation ○ Tertiary intention ■ Widely separated ■ Deep ■ Long healing time ■ Wound may be left open until infection is gone ● Factors affecting wound healing ○ Desiccation (dehydration) ○ Maceration (overhydration) ○ Trauma ○ Edema ○ Infection ○ Excessive bleeding ○ Necrosis (death of tissue) ○ Presence of biofilm (thick grouping of microorganisms) ● Systemic affecting wound healing ○ Age: children and healthy adults heal more rapidly ○ Circulation and oxygenation: adequate blood flow is essential ○ Nutritional status: healing requires adequate nutrition

○ Wound condition: specific condition of the wound affects healing ○ Health status: corticosteroid drugs and postoperative radiation therapy delay healing ○ Immunosuppression ○ Medication use ● Wound complication ○ Fistula formation-secondary to infection ■ Infection that has become abscess which leads to pressure around the surrounding tissues causing a fistula ■ Delays healing, risk for increased infection, skin breakdown, fluid/electrolyte imbalances ○ Dehiscence and evisceration ■ Emergency ■ Dehiscence= separation of sutured wound and can include underlying tissues ■ Evisceration=a separation of a wound that includes the protrusion of an organ ○ Hemorrhage- caused by clot dislodgement, blood vessel damage ■ Emergency ● Apply pressure dressing, assess VS, notify provider ○ Infection■ Can be at higher risk due to age, circulatory impairment, malnutrition, diabetes ■ Provide aseptic technique, adequate nutrition, antibiotics if needed Hemorrhage- caused by clot dislodgement, blood vessel damage

● Maceration is caused by overhydration related to incontinence that causes impaired skin integrity. ● Necrosis is dead tissue present in the wound that delays healing. ● Edema is swelling at a wound site that interferes with blood supply to the area. ● Desiccation is the process in which the cells dehydrate and die.

● Pressure Ulcer Assessment ○ Risk assessment ○ Mobility ○ Nutritional status ○ Moisture and incontinence ○ Appearance of existing pressure ulcer ○ Pain assessment ● How does pressure ulcer occur? ○ External pressure compressing blood vessels ○ Friction or shearing forces tearing or injuring blood vessels

● Stages of Pressure Ulcers ○ Stage I: non-blanchable erythema of intact skin’ lightly pigment ○ Stage II: partial-thickness skin loss ○ Stage III: full-thickness skin loss; not involving underlying fascia

○ Stage IV: full-thickness skin loss with extensive destruction ○ Unstageable: base of ulcer covered by slough and/or eschar in wound bed ● A stage III pressure ulcer requires debridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes. ● Cleaning pressure ulcer ○ Clean w/ each dressing change ○ Clean w/ 0.9 % NaCl ○ New gauze for each downward stroke/circle ○ Top to bottom if approximated wound or center of wound outward for unapproximated edges ○ At least 1 inch beyond end of new dressing or 2 inches if no dressing ● Wound assessment ○ Inspection for sight and smell ○ Assess appearance, drainage, and pain ■ Serous– serum fluid= watery/clear or slightly yellow ■ Sanguineous- serum and red blood cells=thick and red ■ Serosanguineous –serum and some red blood cells=watery and blood streaked ■ Purulent- (pus)white blood cells, tissue debris/bacteria= yellow/tan/brown. Possibly foul odor. INFECTION! ■ Puro-sanguineous- mix of blood and pus ○ Sutures, drains or tubes, and manifestation of complications ● Measurement of wound ○ Size, depth, presence of underming, tunneling or sinus tract ● Purpose of wound dressing? ○ Provide physical, psychological, and aesthetic comfort ○ Remove necrotic tissue ○ Prevent, eliminate, or control infection ○ Absorb drainage ○ Maintain a moist wound environment ○ Protect wound from further injury ○ Protect skin surrounding wound * ● Types of wound dressing ○ Non-adherent- does not stick to wound ○ Gauze dressings -absorbs exudates ○ Damp to Damp-mechanically debrides wound until granulation tissue forms. Must keep moist! ○ Transparent dressings- small wounds ○ Hydrocolloid- occlusive dressing that swells to fill wound space when exudate present ○ . Prevents moisture loss ○ Hydrogel-Made of water- turns to gel w/exudate contact. Promotes debridement, Hydration.

● Presence infection ○ Wound swollen ○ Deep red ○ Feels hot ○ Drainage and possible purplent ○ Foul odor ○ Wound edges separated and dehiscence ● Drainage system ○ Open ■ penrose ○ Closed ■ Jacksin pratt ■ Hemovac ● Applying heat ○ Dilates peripheral blood vessels ○ Increases tissue metabolism ○ Reduces blood viscosity and increases ○ capillary permeability ○ Reduces muscle tension ○ Helps relieve pain ● Types of heat appliance ○ Devices to Apply Heat ○ Hot water bags or bottles ○ Electric heating pads ○ Aquathermia pads ○ Hot packs ○ Warm, moist compresses ○ Sitz baths ○ Warm soaks

● Applying cold pack ○ Effects of Applying Cold ○ Constructs peripheral blood vessels ○ Reduces muscle spasms ○ Promotes comfort ● Cold pack types ○ Ice bags ○ Cold packs ○ Hypothermia blankets ○ Cold compresses to apply moist cold ● Health—a state of complete physical, mental, and social well-being, not merely the absence of disease o ● Illness—the unique response of a person to a disease; an abnormal process involving changed level of functioning

● Disease—medical term, referring to pathologic changes in the structure or function of the body or mind ● Wellness—an active state of being healthy by living a lifestyle promoting good physical, mental, and em health ● Acute illness: rapit onset and lastly short term ○ Ex: appendicitis, pneumonia, diarrhea, common cold ● Chronic illness ○ A broad term that encompasses many different physical and mental alterations in health ○ Usually has a slow onset and may have periods of remission and exacerbation ○ Examples: diabetes mellitus, lung disease, arthritis, lupus ○ It is a permanent change. ○ It causes, or is caused by, irreversible alterations in normal anatomy and physiology. ○ It requires special patient education for rehabilitation. ○ It requires a long period of care or support. ● Stages of Illness Behavior ○ Stage 1: Experiencing symptoms ○ Stage 2: Assuming the sick role-oneself as sick and self-medicates or visits a doctor ○ Stage 3: Assuming a dependent role ○ Stage 4: Achieving recovery and rehabilitation ● The Human Dimensions Affecting Health ○ Physical dimension—genetic inheritance, age,developmental level, race, and gender ○ Emotional dimension—how the mind affects body function and responds to body Conditions ○ Intellectual dimension—cognitive abilities, educational background, and past experiences ○ Environmental dimension—housing; sanitation; climate;pollution of air, food, and water ○ Sociocultural dimension—economic level, lifestyle, family,and culture ○ Spiritual dimension—spiritual beliefs and values ● Primary: directed toward promoting health and preventing the development of disease processes or injury. ● Examples are immunization clinics, family planning services, poison-control information, and a prevention education. ● Secondary: focus on screening for early detection of disease with prompt diagnosis and treatment of any found ○ Examples are assessing children for normal growth and development and encouraging regular medical, dental, and vision examinations. ● Tertiary: begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning ○ Examples include teaching a patient with diabetes how to recognize and prevent complications, using physical therapy to prevent contractures in a patient who has had a stroke or spinal cord injury, and referring a woman to a support group after removal of a breast because of cancer. ● Models ○ The health–illness continuum measures a person's level of health on a graduated scale. ● Conceptualizes a person’s level of health

● Views health as a constantly changing state with highlevel wellness and death on opposite sides of a continuum ● Illustrates the dynamic (ever-changing) state of health as a person adapts to changes in internal and external environments to maintain a state of well being. ○ The agent–host–environment model (leveal and clark model): refers to the interaction of the agent, host, and environment creating risk factors that must be examined. ● Views the interaction between an external agent, a susceptible host, and the environment as causes of disease in a person. ● It is a traditional model that explains how certain factors place some people at risk for an infectious disease. ● These three factors are constantly interacting, and a combination of factors may increase the risk of illness. ● The use of this model is limited when dealing with noninfectious diseases ○ Three additional variables: (revised) ■ Activity-related affect ■ Commitment to a plan of action ■ Immediate competing demands and preferences ○ Behaviors may induce either a positive or negative subjective response or affect

○ The health promotion model: illustrates how people react to their environment as they pursue health. ● Developed to illustrate how people interact with their environment as they pursue health ● Incorporates individual characteristics and experiences and behavior-specific knowledge and beliefs, to motivate health-promoting behavior ● Personal, biologic, psychological, and sociocultural factors are predictive of a certain health-related habit. ● Health-related behavior is the outcome of the model and is directed toward attaining positive health outcomes and experiences throughout the lifespan. ○ The health belief model is concerned with what people believe to be true about their health. ● Concerned with what people perceive to be true about themselves in relation to their health ● Modifying factors for health include demographic, sociopsychological, and structural variables. ● Based on three components of individual perceptions of threat of a disease ○ Perceived susceptibility to a disease ○ Perceived seriousness of a disease ○ Perceived benefits of action ● After breakfast/ morning care ○ Toileting

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Oral care Bathing Back massage Special skin measures Hair care, cosmetics Copyright © 2019 Wolters Kluwer • All Rights Reserved Dressing Positioning for comfort Refreshing or changing bed linens Tidying up bedside

* ● Afternoon care (PM)- after lunch: ○ Offer assistance with toileting, handwashing, oral care. ○ Straighten bed linens. ○ Help patient with mobility to reposition self. ● Sleep (HS) care ○ Offer assistance with toileting, washing, and oral care. ○ Offer a back massage. ○ Change any soiled bed linens or clothing. ○ Position patient comfortably. ○ Ensure that call light and other objects patient requires are within reach ● PRN care ○ Offer individual hygiene measures as needed. ○ Change clothing and bed linens of diaphoretic patients (sweaty patients). ○ Provide oral care every 2 hours if indicated. ● Purpose of Back massages ○ Acts as a general body conditioner ○ Relieves muscle tension and promotes relaxation ○ Provides opportunity for nurse to observe skin for signs ○ of breakdowns ○ Improves circulation ○ May decrease pain, distress, and anxiety ○ May improve sleep quality ○ Provides a means of communication through use of touch ● Purpose of bathing? ○ Promotes comfort through muscle relaxation and skin ○ stimulation ○ Provides person with sensory input ○ Helps improve self-image ○ Strengthens nurse–patient relationship ○ Cleanses the skin ○ Acts as a skin conditioner ○ Helps to relax a person ○ Promotes circulation

○ Serves as musculoskeletal exercise ○ Stimulates the rate and depth of respirations ○ ● Gingivitis and periodontitis both involve inflammation of the gums, but periodontitis also affects the dental periosteum and bone. ● Dental caries is the decay of teeth that forms cavities. ● Plaque is an invisible destructive bacterial film that builds up in everyone’s teeth destroying tooth enamel if not removed. ● Cheilosis is an ulceration of the lips (reddened tissures at the angles of the mouth); Vit B deficiency ● Stomatitis is an inflammation of the oral mucosa. ● Glossitis is an inflammation of the tongue. Dry oral mucosa may be related to dehydration or caused by mouth breathing, altered salivation, or medications. ● Place brush at 45 degree angle ● Eye care: ○ Clean from inner canthus to outer canthus ○ Use artificial tear solution or normal saline every 4 hours if blink reflex is absent ● Ear/Nose care: ○ Ear: Use wash cloth, never a cotton swab ○ Nose: blow into cloth if nares are patent/ remove crust and apply warm compress

● Hair : ○ Pediculosis (lice) can be spread directly by contact with the infested areas or indirectly through contact with clothing, bed linen, brushes, or combs ● Use protestive pad and tray during shampooing ● nail/foot care ○ Soak nails and feet and assist with cleaning and trimming nails (if not contraindicated). ○ Massage ● Monthly douching is not recommended to control odor in the perineal area and may even be harmful since it tends to remove normal bacterial flora from the vagina. ● Vaginal care: ○ Clean each labia 1st from top to bottom (meatus to rectum) ○ Clean meatus

Patient teaching

● Cognitive learning involves the storing and recalling of new knowledge in the brain, such as learning food portions to maintain a calorie count. ● Demonstrating how to change a wound dressing or care for an umbilical cord is an example of psychomotor leaning. ● Expressing renewed confidence following a teaching session is an example of affective learning.

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C– creativity O– optimism P– planning E– expert information Adult learner: ○ As a person matures, one’s self-concept is likely to move from dependence to independence. ○ The previous experience of the adult is a rich resource for learning. ○ An adult’s readiness to learn is often related to a developmental task or a social role. ○ Most adults’orientation to learning is that material should be useful immediately, rather than at some time in the future. ● Teaching stragteies: ○ Cognitive domain: lecture, panel, discovery, written materials ○ Affective domain: role modeling, discussion, audiovisual materials ○ Psychomotor domain: demonstration, discovery, printed materials ■ Demonstration of techniques, procedures, exercises, and the use of special equipment, combined with a lecture and discussion, is an effective strategy to facilitate psychomotor learning, such as caring for a catheter.

● Source for info ○ Primary: patient ○ Secondary: medical records, patient’s family ● Obtainng feedback ○ Reinforcing and celebrating learning ○ Evaluating teaching ○ Revising the plan ● Documention of teaching process ○ Summary of the learning need ○ The plan ○ The implementation of the plan ○ Evaluation results ● Types of counseling ○ Short-term: for situational crisis ○ Long-term: for developmental crisis ○ Motivational interviewing ○

● A process is a series of actions,changes, or functions to bring about a desired result taking systematic steps. ● A science implies a body of knowledge. ● A philosophy is the study of wisdom, fundamental knowledge, and the processes used to develop a perception of life. ● A theory is composed of a group of concepts that describe a pattern of reality. ○ Can be changed/tested/ used as guideline for research

● Concept- Conceptual framework or model ● Deductive reasoning—examines general ideas and considers specific actions or ideas ○ nurse who tests a nursing theory by examining the theory itself and then considering the specific actions or ideas is using deductive reasoning. ● Inductive reasoning—builds from specific ideas or actions to conclusions about general ideas ● Interdisciplinary ○ General systems theory—theory for universal application; break whole things into parts to see how they work together in systems ○ Adaptation theory—adjustment of living matter to other living things and environment ○ Developmental theory—orderly and predictable growth and development from conception to death ○ ● Theoretical frameworks of nursing provide a focus for nursing care activities. The person receiving care is the central theme, but the way each theorist defines that person, the environment, health, and nursing gives a unique focus, specific to a particular theory. ○ Holistic patient care ○ Individualized care to meet needs of patients ○ Promotion of health ○ Prevention or treatment of illness ○ ● Quantitative ○ Involves concepts of basic and applied research ■ Descriptive ■ Correlational ■ Quasi-experimental ■ Experimental ● Steps ○ State the research problem. ○ Define purpose of the study. ○ Review related literature. ○ Formulate hypotheses and variables. ○ Select research design. ○ Select population and sample. ○ Collect data. ○ Analyze data. ○ ● Qualitative ○ Conducted to gain insight by discover...