Found. for Nursing Pract. II PDF

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Found. for Nursing Pract. II Notes Week 1 Oxygen therapy Physiology of Respiration ● Oxygen is required to sustain life ● Cardiac and respiratory systems function to supply body’s oxygen demands ● Diaphragm (major muscle) ● Accessory muscles (neck and abdomen muscle) ● Lungs: left (2 lobes), right (3 lobes) ● breathing is expanding the lungs to bring in air. it is determined by the compliance of the lungs and how well they can move in and out. FActors that affect oxygenation are hemoglobin, how good pump is, copd, asthma, airway obstructions, metabolic rate, ability to move chest, lifestyle, environment Respiratory Assessment ● 12-20 breathes per min, depth, use of accessory muscles (dont want to see that), rhythm, chain stokes= periods of fast and slow and somtimes apnea, syonatoc is dusty lips, syanosis, Pulse Oximetry ● measures of saturation of arterial blood with oxygen in percentage, should be greater than 90. percent of available hemoglobin that is saturated with oxygen. if number looks okay but pt is in distress they could have low hemoglobin, poor circulation Pulse Oximeter - Procedure ● clean site with alcohol wipe and allow to dry ● remove nail polish and artificial nails if necessary ● apply to skin (use adhesive if required) ● check equipment is functioning properly ● set alarms if present ● check Hgb status Dyspnea Management ● Pharmacological agents (inhalers, anti anxiety med ● Oxygen Therapy (#1, needs to be order by physian, is a drug, ) ● Raise HOB (head of bed) ● Relaxation & Deep Breathing Techniques (pursed lips breathing, in thru nose, out mouth)

Oxygen Therapy ● O2 therapy requires safe and accurate administration ● Requires a doctor’s order for type, amount, method of delivery and frequency ● Check agency policy Oxygen Safety Precautions ● When handled properly O2 is a safe & valuable drug. ● O2 – does not burn, but supports combustion ● Do not use in presence of open flame or any strong heat source ● Do not store O2 near radiators, heat ducts, steam pipes or other sources of heat ● All smoking materials must be removed from the room ● Smoking within 3 metres is prohibited ● Do not lubricate O2 equipment. Oil and grease (vaseline/petroleum jelly) ignites easily (lotion, face creams, hair dressings) ● Do not use aerosol sprays in vicinity of O2 equipment Nursing Responsibilities ● chcek all connections and tubing, and flow rate is correct, check order, vital signs as needed or change in status, beginning of shift and end of shift, every four hours, skin integraty under tubing, around ears and nose. Bowel Elimination Overview of A & P ● The GI tract includes: ○ Mouth ○ Esophagus ○ Stomach ○ Small intestine ○ Large intestine ○ Rectum ● take food in and break it down so it is in absorbable, Valsalva maneuver is constipation and could damage thorax bc increase pressure, decrease cardiac output and venous return, they could pass out on toliet- remind to keep breathing in and out, Peristalsis ● help move food along, surgey and level of activity and age can slow it down, infection, activty, anxiety, could speed it up Factors Affecting Bowel Elimination ● -Age ● -Diet ● -Physical activity

-Infection -Fluid intake -Personal habits

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-Toileting position -Pain Pregnancy -Medication -Surgery/ anesthesia -Psychological factors around 2-3 is when we gain control, c. diff is an infection effecting bowels, 25-30 grams of fibre per day for adults, must also 1500- 2400 mils per day of fluid, 5-40 mins after a meal ask if they need to go to bathroom, bed 90 degrees up if pt on bedpan, depression can decrease peristaltion

Alterations in Bowel Elimination ● PREVENTION IS KEY!!! ● Constipation ● Fecal Impaction ● Diarrhea ● Fecal Incontinence ● Flatulence ● Hemorrhoids (swollen vins around rectum) & Fissures (cracks or tears) ● none of these are a normal part of aging, Psychological Considerations of an Ostomy or Stoma ● Consider impact on body image ● Nurses need to be aware of their own response to the ostomy ● also impacts relationships, feelings of loss of control, respond sensitive, listent to pt and demonstrate empathy, involve pt family in care Assessment of Bowel Elimination- History ● Usual pattern ● Routines around elimination ● Characteristics of stool (colour, loose, formed, hard, watery, soft) ● Diet history ( anything changed?) ● Fluid intake (encourage fluids) ● Exercise, mobility and dexterity ● Any aids ● Illnesses affecting GI tract ● Medications ● Emotional, social history Abdominal Assessment ● Inspect abdomen ○ Contour, shape, symmetry, skin colour ○ Scars, stomas, lesions ○ Distention ( bladder retention) ● Auscultate (listen) (5-30 bowel sounds a minute) ● Palpation (feel) ● Percussion

Enemas ● Cleansing enemas ● Tap water ● Normal saline ● Soapsuds ● Oil retention ● Medicated (kayexulate) ● considered medication Clinical assessment of dehydration

Mild

Moderate

Severe

Weight loss

Up to 5%

6-10%

More than 10%

Appearance

Active, alert

Irritable, alert, thirsty

Lethargic, looks sick

Capillary filling (compared to your own)

Normal

Slightly delayed

Delayed

Pulse

Normal

Fast, low volume

Very fast, thready

Respiration

Normal

Fast

Fast and deep

Blood pressure

Normal

Normal or low Orthostatic hypotension

Very low

Mucous memb.

Moist

Dry

Parched

Tears

Present

Less than expected

Absent

Eyes

Normal

Normal

Sunken

Pinched skin

Springs back

Tents briefly

Prolonged tenting

Fontanel (infant sitting)

Normal

Sunken slightly

Sunken significantly

Urine flow

Normal

Reduced

Severely reduced

Week 2

Surgical Asepsis Introduction Overview of Surgical Asepsis Labs ● Asepsis 1- principles, gloving, setting up sterile fields, peer critique ● ● Asepsis 2- wound classifications, suture/staple removal, surgical incision ● ● Asepsis 3- complex wound care & culturing, Surgical Asepsis ● Procedures used to eliminate ALL microorganisms, pathogens & spores from an object or area ● Procedures may include ● Wearing a mask ● Protective eyewear ● Caps & gowns ● Sterile gloves ● “no touch” method ● Following principles of surgical asepsis for procedures ● Objective: to maintain asepsis & NOT contaminate area or objects 7 Principles of Surgical Asepsis ● Sterile objects maintain sterility only when touched by other sterile objects ● Only sterile objects are placed on a sterile field ● Objects are considered contaminated if they are: ○ below waist level ○ out of sight ● Contamination occurs with exposure to air ● Capillary contamination occurs when a sterile field comes in contact with a wet unsterile field ● Sterile objects are placed so that gravity does not cause fluid contamination ● Sterile field borders of 1 inch are considered contaminated Principles of Asepsis in Detail ● Sterile objects remain sterile when touched by only sterile objects ● Sterile touching sterile = sterile ● Sterile touching clean = contaminated ● Sterile touching contaminated = contaminated ● Sterile touching/?maybe touched=contaminated

Only sterile objects are placed on a sterile field ● Sterile objects are those which have been properly prepared and identified as sterile ● They must have certain characteristics ○ Clean

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Identified as sterile Dry Packaging intact – not torn, punctured, wet or open

Objects are contaminated if below waist or out of sight ● Contamination can accidentally occur from clothing, hair, patient ● Nurses never turn their backs on a sterile field ● Hands are kept above the waist and together ● Anything that falls below the waist or is out of sight is considered contaminated and discarded Prolonged exposure to air causes contamination ● Sterile fields can be contaminated by air currents carrying microorganisms and by droplet contamination ● When doing sterile procedures avoid creating air currents with linen, curtains or movement in the room ● No one should cough, sneeze, or talk over a sterile field ● Placing equipment onto a sterile field should be done from as close as possible with out contamination by touching ● Minimal rearranging of field reduces air contamination Capillary Contamination ● Microorganisms will travel quickly through water or dampness like a wick (sometimes called wicking) ● All wet objects are discarded or resterilized ● Sterile liquids spilled onto sterile trays which sit on clean or contaminated surfaces contaminates the field ● Sterile objects placed on wet surfaces ie gauze are considered contaminated by capillary contamination Fluids flow to gravity ● Contaminated liquids can flow over sterile field/areas by gravity ● Important for hand washing principles ● Hands held above elbows while washing ● Water and contaminants flow from clean-(hands) to dirty-(elbows) ● Hands are dried from fingers to elbows ● Hands then kept above the waist and together

1’’ Edge of a Sterile Field is Contaminated ● Edges include drapes, sterile towels, package containers, needle covers etc. ● Anything touching the edge or 1’’ perimeter of a field is considered contaminated and discarded ● When pouring fluids the edge of a container is considered contaminated and rinsed clean by pouring a small amount of the liquid over the rim and then fluids onto you sterile field container

Sterile Gloving ● through hand washing ● Open and remove outer package from gloves ● Grasp inner package and place on a clean, dry surface which is above waist level ● Carefully open package keeping gloves in the middle of the packaging ● ID right and left gloves ● Glove dominant hand first Donning Gloves ● Using thumb and 2 fingers of nondominant hand, carefully, touching only the inner surface of the glove, pull glove onto dominant hand ● Do not unroll cuff Non-dominant Hand ● With gloved hand slip fingers under the cuff ● Keep thumb up and away ● Carefully pull glove over nondominant hand ● With both gloves on interlock fingers and adjust gloves to a snug fit Removing Contaminated Gloves ● Grasp dominant glove by wrist area and remove while turning inside out ● Glove may be discarded or held in nondominant hand ● Tuck bare dominant hand into cuff of nondominant hand and peel off turning inside out ● Discard in appropriate receptacle Latex Allergies ● Observe patients for sensitivity to latex ● Itching ● Hives ● Redness ● Runny nose ● Changes in V S ● Document observations in detail

Establishing a Sterile Field ● ALL principles of asepsis apply in establishing a sterile field. ● Gather all supplies you will need for the dressing ● Wash hands ● Choose a flat, dry surface- have lots of room ● Holding tray firmly, peel off cover of package away from your body, do not reach over tray

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Carefully pick up the forceps tucked on top, always keep the forcep tips down In the following order, open each of the flaps of the wrapper around the tray being careful not to contaminate the forceps or the inner wrapper layer Place the forceps down on the edge of the outer wrapper with the contaminated end on the flat surface and the sterile tips on the wrapper inside the 1”margin

Adding Items to the Sterile Field ● Ensure that each item meets the criteria for sterility ● Hold the item as close to the tray as possible but not within touching distance ● Peel open the wrapper ● Allow gauze to drop onto the middle of the tray/field ● Ensure that it does not touch the 1” perimeter considered contaminated *Most noscomial infections are the result of the transfer of microorganisms from staff members’ hands. Sound aseptic technique can reduce a patient’s length of stay, speed healing, and reduce patient discomfort. Medical vs Surgical Asepsis ● Medical Asepsis ● Known as the clean technique ● Handwashing, clean gloves, clean equipment & handling clean linen ● Reduce and prevent the spread of microorganism ● More external, on the surface. ● ● ● ● ●

Surgical Asepsis Known as the sterile technique All things used are STERILE Procedures used to eliminate microorganisms Invasive procedures internally

ASEPSIS - 2 WOUNDS AND HEALING ● “A Wound is a disruption of the integrity and function of tissues in the body  “(Baharestani, 1994) ● ● ● ● ● ● ●

Wound Classification Systems describe: Skin integrity Cause Severity of Injury Cleanliness Descriptive qualities The wound treatment depends on the underlying disease process

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Skin integrity: open, closed, acute i.e. surgery/trauma, chronic i.e chronic inflammation, vascular comprimise ● Cause: intentional (surgery) & unintentional (trauma, pressure ulcer) ● Severity / extent of tissue damage o injury: superficial, penetrating, perforating ● Cleanliness of wound: clean, clean-contaminated, contaminated, infected, colonized(pathogens growing without signs and symptoms) ● Descriptive qualities: i.e. colour (laceration-cut,wound, abrasion-scrap or superficial, contusion-an area of skin where capilleries have been ruptured, bruise) . ● In essence, the critically colonized stage is the calm before the storm. By recognizing trouble now, you can initiate appropriate treatment before the balance is tipped further and deeper tissue infection occurs. What's appropriate treatment? ● Most experts recommend topical treatments to prevent the microorganisms from invading deeper tissues.1–3 Deeper tissue involvement generally requires systemic management.2 ● Antimicrobial dressings containing silver or cadexomer iodine are available as topical treatments. A vast array of silver products is available, so choose a dressing that best suits the wound characteristics.3 For example, if the wound has profuse exudate, a Hydrofiber with silver or a foam dressing with silver may be the best choice. (A Hydrofiber dressing combines moist wound healing with the look, feel, and handling properties of gauze and alginates.) ● For a wound that has a foul odor as well as toxins from Gram-negative bacteria, charcoal/silver combination dressings may be effective. Drier wounds with necrotic tissue may benefit from a silver-based gel. Using the best possible dressing is key to avoiding tissue toxicity and possible bacterial resistance.2 ● The cause of the patient's colonization also should be identified and corrected if possible. Maintain the patient's nutritional status and monitor any coexisting disorders. ● Once bacterial balance is achieved, discontinue the use of topical antimicrobials and initiate moist wound healing if the area has an adequate vascular supply. (Patients who are at high risk for infection—for example, patients with severely weakened immune systems—may need topical antimicrobials for a longer period.2 ) VENUS STASIS ULCER ●

congestion and slowing of circulation in veins due to blockage by either obstruction or high pressure in the venous system, usually best seen in the feet and legs.

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Reminder of Pressure assessment: Ischemia can lead to tissue death (necrosis). Reposition patient at least q 2h. Gentle massage may help blood return After a period of tissue ischemia, if pressure is relieved and blood flow returns the skin turns red = vasodilation (blood vessel expansion) With area of hyperemia (redness with vasodilation) press finger over area. It area blanches and when you remove finger returns to redness (blanching hyperemia) this is transient. If area does not blanch (non blanching erythema) deep tissue damage is probable.

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For dark skinned person then use halogen light and assess temperature of area. Appears darker than surrounding skin, warmer when compared to surrounding skin = risk of skin breakdown

HEALING Factors that Impair Wound Healing ● age, ● nutrition, ● obesity, ● impaired oxygenation, ● smoking, drugs, ● diabetes, ● radiation, ● wound stress What are some factors that would impair wound healing? ● Anything that impairs tissue perfusion ● age, nutrition, obesity, impaired oxygenation, smoking, drugs, diabetes, radiation, wound stress SIGNS OF WOUND INFECTION ● Pain ● Inflammation ● Purulent drainage ● Foul odour ● Fever / chills ● Elevated WBC/ LKC ● Delayed healing ● Pain / tenderness at wound site ● Erythema – redening of the surrounding tissue ● Edema (swelling) ● Induration (increased firmness of the tissue) ● Inflammation of the wound edges ● Warmth of surrounding tissues 2 TYPES OF WOUND ● 1. wound with loss of tissue ● 2. wound without loss of tissue ● Little tissue loss – clean surgical wound –heals by primary intention, edges are approximated/closed (sutures/staples) and risk of infection is low – ● Healing occurs quickly ● Drainage usually lasts only ~ 3 days ● Epithelial cells evident by ~ day 4 ● Inflammation lasts only ~ 5 days ● Healing ridge obvious by ~ day 9 ●

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Burn, pressure ulcer or severe lacerations are wounds with loss of tissue, heal by secondary intention, wound is left open until it becomes filled by scar tissue, takes longer to heal and chance of infection is greater The development of granulation tissue Increased scarring Wound edges don’t approximate (too wide) If severe, may have permanent loss of tissue function

TERMS ● Granulation ○ Red, moist tissue composed of new blood cells ● Slough ○ Soft, yellow or white tissue ● Eschar ○ Black / brown necrotic tissue ● Exudate ○ Wound drainage slough (yellow/white stringy substance attached to wound bed) – need to remove in order for the wound to heal ● Eschar is black/brown necrotic tissue. Which also needs to be removed before wound can heal = sharp debridment (cut with scapel) can only be done by nurse with appropriate knowledge, skill and judgement = usually wound care nurse ● Exudate includes amount, colour consistency and odour of drainage WOUND COMPLICATIONS ● Hemorrhage ○ Abnormal bleeding from a wound ● Infection ○ Wounds which drain purulent drainage (pus) ● Primary wound demonstrate usually ~day 4-5 ● Secondary wound, traumatic, contaminated demonstrate ~ day 2-3 ● Dehiscence ○ when a wound fails to heal properly and the layers of skin and tissue separate ○ Partial or total separation of wound layers ○ Usually occurs before collagen forms ~ day 3-11 ~ day 3-11 ● A pt at risk of poor wound healing is at risk of dehiscence * watch for a sudeen increased amount of serosanguineous drainage ● ● ● ● ●

Fever and Post op complications Wind (pneumonia) within 2 to 3 days Wound (wound infection) 4 to 5 days Water (urinary track infection) 5 to 7 Walk (thrombophlebitis) 7 plus days post op

WOUND COMPLICATIONS ● Evisceration ○ Total separation of wound layers ● Fistulas ○ Abnormal passageway ● Delayed wound closure (third intention) ●

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Evisceration ○ Visceral organs may be exposed ○ Constitutes a surgical emergency ○ Cover with sterile towels soaked in sterile saline Fistulas ○ between organs or from organs to the outside of the body ○ Increases patients risks

TYPES OF WOUND DRAINAGE ● Serous ○ Clear, watery, plasma-like ○ May be slightly pinkish ● Purulent ○ Thick, yellow, green, tan, or brown ○ May have distinct odour ● Serosanguineous ○ Pale, reddish, watery ○ Mixture of serous and sanguineous ● Sanguineous ○ Bright red ○ Active bleeding SIMPLE DRESSINGS ● Purposes of Simple Dressings ○ protect wounds from microorganisms & reduce infection risks ● Aid hemostasis(stopping bleeding) & reduce risk of hemorrhage (pressure dressings) ● Absorb drainage & promote healing ● Splint/support wound & promote comfort ● Prevent patient from viewing wound & promote psychological comfort ● Keep wound area warm ● Provide humidity to wound with wet dressin...