1430 FINAL

*COMFORT* Neurologic pain

results from the abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerve. Typically chronic, described as burning, electric, or tingling. Diabetic peripheral neuropathy, phantom limb pain, carpal tunnel, multiple sclerosis, spinal injury.

*FUNCTIONAL ABILITY* IADLs and BADLs

IADLs and BADLsComprehensive assessment of functional capacity is the basis for developing a rehabilitation program. Functional capacity is a person's ability to perform activities of daily living and instrumental activities of daily living. Activities of daily living (ADLs) are those self-care activities that the patient must accomplish each day to meet personal needs; they include personal hygiene/bathing, dressing/grooming, feeding, and toileting. Many patients cannot perform such activities easily. Instrumental activities of daily living (IADLs) include those complex skills needed for independent living, including meal preparation, grocery shopping, household management, finances, and transportation. The nurse observes the patient performing specific activities (e.g., eating, dressing) and notes the degree of independence; the time taken; the patient's mobility, coordination, and endurance; and the amount of assistance required. The nurse also carefully assesses joint motion, muscle strength, cardiovascular reserve, and neurologic function, because functional ability depends on these factors as well. Observations are recorded on a functional assessment tool. These tools provide a way to standardize assessment parameters and include a scale or score against which improvements may be measured. They also clearly communicate the patient's level of functioning to all members of the rehabilitation team. Rehabilitation staff members use these tools to provide an initial assessment of the patient's abilities and to monitor the patient's progress in achieving independence. One of the most frequently used tools to assess the patient's level of independence is the Functional Independence Measure (FIM™) (Keith, Granger, Hamilton, et al., 1987). The FIM™ is a minimum data set, measuring 18 self-care items including eating, bathing, grooming, dressing upper body, dressing lower body, toileting, bladder management, and bowel management. The FIM™ addresses transfers and the ability to ambulate and climb stairs and also includes communication and social cognition items. Scoring is based on a seven-point scale, with items used to assess the patient's level of independence. The Alpha FIM™, a short version of the FIM™, is used frequently within 72 hours of admission in acute care settings to measure functional independence and the amount of assistance the patient needs to perform ADLs. Although there are many disease-specific tools used to assess the patient's functional ability, some frequently used generic measures include the following: • The PULSES profile (Granger, Albrecht, & Hamilton, 1979) is used to assess physical condition (e.g., health/illness status), upper extremity functions (e.g., eating, bathing), lower extremity functions (e.g., transfer, ambulation), sensory function (e.g., vision, hearing, speech), bowel and bladder function (i.e., control of bowel or bladder), and situational factors (e.g., social and financial support). Each of these areas is rated on a scale from one (independent) to four (greatest dependency). • The Barthel Index (Mahoney & Barthel, 1965) is used to measure the patient's level of independence in ADLs, continence, toileting, transfers, and ambulation (or wheelchair mobility). This scale does not address communicative or cognitive abilities. • The Patient Evaluation Conference System (PECS) (Harvey, Hollis, & Jellinek, 1981), which contains 15 categories, is a comprehensive assessment scale that includes such areas as medications, pain, nutrition, use of assistive devices, psychological status, vocation, and recreation. A detailed functional evaluation of secondary conditions related to the patient's disability, such as muscle atrophy and deconditioning, skin integrity, bowel and bladder control, and sexual function, together with residual strengths unaffected by disease or disability, is necessary. In addition, the nurse assesses the patient's physical, mental, emotional, spiritual, social, and economic status, as well as cultural and familial environment. These elements may provide a context to the functional findings and influence the rehabilitation plan. For example, the patient's perception of what it means to have a disability and the implications that this might have on familial and social roles can influence the rehabilitation process. Med surg 156

*ELIMINATION* Incontinence education, urinary and bowel training (behavioral therapy)

Incontinence education, urinary and bowel training (behavioral therapy) Timed voiding involves establishing a set voiding frequency (such as every 2 hours if incontinent episodes tend to occur 2 or more hours after voiding). The individual chooses to "void by the clock" at the given interval while awake rather than wait until a voiding urge occurs. • Prompted voiding is timed voiding that is carried out by staff or family members when the individual has cognitive difficulties that make it difficult to remember to void at set intervals. The caregiver checks the patient to assess if he or she has remained dry and, if so, assists the patient to use the bathroom while providing positive reinforcement for remaining dry. • Habit retraining is timed voiding at an interval that is more frequent than the individual would usually choose. This technique helps to restore the sensation of the need to void in individuals who are experiencing diminished sensation of bladder filling due to various medical conditions such as a cerebrovascular accident. • Bladder retraining, also known as "bladder drill," incorporates a timed voiding schedule and urinary urge inhibition exercises to inhibit voiding, or leaking urine, in an attempt to remain dry for a set time. When the first timing interval is easily reached on a consistent basis without urinary urgency or incontinence, a new voiding interval, usually 10-15 minutes beyond the last, is established. Again, the individual practices urge inhibition exercises to delay voiding or avoid incontinence until the next preset interval arrives. When an acceptable voiding interval is reached, the patient continues that timed voiding sequence throughout the day. Pelvic Muscle Exercise Also known as Kegel exercises, pelvic muscle exercise (PME) aims to strengthen the voluntary muscles that assist in bladder and bowel continence in both men and women. Research shows that written or verbal instruction alone is usually inadequate to educate an individual about how to identify and strengthen the pelvic floor for sufficient bladder and bowel control. Biofeedbackassisted PME uses either electromyography or manometry to help the individual identify the pelvic muscles as he or she attempts to learn which muscle group is involved when performing PME. The biofeedback method also allows assessment of the strength of this muscle area. PME involves gently tightening the same muscles used to stop flatus or the stream of urine for 5-10-second increments, followed by 10-second resting phases. To be effective, these exercises need to be performed 2 or 3 times a day for at least 6 weeks. Depending on the strength of the pelvic musculature when initially evaluated, anywhere from 10-30 repetitions of PME are prescribed at each session. Older patients may need to exercise for an even longer time to strengthen the pelvic floor muscles. Pelvic muscle exercises are helpful for women with stress, urge, or mixed incontinence and for men who have undergone prostate surgery. Vaginal Cone Retention Exercises Vaginal cone retention exercises are an adjunct to the Kegel exercises. Vaginal cones of varying weight are inserted intravaginally twice a day. The patient tries to retain the cone for 15 minutes by contracting the pelvic muscles. Transvaginal or Transrectal Electrical Stimulation Commonly used to treat urinary incontinence, electrical stimulation is known to elicit a passive contraction of the pelvic floor musculature, thus re-educating these muscles to provide enhanced levels of continence. This modality is often used with biofeedback-assisted pelvic muscle exercise training and voiding schedules. At high frequencies, it is effective for stress incontinence. At low frequencies, electrical stimulation can also relieve symptoms of urinary urgency, frequency, and urge incontinence. Intermediate ranges are used for mixed incontinence. Neuromodulation Neuromodulation via transvaginal or transrectal nerve stimulation of the pelvic floor inhibits detrusor overactivity and hypersensory bladder signals and strengthens weak sphincter muscles.

*COMFORT* Terminology (i.e., tolerance, addiction, dependence)

*Tolerance:* - occurrence of the body's becoming accustomed to an opioid and needing a larger dose each time for pain relief. Tolerance does not indicate addiction. *Addiction:* - a pattern of compulsive use of addictive substances for means other than those prescribed. *Dependence:* phenomenon in which the body physiologically becomes accustomed to an opioid and suffers withdrawal symptoms if the opioid is suddenly removed or the dose is rapidly decreased. *Adjuvant* - drugs typically used for other purposes, but also used to enhance the effect of opiods by providing additional pain relief. *exacerbation* - period in chronic illness when the symptoms of the disease reappear. * *Taylor 1174*

Stage 4 NREM

- Called Delta sleep - Deepest sleep - 15 to 30 min long - vital signs low - very difficult to awaken - physiologic rest and relaxation - Enuresis, sleepwalking, sleeptalking possible - Repair and renewal of tissue

Stage 2 NREM

- Deeper sleep - 10 to 20 min long - Vital signs and metabolism continuing to slow - Requires slightly more stimulation to awaken - Increased relaxation

*SLEEP* Interventions to promote sleep

- Help clients establish and follow a bedtime routine - Limit walking clients during the night - Promote a quiet hospital environment - Help with personal hygiene needs or a back rub prior to sleep to increase comfort - Consider continuous positive airway pressure (CPAP) devices for clients who have sleep apnea - Consult the provider about trying sleep-promoting over-the-counter products (melatonin, valerian, chamomile) - As a last resort, suggest that the provider prescribe a pharmacological agent. Medications of choice for insomnia are benzodiazepine-like medications, which include the sedative-hypnotics zolpidem, eszopiclone, and zaleplon. *Client Education* - Exercise regularly at least 2 hr before bedtime. - Establish a bedtime routine and a regular sleep pattern - Arrange the sleep environment for comfort - Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime - Limit fluids 2 to 4 hr. before bedtime - Engage in muscle relaxation if anxious or stressed *Newborns and Infants* *Sleep Pattern* Newborn: Sleeps an average of 16 hours/24 hours; averages about 4 hours at a time. Each infant's sleep pattern is unique. On average, infants sleep 10 to 12 hours at night, with several naps during the day. Usually by 8 to 16 weeks of age, an infant sleeps through the night. REM sleep constitutes much of the sleep cycle of a young infant. *Nursing Implications* Teach parents to position infant on the back. This is the only safe sleeping position for infants less than 1 year old. Sleeping in the prone position increases the risk for sudden infant death syndrome (SIDS). Advise parents that eye movements, groaning, grimacing, and moving are normal activities at this age. Encourage parents to have infant sleep in a separate area rather than their bed. Caution parents about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib because this may pose a suffocation risk. *Toddlers* *Sleep Pattern* Need for sleep declines as this stage progresses. May initially sleep 12 hours at night with two naps during the day and end this stage sleeping 8 to 10 hours a night and napping once during the day. Toddlers may begin to resist naps and going to bed at night. They may move from crib to youth bed or regular bed at around 2 years. *Nursing Implications* Establish a regular bedtime routine (e.g., reading a story, singing a lullaby, saying prayers). Advise parents of the value of a routine sleeping pattern with minimal variation. Encourage attention to safety once child moves from crib to bed. If child attempts to wander out of room, a folding gate may be necessary across the door of the room. *Preschoolers* *Sleep Pattern* Children in this stage generally sleep 9 to 16 hours at night, with 12 hours being the average. The REM sleep pattern is similar to that of an adult. Daytime napping decreases during this period, and by the age of 5 years, most children no longer nap. This age group may continue to resist going to bed at night. *Nursing Implications* Encourage parents to continue bedtime routines. Advise parents that waking from nightmares or night terrors (awakening screaming about 20 minutes after falling asleep) are common during this stage. Waking the child and comforting the child generally helps. Sometimes use of a night light is soothing. *School-Aged Children* *Sleep Pattern* Younger school-aged children may require 10 to 12 hours nightly, whereas older children in this stage may average 8 to 10 hours. Sleep needs usually increase when physical growth peaks. *Nursing Implications* Discuss the fact that the stress of beginning school may interrupt normal sleep patterns. Advise that a relaxed bedtime routine is most helpful at this stage. Inform parents about child's awareness of the concept of death possibly occurring at this stage. Encourage parental presence and support to help alleviate some of the child's concerns. *Adolescents* *Sleep Pattern* Sleep needs of teenagers vary widely, but the average requirement is 9 to 10 hours. The growth spurt that normally occurs at this stage may necessitate the need for more sleep; however, the stresses of school, activities, and part-time employment may cause adolescents to have a restless sleep. Adolescents tend to go to bed later than younger children and adults, but early morning start times for high school frequently require an early awakening time. This can result in an average of only 7 to 7.5 hours of sleep a night. Many adolescents do not get enough sleep. *Nursing Implications* Advise parents that their adolescents' complaints of fatigue or inability to do well in school may be related to not enough sleep. Excessive daytime sleepiness (EDS) may also make the teenager more vulnerable to accidents and behavioral problems. *Young Adults* *Sleep Pattern* The average amount of sleep required is 8 hours, but in fact, many young adults require less sleep. Sleep is affected by many factors: physical health, type of occupation, exercise. Lifestyle demands may interfere with sleep patterns. REM sleep averages about 20% of sleep. *Nursing Implications* Reinforce that developing good sleep habits has a positive effect on health, particularly as a person ages. If loss of sleep is a problem, explore lifestyle demands and stress as possible causes. Suggest use of relaxation techniques and stress-reduction exercises rather than resorting to medication to induce sleep. Sleep medications decrease REM sleep, may be habit forming, and frequently lose their effectiveness over time. *Middle-Aged Adults* *Sleep Pattern* Total sleep time decreases during these years, with a decrease in stage IV sleep. The percentage of time spent awake in bed begins to increase. People become more aware of sleep disturbances during this period. *Nursing Implications* Encourage adults to investigate consistent sleep difficulties to exclude pathology or anxiety and depression as causes. Encourage adults to avoid use of sleep-inducing medication on a regular basis. *Older Adults* *Sleep Pattern* An average of 7 to 9 hours of sleep is usually adequate for this age group. Sleep is less sound, and stage IV sleep is absent or considerably decreased. Periods of REM sleep shorten. Elderly people frequently have great difficulty falling asleep and have more complaints of problems sleeping. Decline in physical health, psychological factors, effects of drug therapy (e.g., nocturia), or environmental factors may be implicated as causes of inability to sleep. *Nursing Implications* A comprehensive nursing assessment and individualized interventions may be effective in the long-term care of this age group. Emphasize concern for a safe environment because it is not uncommon for older people to be temporarily confused and disoriented when they first awake. Use sedatives with extreme caution because of declining physiologic function and concerns about polypharmacy. Encourage people to discuss sleep concerns with their physicians.

Stage 3 NREM

- Initial stages of deep sleep - 15 to 30 min long - Vital signs continuing to decrease but remain regular - Difficult to awaken - Relaxation with little movement

Stage 1 NREM

- Very light sleep - Only a few minutes long - Vital signs and metabolism beginning to decrease - Awaken easily - Feels relaxed and drowsy

REM

- Vivid dreaming - About 90 min after falling asleep - Longer with each sleep cycle - Average length 20 min - Varying vital signs - Very difficult to awake - Cognitive restoration

*TISSUE INTEGRITY* Tissue Integrity exemplar

-Dermal UlcersMany factors contribute to the development of pressure ulcers, such as length of stay in the hospital, vasopressure infusion, spinal cord injury, age, and body mass index.54 Pressure, shearing forces, friction, and moisture contribute to the incidence of pressure ulcers. External pressures that exceed capillary pressure interrupt blood flow in the capillary beds. When the pressure between a bony prominence and a support surface exceeds the normal capillary filling pressure, capillary flow essentially is obstructed. If this pressure is applied constantly for 2 hours, oxygen deprivation coupled with an accumulation of metabolic end products leads to irreversible tissue damage. While pressure magnitude and duration are important in the creation of a pressure ulcer, no specific amount of pressure necessary to compress capillaries and interrupt blood flow has been determined.55 Tolerance to pressure loads differs according to tissue, location, and metabolism.55 Persons with impaired circulation require less pressure to interrupt circulation. The same amount of pressure causes more damage when it is distributed over a small area than over a larger area. Whether a person is sitting or lying down, the weight of the body is borne by tissues covering the bony prominences. Most pressure ulcers are located on the lower part of the body, such as the sacrum, the coccygeal area, the ischial tuberosities, and the greater trochanters. Pressure over a bony area is transmitted from the surface to the underlying dense bone, compressing all of the intervening tissue. As a result, the greatest pressure occurs at the surface of the bone and dissipates outward in a conelike manner toward the surface of the skin (Fig. 46-19). Thus, extensive underlying tissue damage can be present when a small superficial skin lesion is first noticed. Altering the distribution of pressure from one skin area to another prevents tissue injury. Pressure ulcers most commonly occur in persons with conditions such as spinal cord injury in which normal sensation and the ability to move to redistribute body weight are impaired. Normally, persons unconsciously shift their weight to redistribute pressure on the skin and underlying tissues. For example, during the night, people turn in their sleep, preventing ischemic injury of tissues that overlie the bony prominences that support the weight of the body; the same is true for sitting for any length of time. The movements needed to shift the body weight are made unconsciously, and only when movement is restricted do people become aware of discomfort. Figure 46-19. Pressure over a bony prominence compresses all intervening soft tissue, with a resulting wide, three-dimensional pressure gradient that causes various degrees of tissue damage. (From Shea JD. Pressure sores: classification and management. Clin Orthop Relat Res. 1975;112:90.) Shearing forces are caused by the sliding of one tissue layer over another with stretching and angulation of blood vessels, causing injury and thrombosis. Shear occurs when the skeleton moves, but the skin remains fixed to an external surface, such as occurs with transfer from a stretcher to a bed or pulling a person up in bed. The same thing happens when the head of the bed is elevated, causing the torso to move toward the foot of the bed while friction and moisture cause the skin to remain fixed to the bed linens. Friction contributes to pressure ulceration by damaging the skin at the epidermal-dermal interface. It occurs as persons who are bedridden use their elbows and heels to aid in movement. Moisture contributes to pressure ulcer formation by weakening the cell wall of individual skin cells and by changing the protective pH of the skin. This makes the skin more susceptible to pressure, shear, and friction injury. Prevention and Treatment The prevention of pressure ulcers is preferable to their treatment.53 Preventive measures include identifying at-risk persons and the specific factors placing them at risk, maintaining and improving tissue tolerance to prevent injury, and protecting the skin and underlying tissue against the adverse effects of external mechanical forces (i.e., pressure, friction, shear). Risk factors contributing to the development of pressure ulcers are those related to sensory perception and the ability to respond meaningfully to pressure-related discomfort, level of skin moisture, urine and fecal continence, nutrition and hydration status, mobility, and circulatory status. Prevention Methods Methods for preventing pressure ulcers include frequent position changes, meticulous skin care, and frequent and careful observation to detect early signs of skin breakdown. Moisture macerates and injures skin. Sources of moisture include sweat, wound drainage, urine, and feces. Both urinary and fecal incontinence increase the risk of pressure ulcers. Food crumbs, intravenous tubing, and other debris in the bed can greatly increase local skin pressure points. Adequate hydration of the stratum corneum appears to protect the skin against mechanical insult. The prevention of dehydration improves the circulation. It also decreases the concentration of urine, thereby minimizing skin irritation in persons who are incontinent, and it reduces urinary problems that contribute to incontinence. Maintenance of adequate nutrition is important. Anemia and malnutrition contribute to tissue breakdown and delay healing after tissue injury has occurred.56 Staging and Treatment Pressure ulcers can be staged using four categories.57 Stage I ulcers are characterized by a defined area of persistent redness in lightly pigmented skin or an area of persistent redness with blue or purple hues in darker skin. Stage II ulcers represent a partial-thickness loss of skin involving the epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion, a blister, or a shallow crater. Stage III ulcers represent a full-thickness skin loss involving damage and necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. The ulcer manifests as a deep crater with or without undermining of adjacent tissue. Stage IV ulcers involve full-thickness skin loss and necrosis with extensive destruction or damage to the underlying subcutaneous tissues that may extend to involve muscle, bone, and supporting structures (e.g., tendon or joint capsule). After skin breakdown has occurred, special treatment measures are needed to prevent further ischemic damage, reduce bacterial contamination and infection, and promote healing. Treatment methods are selected based on the stage of the ulcer. Stage I ulcers usually are treated with frequent turning and measures to remove pressure. Stage II or III ulcers with little exudate are treated with semipermeable or occlusive dressings. Occlusive dressings are credited with preventing the loss of wound fluid and maintaining a moist environment that is necessary for epithelial cell migration. Wound fluid is thought to contain a variety of growth factors that enhance wound healing. Occlusive dressings may also relieve wound pain and prevent bacterial contamination. Several types of occlusive dressings are available, and each has advantages and disadvantages. Finally, vasopressure infusions may be important in the healing of pressure ulcers.54 Necrotic debris increases the possibility of bacterial infection and delays wound healing. Stage III ulcers with exudate and necrotic debris and stage IV ulcers usually require débridement (i.e., removal of necrotic tissue and eschar). This can be done surgically, with wet-to-dry dressings, or through the use of proteolytic enzymes. Stage IV wounds often require packing to obliterate dead space and are covered with nonadherent dressings. Stage IV ulcers may require surgical interventions, such as skin grafts or myocutaneous flaps. Pathology textbook -Impetigo Impetigo is a common, superficial bacterial infection caused by staphylococci, group A β-hemolytic streptococci, or both.10 It is common among infants and young children, although older children and adults occasionally contract the disease. Impetigo initially appears as a small vesicle or pustule or as a large bulla on the face or elsewhere on the body. As the primary lesion ruptures, it leaves a denuded area that discharges a honey-colored serous liquid that dries as a honey-colored crust with a "stuck-on" appearance (Fig. 46-6). New vesicles erupt within hours. Pruritus often accompanies the lesions, and skin excoriations that result from scratching multiply the infection sites. Although a very low risk, a possible complication of untreated streptococcal impetigo is poststreptococcal glomerulonephritis (see Chapter 25). Topical mupirocin (Bactroban), which has few side effects, may be effective for limited infections. If the area is large or if there is concern about complications, systemic antibiotics are used. tFigure 46-6. The lesions on this patient's forearm proved to be a dermatological condition caused by Staphylococcus aureus bacteria. Note the blister-like rash and the crusted lesion that resulted from the golden brown discharge as it dried. (From the Centers for Disease Control and Prevention rPublic Health Image Library. No. 14927. Courtesy of Dr. Herman Miranda, Univ. of Trujello, Peru; A. Chambers.) Another form of impetigo exists, bullous impetigo, which is usually caused by Staphylococcus aureus.10 Bullous impetigo is more common among children and occurs intermittently, with some cases transmitted among family members, but most often found among the institutionalized. Thin bullae erupt that appear clear to cloudy and coalesce. The bullae open, leaving the original bullous rim with central thin, flat, honey-colored crusts, or in some cases denuded areas. The face is often affected, but bullous impetigo may occur anywhere on the body. The treatment measures are the same as for nonbullous impetigo. Topical antibacterial therapy (e.g., mupirocin [Bactroban], retapamulin [Altabax]) is typically prescribed when the disease is limited to a small area. The medication must be applied to the lesions several times daily for 5 to 7 days. Lesions are first soaked or washed with soap solution to remove the central site of bacterial growth, giving the topical antibiotic an opportunity to reach the infected site. After the crusts are removed, the prescribed topical antibiotic cream is applied. Gloves are worn when providing patient care (Lewis & Friedman, 2013). Systemic antibiotic agents may be prescribed to treat infections that are widespread or in cases where there are systemic manifestations (e.g., a fever is present). These antibiotics are effective in reducing contagious spread, treating deep infections, and preventing acute glomerulonephritis (kidney infection), which may occur as a consequence of streptococcal skin diseases. Amoxicillin-clavulanate (Augmentin), cloxacillin (Cloxapen), or dicloxacillin (Dynapen) may be prescribed. In cases where MRSA is present, antibiotics prescribed may include clindamycin (Cleocin), trimethoprim-sulfamethoxazole (Bactrim), or vancomycin (Vancocin) (Lewis & Friedman, 2013). Nursing Management The nurse educates the patient and family members to bathe at least once daily with bactericidal soap. Cleanliness and good hygiene practices help to prevent the spread of the lesions from one skin area to another and from one person to another. In particular, patients and family members must be educated to practice hand hygiene every time after a lesion is touched. Each person should have a separate towel and washcloth. Because impetigo is a contagious disorder, infected people should avoid contact with other people until the lesions heal (Lewis & Friedman, 2013). pathology and Brunner -Psoriasis Considered one of the most common chronic noncommunicable skin diseases, psoriasis is typically characterized by the appearance of silvery plaques that most commonly appear on the skin over the elbows, knees, scalp, lower back, and buttocks, although lesions may appear anywhere, including the oral cavity, eyes (including the lids, conjunctivae, and corneas), and joints (Meffert, Arffa, Gordon, et al., 2013). Psoriasis affects approximately 7.5 million Americans, or 2% to 3% of the world's population (Dowling, 2010). Onset may occur at any age, with a median onset at 28 years. It is more prevalent among women and Caucasians and among persons who are obese. It is thought that most patients with psoriasis have a genetic predisposition to develop the disease (Meffert et al., 2013). Psoriasis has a tendency to improve and then recur periodically throughout life (Porth & Matfin, 2009). Pathophysiology Current evidence supports an autoimmune basis for psoriasis (Porth & Matfin, 2009). Periods of emotional stress and anxiety aggravate the condition, and trauma, infections, and seasonal and hormonal changes may also serve as triggers. In this disease, the epidermis becomes infiltrated by activated T cells and cytokines, resulting in both vascular engorgement and proliferation of keratinocytes. Epidermal hyperplasia results. These epidermal cells tend to improperly retain their nuclei, crippling their ability to release lipids that encourage cellular adhesion. This results in rapid turnover of poorly matured cells that do not adhere well to each other, resulting in the classic presentation of plaquelike lesions that have a silvery, scaly, flaky appearance (Meffert et al., 2013). Clinical Manifestations Psoriasis may range in severity from a cosmetic source of annoyance to a physically disabling and disfiguring disorder. Lesions appear as red, raised patches of skin covered with silvery scales. The scaly patches are formed by the buildup of living and dead skin (Fig. 61-4). If the scales are scraped away, the dark red base of the lesion is exposed, producing multiple bleeding points. The patches are not moist and may be pruritic. In many cases, the nails are also involved, with pitting, discoloration, crumbling beneath the free edges, and separation of the nail plate (Weber & Kelley, 2010). Complications Asymmetric rheumatoid factor-negative arthritis of multiple joints occurs in up to 30% of people with psoriasis, most typically after the skin lesions appear. The most typical joints affected include those in the hands or feet, although sometimes larger joints such as the elbows, knees, or hips may be affected (Meffert et al., 2013). It is recommended that a rheumatologist be consulted to assist in the diagnosis and long-term treatment of this disorder. (See Chapter 39 for further discussion of spondyloarthropathies, including psoriatic arthritis.) Generalized exfoliative dermatitis, also called erythroderma, may also result from psoriasis (see discussion later in this chapter). Assessment and Diagnostic Findings The presence of the classic plaque-type lesions generally confirms the diagnosis of psoriasis. If in doubt, the health care provider should assess for signs of nail and scalp involvement and for a positive family history. Biopsy of the skin is of little diagnostic value. Medical Management The goals of management are to slow the rapid turnover of epidermis, to promote resolution of the psoriatic lesions, and to control the natural cycles of the disease. There is no known cure. FIGURE 61-4 • Psoriasis. The therapeutic approach should be one that the patient understands; it should be cosmetically acceptable and minimally disruptive of lifestyle. Treatment involves the commitment of time and effort by the patient and possibly the family. Any precipitating or aggravating factors are addressed. An assessment is made of lifestyle because psoriasis is significantly affected by stress. Management of emotional factors should be addressed as part of the overall treatment of psoriasis. The patient is informed that treatment of severe psoriasis can be time-consuming, expensive, and aesthetically unappealing at times. Many patients report difficulty adhering to treatment plans, either for time reasons or lack of response to the treatment (National Institute for Health and Clinical Excellence [NICE], 2012). Gentle removal of scales is an important principle of psoriasis treatment. This can be accomplished by taking baths with added oils (e.g., olive oil, mineral oil), colloidal oatmeal preparations or coal tar preparations. A soft bush may be used to gently scrub the psoriatic plaques. After bathing, the application of emollient creams containing alphahydroxy acids (e.g., Lac-Hydrin, Penederm) or salicylic acid can soften thick scales. The patient and family should be encouraged to establish a regular skin care routine that can be maintained even when the psoriasis is not in an acute stage (NICE, 2012). Pharmacologic Therapy Three types of therapy are commonly indicted: topical, phototherapy, and systemic. Topical Agents Topically applied agents are used to slow the overactive epidermis. Topical corticosteroids may be applied for their antiinflammatory effects (see Table 61-3). Choosing the correct strength of corticosteroid for the involved site and choosing the most effective vehicle base are important aspects of topical treatment. In general, high-potency topical corticosteroids should not be used on the face and intertriginous areas, and their use on other areas should be limited to a 4-week course of twice-daily applications. A 4-week break should be taken before repeating treatment with the high-potency corticosteroids. For long-term therapy, moderate-potency corticosteroids are used. On the face and intertriginous areas, only low-potency corticosteroids are appropriate for long-term use (NICE, 2012) (see Table 61-3). Occlusive dressings may be applied to increase the effectiveness of the corticosteroid. Large plastic bags may be used—one for the upper body with openings cut for the head and arms and one for the lower body with openings for the legs. Large rolls of tubular plastic can be used to cover the arms and legs. Another option is a vinyl jogging suit. The medication is applied, and the suit is put on over it. The hands can be wrapped in gloves, the feet in plastic bags, and the head in a shower cap. Occlusive dressings should not remain in place longer than 8 hours. The skin should be inspected carefully for the appearance of atrophy, hypopigmentation, striae, and telangiectasias—all of which are side effects of corticosteroids. When psoriasis involves large areas of the body, topical corticosteroid treatment can be expensive and involve some systemic risk. The more potent corticosteroids, when applied to large areas of the body, have the potential to cause adrenal suppression through percutaneous absorption of the medication. In this event, other treatment modalities (e.g., nonsteroidal topical medications, ultraviolet light) may be used instead or in combination to decrease the need for corticosteroids (NICE, 2012). Two relatively new topical nonsteroidal treatments are calcipotriene (Dovonex) and tazarotene (Tazorac). Treatment with these agents tends to suppress epidermopoiesis (i.e., development of epidermal cells) and cause sloughing of the rapidly growing epidermal cells. Calcipotriene 0.05% is a derivative of vitamin D2. It works by decreasing the mitotic turnover of the psoriatic plaques. Its most common side effect is local irritation. The intertriginous areas and face should be avoided when using this medication. The patient should be monitored for symptoms of hypercalcemia. Calcipotriene is available as a cream for use on the body and a solution for the scalp. It is not recommended for use by older adult patients because of their more fragile skin or by pregnant or lactating women (Meffert et al., 2013). Tazarotene, a retinoid, causes sloughing of the scales covering psoriatic plaques. As with other retinoids, it causes increased sensitivity to sunlight by loss of the outermost layer of skin, so the patient should be cautioned to use an effective sunscreen and avoid other photosensitizers (e.g., tetracycline, antihistamines). Tazarotene is listed as a category X drug in pregnancy; reports indicate evidence of fetal risk, and the risk of use in pregnant women clearly outweighs any possible benefits. A negative result on a pregnancy test should be obtained before initiating this medication in women of childbearing age, and an effective contraceptive should be continued during treatment. Side effects include burning, erythema, or irritation at the site of application, and worsening of psoriasis (Meffert et al., 2013). Intralesional injections of the corticosteroid triamcinolone acetonide (Aristocort, Kenalog-10, Trymex) can be administered directly into highly visible or isolated patches of psoriasis that are resistant to other forms of therapy. Care must be taken to ensure that the medication is not injected into normal skin (Meffert et al., 2013). Phototherapy For patients who do not respond well to topical treatments, phototherapy using narrow-band ultraviolet-B (UVB) therapy may be effective as a single-therapy modality. However, phototherapy is generally more effective when it is administered as ultraviolet-A (UVA) in conjunction with a photosensitizing oral medication (a combination referred to as PUVA). Here, the patient takes a photosensitizing medication (i.e., psoralen) in a standard dose and is subsequently exposed to long-wave ultraviolet light as the medication plasma levels peak. It is thought that when psoralen-treated skin is exposed to UVA light, the psoralen binds with DNA and decreases epidermal cellular proliferation. PUVA has been associated with long-term risks of skin cancer, cataracts, and premature aging of the skin (Porth & Matfin, 2009; Meffert et al., 2013; NICE, 2012). The patient is usually treated two or three times each week until the psoriasis clears. An interim period of 48 hours between treatments is necessary to allow any burns resulting from PUVA therapy to become evident. After the psoriasis clears, the patient begins a maintenance program. Once little or no disease is active, less potent therapies are used to keep minor flare-ups under control (NICE, 2012). Systemic Agents Although systemic corticosteroids may cause rapid improvement of psoriasis, the usual risks and the possibility of triggering a severe flare-up on withdrawal limit their use; therefore, they are not indicated for treatment of psoriasis. Systemic cytotoxic preparations, such as methotrexate, have long been used successfully in treating extensive psoriasis that fails to respond to other forms of therapy. Methotrexate appears to inhibit DNA synthesis in epidermal cells, thereby reducing the turnover time of the psoriatic epidermis. However, the medication can be toxic, especially to the liver, kidneys, and bone marrow. Laboratory studies must be monitored to ensure that the hepatic, hematopoietic, and renal systems are functioning adequately. The patient should avoid drinking alcohol while taking methotrexate because alcohol ingestion increases the possibility of liver damage. The medication is teratogenic and thus should not be administered to pregnant women. Cyclosporine (Neoral -Wounds (traumatic and surgical) -Tinea Pedis Tinea pedis (athlete's foot) is the most common fungal dermatosis, primarily affecting the spaces between the toes, the soles, or the sides of the feet (Fig. 46-3). The lesions vary from a mildly scaling lesion to a painful, exudative, erosive, inflamed lesion with fissuring. Lesions often are accompanied by pruritus, pain, and foul odor. Mild forms are more common during dry environmental conditions. Exacerbations occur as a result of hot weather, sweating, and exercise or when the feet are exposed to moisture, occlusive shoes, and communal swimming. Figure 46-3. Chronic tinea of the sole caused by Trichophyton rubrum. (From the Centers for Disease Control and Prevention Public Health Image Library. No. 15441.) Tinea of the hand (Tinea manus) is usually a secondary infection with tinea pedis as the primary infection. In contrast to other skin disorders, it usually occurs only on one hand. The characteristic lesion is a blister on the palm or finger surrounded by erythema. Chronic lesions are scaly and dry. Cracking and fissuring may occur. The lesions may spread to the plantar surfaces of the hand. If chronic, tinea manus may lead to tinea of the fingernails. Simple forms of tinea pedis and tinea manus are treated with topical applications of antifungals. Complex cases are treated with oral antifungals. Other treatment and preventive measures include careful cleaning and drying of affected areas. -CandidaCandidiasis (moniliasis) is a fungal infection caused by C. albicans. This yeastlike fungus is a normal inhabitant of the gastrointestinal tract, mouth, and vagina (see Chapter 41). The skin problems result from the release of irritating toxins on the skin surface. C. albicans is almost always found only on the surface of the skin; it rarely penetrates deeper. Some persons are predisposed to candidal infections by conditions such as diabetes mellitus, antibiotic therapy, pregnancy, oral contraceptive use, poor nutrition, and immunosuppressive diseases.9 Oral candidiasis may be the first sign of infection with human immunodeficiency virus (HIV). Figure 46-5. Dermatophytid or id reaction on the fingers due to a tinea infection. An id immunologic reaction, also known as autoeczematization, is an itchy, vesicular rash produced in response to an intense inflammatory process that can be located in another region of the body. (From the Centers for Disease Control and Prevention Public Health Image Library. No. 4805.) Candida albicans thrives on warm, moist, intertriginous areas (i.e., between folds or adjacent surfaces) of the body. The rash is red with well-defined rborders. Patches erode the epidermis, and there is scaling. Mild to severe itching and burning often accompany the infection. Severe forms of infection may involve pustules or vesiculopustules as well as maculopapular satellite lesions found outside the clearly demarcated borders of the candidal infection. Satellite lesions often are diagnostic of diaper rash complicated by Candida. The appearance of candidal infections varies according to the site (see Chapter 41 for a discussion of vaginal candidiasis). Diagnosis usually is based on microscopic examination of skin or mucous membrane scrapings placed in a KOH solution. Treatment measures vary according to the location. Preventive measures such as wearing rubber gloves are encouraged for persons with infections of the hands. Intertriginous areas often are separated with clean cotton cloth and allowed to air dry as a means of decreasing the macerating effects of heat and moisture. Topical and oral antifungal agents, such as clotrimazole, econazole, ketoconazole, and miconazole, are used in treatment depending on the site and extent of The Wood light is an ultraviolet (UV) light that can assist with the diagnosis of tinea, as some types of fungi fluoresce yellow-green when the light is directed onto the affected area.involvement. Pathology Under fungus Skin disorders -Pediculosis (lice) Parasitic skin infestations include those of the skin by lice (pediculosis) and the itch mite (scabies). Pediculosis: Lice Infestation Lice infestation affects people of all ages. Three varieties of lice infest humans: Pediculus humanus capitis (head louse), Pediculus humanus corporis (body louse), and Phthirus pubis (pubic louse or "crab"). Lice are called ectoparasites because they live on the outside of the host's body. They depend on the host for their nourishment, feeding on human blood approximately five times each day. They inject their digestive juices and excrement into the skin, which causes severe itching (Guenther, Maguiness, & Austin, 2012). Types of Pediculosis Pediculosis Capitis Pediculosis capitis is an infestation of the scalp by the head louse. The female louse lays her eggs (nits) close to the scalp. The nits become firmly attached to the hair shafts with a tenacious substance. The young lice hatch in about 10 days and reach maturity in 2 weeks. Head lice may be transmitted directly by physical contact or indirectly by infested combs, brushes, wigs, hats, and bedding (Guenther et al., 2012). Pediculosis Corporis and Pubis Pediculosis corporis is an infestation of the body by the body louse. This is a disease of those who live in close quarters. Pediculosis pubis is extremely common. The infestation is generally localized in the genital region and is transmitted chiefly by sexual contact (Guenther et al., 2012). Clinical Manifestations Head lice are found most commonly along the back of the head and behind the ears. To the naked eye, the eggs look like silvery, glistening oval bodies. The bite of the insect causes intense pruritus, and the resultant scratching often leads to secondary bacterial infection, such as impetigo or furunculosis. The infestation is more common in children and people with long hair (Guenther et al., 2012). With body lice, the areas of the skin that come in closest contact with the underclothing (i.e., neck, trunk, and thighs) are chiefly involved. The body louse lives primarily in the seams of underwear and clothing, to which it clings as it pierces the skin with its proboscis. Its bites cause characteristic minute hemorrhagic points. Widespread excoriation may appear as a result of intense pruritus and scratching, especially on the trunk and neck. Among the secondary lesions produced are parallel linear scratches and a slight degree of eczema. In long-standing cases, the skin may become thick, dry, and scaly, with dark pigmented areas (Guenther et al., 2012). Pruritus, particularly at night, is the most common symptom of pediculosis pubis. Reddish-brown dust (i.e., excretions of the insects) may be found in the patient's underclothing. The pubic area should be examined with a magnifying glass for lice crawling down a hair shaft or nits cemented to the hair or at the junction with the skin. Infestation by pubic lice may coexist with sexually transmitted infections (STI) such as gonorrhea, herpes, or syphilis. There may also be infestation of the hairs of the chest, axillae, beard, and eyelashes. Gray-blue macules may sometimes be seen on the trunk, thighs, and axillae as a result of either the reaction of the insects' saliva with bilirubin (converting it to biliverdin) or an excretion produced by the salivary glands of the louse (Guenther et al., 2012). Medical Management Treatment of head and pubic lice involves washing the hair with a shampoo containing pyrethrin compounds with piperonyl butoxide (RID or R&C Shampoo) or rinsing with permethrin (Nix). Although it had been first-line treatment for many years, lindane (Kwell) is no longer recommended because of its neurotoxic adverse effects (Guenther et al., 2012). The patient is instructed to shampoo the scalp and hair according to the product directions. After the hair is rinsed thoroughly, it is combed with a fine-toothed comb dipped in vinegar to remove any remaining nits or nit shells freed from the hair shafts. They are extremely difficult to remove and may have to be picked off one by one. The patient with body lice is instructed to bathe with soap and water. Typically, no medications are indicated because the lice live on the patient's clothing. Topical medications used to treat head and pubic lice may be applied to the clothing, however, particularly in the seams of garments (see following pdiscussion about general hygiene measures). If the eyelashes are involved, petrolatum may be thickly applied twice daily for 8 days, followed by mechanical removal of any remaining nits (Guenther et al., 2012). All articles of clothing, towels, and bedding that may have lice or nits should be washed in hot water—at least 54°C (130°F)—or dry-cleaned to prevent reinfestation. Upholstered furniture, rugs, and floors should be vacuumed frequently. Combs and brushes are also disinfected with the shampoo or discarded. All family members and close contacts are treated (Guenther et al., 2012). Complications, such as severe pruritus, pyoderma, and dermatitis, are treated with antipruritics, systemic antibiotics, and topical corticosteroids. Body lice can transmit epidemic rickettsial disease (e.g., epidemic typhus, relapsing fever, and trench fever) to humans (Guenther et al., 2012). The causative organism may be in the gastrointestinal tract of the insect and may be excreted on the skin surface of the infested person. Nursing Management The nurse informs the patient that head lice may infest anyone and are not a sign of uncleanliness. Because the condition spreads rapidly, treatment must be started immediately. Epidemics among those living in close quarters (e.g., dormitories, military barracks) may be managed by having everyone shampoo their hair on the same night. Cohabitants and family members should be warned not to share combs, brushes, and hats; they should be inspected for head lice daily for at least 2 weeks. Treatment is necessary for all family members and sexual contacts of patients with body and/or pubic lice. The nurse educates them about personal hygiene and methods to prevent or control infestation. The patient and partner must also be scheduled for a diagnostic workup for coexisting )A wide range of diagnostic studies may be performed in patients with altered integumentary function. The nurse should educate the patient about the purpose, what to expect, and any possible side effects related to these examinations prior to testing. The nurse should note trends in results because they provide information about whether lesions are primary or secondary, disease progression, and the patient's response to therapy. Skin Biopsy Performed to obtain tissue for microscopic examination, a skin biopsy may be obtained by scalpel excision or by a skin punch instrument that removes a small core of tissue. Biopsies are performed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and to establish an exact diagnosis. Immunofluorescence Designed to identify the site of an immune reaction, immunofluorescence testing combines an antigen or antibody with a fluorochrome dye. Antibodies can be made fluorescent by attaching them to a dye. Direct immunofluorescence tests on skin are techniques to detect autoantibodies directed against portions of the skin. The indirect immunofluorescence test detects specific antibodies in the patient's serum. Patch Testing Performed to identify substances to which the patient has developed an allergy, patch testing involves applying the suspected allergens, such as nickel or fragrances, to normal skin under occlusive patches. Patients wear these occluded strips on their backs for 48 hours, and the area is assessed after 72 hours. The development of redness, fine elevations, or itching is considered a weak positive reaction; fine blisters, papules, and severe itching indicate a moderately positive reaction; and blisters, pain, and ulceration indicate a strong positive reaction. The nurse educates the patient with a positive reaction to avoid the allergen, which is often quite difficult, because of the common ambience of some topical allergens. Skin Scrapings Tissue samples are scraped from suspected fungal lesions with a scalpel blade moistened with oil so that the scraped skin adheres to the blade. The scraped material is transferred to a glass slide, covered with a coverslip, and examined microscopically. The spores and hyphae of dermatophyte infections, as well as infestations such as scabies, can be visualized. Tzanck Smear The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined. Wood's Light Examination Wood's light is a special lamp that produces long-wave ultraviolet rays, which result in a characteristic blue to dark purple fluorescence. The color of the fluorescent light is best seen in a darkened room, where it is possible to differentiate epidermal from dermal lesions and hypo- and hyperpigmented lesions from normal skin. The patient is reassured that the light is not harmful to skin or eyes. Lesions that still contain melanin almost disappear under ultraviolet light, whereas lesions that are devoid of melanin increase in whiteness with ultraviolet light. Clinical Photographs Photographs are taken to document the nature and extent of the skin condition and are used to determine progress or improvement resulting from treatment. They are sometimes used to track the status of moles to document if the characteristics of the mole are changing. Nursing Implications The nurse may be responsible to ensure that consent forms are completed for surgical procedures and for clinical photography, that all specimens collected are managed according to protocol, that a log is maintained tracking specimens to and from the laboratory, and that results are received in a timely manner. The nurse educates the patient regarding appropriate care of surgical sites and implication of test results (Uhlenhake & Feldman, 2010).

*TISSUE INTEGRITY* Assessment tools

-braden scale The Braden scale assesses a patient's risk of developing a pressure ulcer by examining six criteria:[3] Sensory perception Edit This parameter measures a patient's ability to detect and respond to discomfort or pain that is related to pressure on parts of their body. The ability to sense pain itself plays into this category, as does the level of consciousness of a patient and therefore their ability to cognitively react to pressure-related discomfort. Moisture Edit Excessive and continuous skin moisture can pose a risk to compromise the integrity of the skin by causing the skin tissue to become macerated and therefore be at risk for epidermal erosion. So this category assesses the degree of moisture the skin is exposed to. Activity Edit This category looks at a patient's level of physical activity since very little or no activity can encourage atrophy of muscles and breakdown of tissue.[4] Mobility Edit This category looks at the capability of a patient to adjust their body position independently. This assesses the physical competency to move and can involve the clients willingness to move. Nutrition Edit The assessment of a clients nutritional status looks at their normal patterns of daily nutrition. Eating only portions of meals or having imbalanced nutrition can indicate a high risk in this category. Friction and Shear Edit Friction and shear looks at the amount of assistance a client needs to move and the degree of sliding on beds or chairs that they experience. This category is assessed because the sliding motion can cause shear which means the skin and bone are moving in opposite directions causing breakdown of cell membranes and capillaries.[5]Wikepedia -comprehensive history -skin and overall health assessment • Mobility • Nutritional status - Albumin <3.2 mg/dL (3.5-5 mg/dL)- Prealbumin < 19 mg/dL(16-40 mg/dL)- Body weight decreased of >15%- Total lymphocyte <1,800/mm³ (1,000-4000 mm³)- Hemoglobin A1C > 8% (< 6%)- Glucose > 120 (70-120mg/dL) • Moisture and incontinence • Evaluation of existing pressure ulcers - Location, size, stage, presence of undermining, color and type,abnormal pathways (sinus tract), necrotic tissue, sloughing,exudate or drainage, granulation tissue, epithelialization •Wound assessment - Drains, color, dehiscence, healing, etc., measure (pg. 938, Taylor) •Pain assessment •Inspect systematically: head to toe •Acute care: On admission then reassessed at least every 48 hours •Intensive care: daily •Unstable patients: every shift or asneeded •Long term care: on admission then every 48 hours for first week, then weeklyfor first month followed by monthly to quarterly •Home health care: on admission, then every visit (slide 20 on tissue integrity powerpoint)

*FUNCTIONAL ABILITY* Assessment tools

1. Assessment toolsThe nurse observes the patient performing specific activities (e.g., eating, dressing) and notes the degree of independence; the time taken; the patient's mobility, coordination, and endurance; and the amount of assistance required. The nurse also carefully assesses joint motion, muscle strength, cardiovascular reserve, and neurologic function, because functional ability depends on these factors as well. Observations are recorded on a functional assessment tool. These tools provide a way to standardize assessment parameters and include a scale or score against which improvements may be measured. They also clearly communicate the patient's level of functioning to all members of the rehabilitation team. Rehabilitation staff members use these tools to provide an initial assessment of the patient's abilities and to monitor the patient's progress in achieving independence. One of the most frequently used tools to assess the patient's level of independence is the Functional Independence Measure (FIM™) (Keith, Granger, Hamilton, et al., 1987). The FIM™ is a minimum data set, measuring 18 self-care items including eating, bathing, grooming, dressing upper body, dressing lower body, toileting, bladder management, and bowel management. The FIM™ addresses transfers and the ability to ambulate and climb stairs and also includes communication and social cognition items. Scoring is based on a seven-point scale, with items used to assess the patient's level of independence. The Alpha FIM™, a short version of the FIM™, is used frequently within 72 hours of admission in acute care settings to measure functional independence and the amount of assistance the patient needs to perform ADLs. Although there are many disease-specific tools used to assess the patient's functional ability, some frequently used generic measures include the following: • The PULSES profile (Granger, Albrecht, & Hamilton, 1979) is used to assess physical condition (e.g., health/illness status), upper extremity functions (e.g., eating, bathing), lower extremity functions (e.g., transfer, ambulation), sensory function (e.g., vision, hearing, speech), bowel and bladder function (i.e., control of bowel or bladder), and situational factors (e.g., social and financial support). Each of these areas is rated on a scale from one (independent) to four (greatest dependency). • The Barthel Index (Mahoney & Barthel, 1965) is used to measure the patient's level of independence in ADLs, continence, toileting, transfers, and ambulation (or wheelchair mobility). This scale does not address communicative or cognitive abilities. • The Patient Evaluation Conference System (PECS) (Harvey, Hollis, & Jellinek, 1981), which contains 15 categories, is a comprehensive assessment scale that includes such areas as medications, pain, nutrition, use of assistive devices, psychological status, vocation, and recreation. A detailed functional evaluation of secondary conditions related to the patient's disability, such as muscle atrophy and deconditioning, skin integrity, bowel and bladder control, and sexual function, together with residual strengths unaffected by disease or disability, is necessary. In addition, the nurse assesses the patient's physical, mental, emotional, spiritual, social, and economic status, as well as cultural and familial environment. These elements may provide a context to the functional findings and influence the rehabilitation plan. For example, the patient's perception of what it means to have a disability and the implications that this might have on familial and social roles can influence the rehabilitation process.Med surg 156

*SENSORY* Age related hearing loss

Auditory changes begin to be noticed at about 40 years of age. Environmental factors, such as exposure to noise, medications, and infections, as well as genetics, may contribute to hearing loss as much as age-related changes. Presbycusis is a gradual sensorineural loss that progresses from the loss of the ability to hear high-frequency tones to a generalized loss of hearing. It is attributed to irreversible inner ear changes. Older people often cannot follow conversation because tones of high-frequency consonants (the sounds f, s, th, ch, sh, b, t, p) all sound alike. Hearing loss may cause older people to respond inappropriately, misunderstand conversation, and avoid social interaction. This behavior may be erroneously interpreted as confusion. Wax buildup or other correctable problems may also be responsible for hearing difficulties. A properly prescribed and fitted hearing aid may be useful in reducing some types of hearing deficits. (See Chapter 64 for discussion of alterations in hearing.)

*ELIMINATION* Constipation

Constipation can be caused by certain medications (i.e., tranquilizers, anticholinergic agents, antidepressants, antihypertensive agents, bile acid sequestrants, diuretic agents, opioids, aluminum-based antacids, iron preparations, selected antibiotics, muscle relaxants, and cytotoxic drugs (e.g., vincristine [Oncovin]); rectal or anal disorders (e.g., hemorrhoids, fissures); obstruction (e.g., bowel tumors); metabolic, neurologic, and neuromuscular conditions (e.g., Hirschsprung disease, Parkinson's disease, multiple sclerosis); endocrine disorders (e.g., hypothyroidism, pheochromocytoma); lead poisoning; and connective tissue disorders (e.g., scleroderma, systemic lupus erythematosus). Constipation is a major issue for patients taking opioids for pain. Diseases of the colon commonly associated with constipation include irritable bowel syndrome (IBS) and diverticular disease. Constipation can also occur with an acute disease process in the abdomen (e.g., appendicitis) (Apau, 2010a; Bouras & Tangalos, 2009; Spinzi, Amato, Imperiali, et al., 2009).

*THERMOREGULATION* Heat stroke vs. heat exhaustion vs. dehydration: S/S and treatment

Heat-induced illnesses may range in severity from mild and self-limiting to life-threatening emergencies. The most serious of these—heat stroke—is an acute medical emergency caused by failure of the heat-regulating mechanisms of the body. The most common cause of heat stroke is nonexertional, prolonged exposure to an environmental temperature of greater than 39.2°C (102.5°F), although a heat index of greater than 35°C (95°F) is associated with increased mortality (Becker & Stewart, 2011). It usually occurs during extended heat waves, especially when they are accompanied by high humidity. Exertional heat stroke is caused by strenuous physical activity that occurs in a hot environment (Cline, Ma, Cydulka, et al., 2012; ENA, 2013).

*MOBILITY* Hip fracture/replacement: S/S and treatment

Patients having orthopedic surgery are particularly at risk for VTE, including DVT and pulmonary embolism (PE). Therefore, factors that compound or further increase this risk are assessed preoperatively. Advanced age, obesity, preoperative leg edema, previous history of any VTE, and varicose veins increase the risk for postoperative DVT and PE (Johanson, Lachiewicz, & Lieberman, 2009). The use of medications that increase the risk of clotting, such as certain hormones and nonsteroidal anti-inflammatory drugs, may be discontinued a week before surgery. Prophylactic low-molecular-weight heparin (LMWH) or another anticoagulant agent may be ordered prior to or after surgery (Johanson et al., 2009). Intermittent compression devices should be applied intraoperatively or immediately postoperatively. Assessing the neurovascular status of the extremity undergoing joint replacement is important, because postoperative assessment data are compared with preoperative assessment data to identify changes and any arterial impairment to the affected extremity. For example, an absent pulse postoperatively is of concern unless the pulse was also absent preoperatively. Nerve palsy could occur as a result of surgery. Preventing Infection Preoperative assessment of the patient for recent or active infections, including urinary tract infection, is necessary because of the risk for postoperative infection. Any infection presenting 2 to 4 weeks before planned surgery may result in postponement of surgery. Preoperative skin preparation, such as showers with antiseptic soap, frequently begins 1 or 2 days before the surgery (Kamel, McGahan, Polisena, et al., 2012). Research findings suggest that prophylactic broad-spectrum antibiotics administered minutes prior to incision are effective in preventing postoperative infection (Smith, Jacobs, Rodier, et al., 2011). If antibiotics are given too early (60 or more minutes before surgery), the patient's risk for postoperative infection may increase (Stefansdottir, Robertsson, W-Dahl, et al., 2009). Culture of the joint during surgery may be important in identifying and treating subsequent infections. If osteomyelitis develops, it is difficult to treat (see Chapter 42). Persistent infection at the site of the prosthesis usually requires removal of the implant and joint revision. It is not always possible to achieve a functional joint when the reconstruction procedure has to be repeated. Managing Pain Assessment of the patient's pain preoperatively and any cultural and value preferences are important components related to the control of pain following joint surgery. Assessing the patient's level of understanding of the surgery and explaining what to expect in the postoperative period (e.g., incentive spirometry, pain control methods, activity limits) can improve outcomes. In particular, research findings suggest that patients who attend structured preoperative education classes report feeling better prepared for surgery and better able to control their pain after surgery (Kearney, Jennrich, Lyons, et al., 2011) (Chart 41-7). Total Hip Arthroplasty Total hip arthroplasty (THA; total hip replacement) is the replacement of a severely damaged hip with an artificial joint. Indications for this surgery include osteoarthritis, rheumatoid arthritis, femoral neck fractures (i.e., hip fracture), failure of previous reconstructive surgeries (failed prosthesis, osteotomy), and conditions resulting from developmental dysplasia or Legg-Calvé-Perthes disease (avascular necrosis of the hip in childhood). A variety of total hip prostheses are available. Most consist of a metal femoral component topped by a spherical ball made of metal, ceramic, or plastic that is fitted into a plastic or metal acetabular socket (see Fig. 41-7). The surgeon selects the prosthesis that is best suited to the individual patient, considering various factors including skeletal structure and activity level. The patient has irreversibly damaged hip joints, and the potential benefits, including improved quality of life, outweigh the surgical risks. With the advent of improved prosthetic materials and operative techniques, the life of the prosthesis has been extended, and today younger patients with severely damaged and painful hip joints are undergoing total hip replacement. Nursing Interventions The nurse must be aware of and monitor for specific potential complications associated with THA. Complications that may occur include dislocation of the hip prosthesis, excessive wound drainage, VTE, infection, and heel pressure ulcer (Chart 41-8). The nurse also monitors for complications associated with immobility. Long-term complications include heterotopic ossification (formation of bone in the periprosthetic space), avascular necrosis, and loosening of the prosthesis. Gerontologic Considerations The older adult patient who has had THA merits special postoperative care considerations. Early THA surgery for hip fractures (within 24 to 36 hours) is recommended for most patients once a medical assessment has been made and the patient's condition has been stabilized appropriately. If there are no contraindications (e.g., history of a bleeding disorder), these patients should receive LMWH for DVT prophylaxis; mechanical devices should be used for patients in whom anticoagulants and antiplatelet agents are contraindicated. Providing an appropriate postoperative analgesic regimen for older adults can be challenging in the presence of impaired cognition, medical comorbidities, and possible drug interactions. Consulting with a pain management specialist to specifically tailor the analgesic type and dose may be helpful (see Chapter 12).All older adult patients post-THA should be placed on a higher-specification, foam pressure-relieving mattress rather than a standard hospital mattress (Jenson, Cameron, & Lyn, 2010). A major goal following surgery in this patient population is early mobilization, in an effort to prevent the complications associated with prolonged immobility and to return the patient to functional activity (Egol & Straus, 2009). Early assisted mobilization and ambulation (begun within 48 hours of surgery) accelerates functional recovery and is associated with more direct discharges to home and less discharges to high-level care in previously community dwelling individuals (Jenson et al., 2010). Preventing Dislocation of the Hip Prosthesis For patients undergoing a posterior or posterolateral approach for THA, maintenance of the femoral head component in the acetabular cup is essential. The risk for dislocation is more common with this approach and may occur when the hip is in full flexion, adducted (legs together), and internally rotated. Therefore, correct positioning is maintained at all times. The patient should be in a supine position with his or her head slightly elevated and the affected leg in a neutral position. The use of an abduction splint, a wedge pillow (Fig. 41-8), or two or three pillows placed between the legs prevent adduction beyond the midline of the body. A cradle boot may be used to prevent leg rotation and to support the heel off the bed, preventing development of a pressure ulcer. When the nurse turns the patient in bed to the unaffected side, it is important to keep the operative hip in abduction (movement away from the center or median line of the body). The patient should not be turned to the operative side, which could cause dislocation, unless specified by the surgeon. The patient's hip is never flexed more than 90 degrees. When using a fracture bedpan, the nurse instructs the patient to flex the unaffected hip and to use the trapeze to lift the pelvis onto the pan. The patient is also reminded not to flex the affected hip. Providing Home Care After Total Hip Arthroplasty Considerations • Pain management • Wound care • Mobility • Self-care (activities of daily living) • Potential complications Nursing Interventions Discuss with patient the following methods to reduce pain: • Periodic rest • Distraction and relaxation techniques • Medication therapy (e.g., nonsteroidal anti-inflammatory drugs, opioid analgesic agents): actions of medications, administration, schedule, side effects Instruct patient in the following: • Keeping incision clean and dry • Cleansing incision daily with soap and water and changing the dressing • Recognizing signs of wound infection (e.g., pain, increased redness, swelling, purulent drainage, fever) Explain that sutures or staples will be removed 10-14 days after surgery. Educate patient about the following: • Safe use of assistive devices • Weight-bearing limits • How to change positions frequently • Limitations on hip flexion and adduction (e.g., avoid acute flexion and crossing legs) • How to stand without flexing hip acutely • Avoidance of low-seated chairs • Sleeping with pillow between legs to prevent adduction • Gradual increase in activities and participation in prescribed exercise regimen • Use of important medications such as warfarin (Coumadin) and aspirin Assess home environment for physical barriers. Instruct patient to use elevated toilet seat and to use reachers to aid in dressing. Encourage patient to accept assistance with activities of daily living during early convalescence until mobility and strength improve. Arrange services and accommodations to address the patient's disability or illness, as appropriate. Assess patient for development of potential problems, and instruct patient to report signs of potential complications: • Dislocation of prosthesis (e.g., increased pain, shortening of leg, inability to move leg, popping sensation in hip, abnormal rotation) • Deep vein thrombosis (e.g., calf pain, swelling, redness) • Wound infection (e.g., pain, increased redness, swelling, purulent drainage, fever) • Pulmonary emboli (e.g., shortness of breath, tachypnea, pleuritic chest pain) Discuss with patient the need to continue regular health care (routine physical examinations) and screenings. The patient will need physical therapy to regain mobility. Assistive devices (crutches, walker, or cane) may be used for a time. After sufficient muscle tone has developed to permit a normal gait without discomfort, these devices are not necessary. In general, by 3 months, the patient can resume routine ADLs. Stair climbing may resume within 3 to 6 weeks following surgery (AAOS, 2011). Some discomfort with activity and at night is common for several weeks. Frequent walks, swimming, and the use of a high rocking chair are excellent for hip exercises. Restrictions must be kept in mind when resuming sexual activity. Sexual intercourse can be resumed based upon surgeon recommendation (typically 3 to 6 months postoperatively) and should be carried out with the patient in the dependent position (flat on the back) to avoid excessive adduction and flexion of the new hip. Attention to positioning and comfort may enhance the intimacy of the experience. At no time during the first 4 months should the patient cross the legs or flex the hip more than 90 degrees. Assistive devices should be used for dressing, such as long-handled shoehorns or dressing sticks for on putting on shoes and socks. The patient should avoid low chairs and sitting for longer than 45 minutes at a time. These precautions minimize hip flexion and the risks of prosthetic dislocation, hip stiffness, and flexion contracture. Driving requires sufficient range of motion and muscle strength; most patients are given permission to drive 4 to 6 weeks postoperatively. Traveling long distances should be avoided unless frequent position changes are possible. Other activities to avoid include tub baths, jogging, lifting heavy loads, and excessive bending and twisting (e.g., lifting, shoveling snow, forceful turning). The primary provider may give the patient a card indicating that he or she has had a joint replacement; this card may be used to alert security personnel who use screening devices at airports or malls. Continuing Care. A home care nurse may assess the patient's home for potential problems and monitor wound healing (see Chart 41-11 later in this chapter). The nurse, physical therapist, or occupational therapist assesses the home environment for physical barriers that may impede the patient's rehabilitation. In addition, the tnurse or therapist may need to assist the patient in acquiring devices such as reachers and long-handled shoehorns or tongs to help with dressing or a toilet seat extender to elevate the toilet seat. After successful surgery and rehabilitation, the patient can expect a hip joint that is free or almost free of pain, has good motion, is stable, and permits normal or near-normal ambulation and function

*TISSUE INTEGRITY* Healing phases

Proliferation -Blood clot dissolves -Fibroblast produce collagen (forming in the wound) and matrix (glycoprotein) starts to hold the wound together -Cytokines released by growth factor will also stimulate angioneogenesis (growth of new blood vessels) -Lymphocytes cause the infiltration of plasma cells that secrete antibodies (immunoglobulin) -In larger wounds (need to keep the wound moist with dressing changes) or the healing cells will dry out. If too wet the wound will macerate. -The growth factors necessary to stimulate the blood vessels will have to be dissolved in the fluid in the wound Phases of Wound Healing -Continue 5-7 days granulation tissue will convert into scar tissue formation will continue for several weeks Wound healing prosess: •Primary intention •Second intention (granulation) and contraction •Third intention (delayed closure) Phases of wound healing: Hemostasis occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate. The accumulation of exudate causes swelling and pain. Increased perfusion results in heat and redness. If the wound is small, the clot loses fluid and a hard scab is formed to protect the injury. The platelets are also responsible for releasing substances that stimulate other cells to migrate to the injury to participate in the other phases of healing. INFLAMMATORY PHASE The inflammatory phase follows hemostasis and lasts about 4 to 6 days. White blood cells, predominantly leukocytes and macrophages, move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hours after the injury, macrophages (a larger phagocytic cell) enter the wound area and remain for an extended period. Macrophages are essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblasts that help to fill in the wound, which is necessary for the next stage of healing. Acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. PROLIFERATION PHASE The proliferation phase is also known as the fibroblastic, regenerative, or connective tissue phase. The proliferation phase lasts for several weeks. New tissue is built to fill the wound space, primarily through the action of fibroblasts. Fibroblasts are connective tissue cells that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number and movement of endothelial cells. Capillaries grow across the wound, bringing oxygen and nutrients required for continued healing. Fibroblasts form fibrin that stretches through the clot. A thin layer of epithelial cells forms across the wound, and blood flow across the wound is reinstituted. The new tissue, called granulation tissue, forms the foundation for scar tissue development. It is highly vascular, red, and bleeds easily. In wounds that heal by first intention, epidermal cells seal the wound within 24 to 48 hours, thus the granulation tissue is not visible. Collagen synthesis and accumulation continue, peaking in 5 to 7 days. Depending on the size of the wound, collagen deposit continues for several weeks or even years. By the end of the second week following the injury, the majority of white blood cells have left the wound area, and the wound is lighter in color. The systemic symptoms now typically disappear. During this phase, adequate nutrition and oxygenation, as well as prevention of strain on the suture line, are important patient care considerations. Wounds that heal by secondary intention eventually follow the same process but take cclonger to heal and form more scar tissue (Grossman, 2014). Granulation tissue fills the wound and is then covered by skin cells that grow over the granulation tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of granulation tissue formed. MATURATION PHASE The final stage of healing, maturation (or remodeling) begins about 3 weeks after the injury, possibly continuing for months or years. Collagen that was haphazardly deposited in the wound is remodeled, making the healed wound stronger and more like adjacent tissue. New collagen continues to be deposited, which compresses the blood vessels in the healing wound, so that the scar, an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight, eventually becomes a flat, thin line. Scar tissue is less elastic than uninjured tissue. The strength of the scar tissue remains less than that of normal tissue, even many years following injury and it is never fully restored (Baranoski & Ayello, 2012, p. 91). Wounds that heal by secondary intention take longer to remodel and form a scar smaller than the original wound. If the scar is over a joint or other body structure, it may limit movement and cause disability. Inflammatory phase Fibroblastic or connective tissue repair phase Maturation or remodeling phase (slide 28 and 29 on tissue integrity ppt)

*SLEEP* Circadian rhythm

Rhythm that completes a full cycle every 24 hours; synonym for diurnal rhythm. The reticular activating system (RAS) and the bulbar synchronizing region, are believed to work together to control the cyclic nature of sleep. Rhythmic biologic clocks are known to exist in plants, animals, and humans. Influenced by both internal and external factors, they regulate certain biologic and behavioral functions in humans. Some cycles are monthly, such as a woman's menstrual cycle. Circadian rhythms complete a full cycle every 24 hours. "Circa" in Latin means "approximately" and "diem" is the Latin word for "day"; circadian represents approximately 1 day (Porth, 2011). Fluctuations in a person's heart rate, blood pressure, body temperature, hormone secretions, metabolism, and performance and mood depend in part on circadian rhythms. Sleep is one of the body's most complex biologic rhythms. Circadian synchronization exists when a person's sleep-wake patterns follow the inner biologic clock located in the hypothalamus. When physiologic and psychological rhythms are high or most active, the person is awake; when these rhythms are low, the person is asleep. Light and dark are powerful regulators of the sleep-wake circadian rhythm; when there is interference with the normal cycle, circadian disruption, or chronodisruption, occurs. For example, nurses who work the night shift may routinely sleep from 2 PM to 8 PM, and peak physiologic activity may occur between 10 PM and 6 AM during work. The exposure to light at night during normal sleeping hours is termed night shift chronodisruption (Stokowski, 2012). Problems of desynchronization occur when sleep-wake patterns are frequently altered and the person attempts to sleep during high-activity rhythms or to work when the body is physiologically prepared to rest. A person's individual biologic clock also responds to numerous influences such as occupational demands and social pressures.

*COMFORT* WHO model

Step 1 - For patients with mild pain (1 - 3 on a 0-10 scale). Use nonopiod analgesics (with or without a coanalgesic) Step 2 - For patients with mild pain that persists or increases. Pain is moderate (4//6). Use of weak opiod (codeine, tramadol, pentazocine) or a combination of opiod and nonopiod (oxycodone w/ acetaminophen). Step 3 - Patient w/ moderate pain that persists or increases or w/ severe pain 7-10. Strong opiods (morphine, hydromorphone, fentanyl).

*SENSORY* Tinnitus

Subjective perception of sound with internal origin; unwanted noises in the head or ear. Ménière's disease is characterized by a triad of symptoms: episodic vertigo, tinnitus (unwanted noises in the head or ear), and fluctuating sensorineural hearing loss. It may also include a feeling of pressure or fullness in the ear and incapacitating vertigo, often accompanied by nausea and vomiting (Nelson & Viire, 2009; NIDCD, 2009). These symptoms range in severity from a minor nuisance to extreme disability, especially if the attacks of vertigo are severe. At the onset of the disease, usually only one or two of the symptoms are manifested. Some characterize the disease into two subsets: cochlear and vestibular. Cochlear Ménière's disease is recognized as a fluctuating, progressive sensorineural hearing loss associated with tinnitus and aural pressure in the absence of vestibular symptoms or findings. Vestibular Ménière's disease is characterized as the occurrence of episodic vertigo associated with aural pressure but no cochlear symptoms. Patients may experience either cochlear or vestibular disease symptoms; however, eventually all of these symptoms develop. Assessment and Diagnostic Findings Vertigo is usually the most troublesome complaint related to Ménière's disease. A careful history is taken to determine the frequency, duration, severity, and character of the vertigo attacks. Vertigo may last minutes to hours, possibly accompanied by nausea or vomiting. Diaphoresis and a persistent feeling of imbalance or disequilibrium may awaken patients at night. Some patients report that these feelings last for days. However, they usually feel well between attacks. Hearing loss may fluctuate, with tinnitus and aural pressure waxing and waning with changes in hearing. These feelings may occur during or before attacks, or they may be constant. Physical examination findings are usually normal, with the exception of those of cranial nerve VIII. Sounds from a tuning fork (Weber test) may lateralize to the ear opposite the hearing loss, the one affected with Ménière's disease. An audiogram typically reveals a sensorineural hearing loss in the affected ear. This can be in the form of a "Pike's Peak" pattern, which looks like a hill or mountain. A sensorineural loss in the low frequencies occurs as the disease progresses. The electronystagmogram may be normal or may show reduced vestibular response.

*SENSORY* Cataract: Postoperative care

The patient with cataracts receives the usual preoperative care for ambulatory surgical patients undergoing eye surgery. The standard battery of preoperative tests (e.g., complete blood count, electrocardiogram, and urinalysis) commonly performed for most surgeries is prescribed only if indicated by the patient's medical history. Alpha-antagonists (particularly tamsulosin [Flomax], which is used for treatment of enlarged prostate) are known to cause a condition called intraoperative floppy iris syndrome. Alpha-antagonists can interfere with pupil dilation during the surgical procedure, resulting in miosis and iris prolapse and leading to complications. Intraoperative floppy iris syndrome can occur even though a patient has stopped taking the drug. The nurse needs to ask patients about a history of taking alpha-antagonists. Surgical team members are then alerted to the risk of this complication (Chatziralli & Sergentanis, 2011). Dilating drops are administered prior to surgery. Nurses in the ambulatory surgery setting begin patient education about eye medications (antibiotic, corticosteroid, and antiinflammatory drops) that will need to be self-administered to prevent postoperative infection and inflammation. Providing Postoperative Care Before discharge, the patient receives verbal and written education regarding eye protection, administration of medications, recognition of complications, activities to avoid, and obtaining emergency care (Chart 63-9). An eye shield is usually worn at night for the first week to avoid injury. The nurse also explains that there should be minimal discomfort after surgery and educates the patient about taking a mild analgesic agent, such as acetaminophen, as needed. Antibiotic, antiinflammatory, and corticosteroid eye drops or ointments are prescribed postoperatively.

*SLEEP* REM/NON-REM

The sleep cycle consists of four stages of *nonrapid eye movement (NREM) sleep* and a period of *Rapid eye movement (REM) sleep*. Typically, after Stage 1 of NREM sleep, people cycle four to six times thorugh the other stages of sleep per night. With each cycle, the length of time in REM sleep increases. NREM sleep accounts for 75% to 80% of sleep time. Sleep averages vary with the developmental stage, with infants and toddlers averaging 9 to 15 hr/day. This declines gradually throughout childhood, with adolescents averaging 9 to 10 hr/day and adults 7 to 8 hr/day.

*TISSUE INTEGRITY* Wound drainage (types of dressings)

Types of drainage: -Serous-Clear and watery; serous portion of the blood -Sanguineous-Consists of large numbers of RBCs and looks like blood-Bright red (fresh bleeding), darker (older bleeding) -Serosanguineous-Mixture of serum and RBCs, light pink to blood tinged -Purulent-Made up of WBCs, liquefied dead tissue debris-dead and live bacteria, thick often has a musty or foul-odor, varies and color (dark yellow or green) *Types of dressings:* - Hydrogel dressings - are used for autolytic debridement, or promoting the body's own natural functions of removing necrotic tissue. - Dry dressings - they generally work well for wounds with small amounts of exudate, but they can stick to the wound bed of heavily exudative wounds or expose the wound to the outside environment - Wet-to-dry dressings - have been used extensively for wounds requiring debridement. - Chemical-impregnated dressings - dressings that are impregnated with chemicals or agents intended to speed up the healing process. Examples are povidone-iodine (Betadine), silver, petroleum, collagen, and antibiotics. -Foam dressings - additional foam padding to protect wound fields. These foam dressings are absorptive and provide a moist healing environment while protecting wounds that resulted from pressure, friction, or shear. These dressings are used widely for early-stage pressure ulcers. - Alginate dressings - provide a moist environment for healing and good absorption of exudate, establish hemostasis, and do not adhere to the wound. They are helpful in treating wounds with large amounts of exudate including ulcers, donor sites, tunneling wounds, and some bleeding wounds. - Hydrofiber dressings - composed of the polymer carboxymethylcellulose, a substance that can absorb exudate vertically. These dressings are manufactured in sheets to place in wounds that have considerable exudate. The sheet materials swell on contact with exudate, thus absorbing the unwanted material. - Transparent film dressings - provides no absorption but does create a barrier to the environment. Transparent dressings do allow some oxygen exchange to reduce anaerobic bacteria growth and a wet environment to promote healing. Transparent film dressings are commonly used for wounds with dry eschar or for superficial skin tears but are not recommended for infected wounds. - Hydrocolloid dressings - used for autolytic debridement instead of the older wet-to-dry dressing technique. Hydrocolloid dressings have the benefit of some absorptive capabilities while still maintaining a moist wound healing environment. Hydrocolloid dressings do not allow oxygen to enter the wound, which can lead to anaerobic bacteria growth. Hydrocolloid dressings are not recommended for infected wounds but they are helpful for wounds that are vulnerable to infection.

*SENSORY* Snellen eye chart

Visual acuity is tested for both near (14 inches away) and distance (20 feet away) vision and is performed on each eye separately with a standardized Snellen chart for distance and a Rosenbaum pocket screener for near vision. A tumbling "E," "illiterate E," number, or picture chart is used if the person is illiterate or unable to read the English alphabet (Riordan-Eva & Cunningham, 2011). The Snellen chart is composed of a series of progressively smaller rows of letters; the person is asked to read the lowest line possible. The fraction 20/20 is considered the standard of normal vision. Most people can see the letters on the line designated as 20/20. The patient should be encouraged to read every letter possible. If 20/20 vision is not obtained with or without corrective lenses, then pinhole vision is tested. Pinhole vision is a quick method to assess best corrected vision. By looking through a pinhole (an occluder with small holes), the refractive errors of the peripheral cornea and crystalline lens of the eye are significantly reduced or eliminated, simulating corrected vision. No pinhole improvement indicates refractive error is less likely the cause of subnormal visual acuity.Visual acuity is then recorded. The following would be an example of visual acuity documentation: A patient reads all five letters from the 20/20 line on the Snellen chart with the right eye (OD) and three of the five letters on the 20/30 line with the left eye (OS); the visual acuity is documented as OD: 20/20 and OS: 20/30. If the patient cannot see the big "E" at the top of the Snellen chart, the examiner should determine next if the patient can count fingers ("CF" in documentation). Initially, the examiner stands 5 feet from the person, holds up a random number of fingers, and then asks the patient to count the number of fingers seen. If the patient is unable to count fingers at 5 feet, the examiner keeps moving a foot closer until either 1 foot away or the person can correctly count fingers. If the patient correctly counts the number of fingers at 3 feet, for example, the examiner would record vision as CF/3ft (American Society of Ophthalmic Registered Nurses [ASORN], 2011