Wounds, nutrition and urine

stage 3 pressure injury

full thickness loss, looks like deep crater extend to fascia, subtaneous tissue damged/necrotic fat visable undermining/tunneling may be present damage to surrounding tissuei If slough(yellowish semi-liquid dead tissue is present or eschar -irrigate the wound bed), dry wound bed, apply protective covering Hydrogel does the same as Hydrocolloid, but additionally it also reduce pain in the area it is placed. Must be covered with a secondary dressing. Non adhesive unlike hydrocolloid dressing.

incomplete protein

incomplete protein Legumes (beans, peas, lentils). Nuts. Seeds (Quinoa). Whole grains. Vegetables.

Iron foods

iron Legumes (mixed beans, baked beans, lentils, chickpeas), fortified bread and breakfast cereal, dark leafy green vegetables (spinach, silver beet, broccoli), and red meat

low albumin levels

liver disease, malnutrition, malabsorption. 15-36

Explain factors that cause dehydration

-Diuretic medication -Not drinking enough water Exposed to the sun for too long -Illness -Diarrhea Kidney failure -Fever -Vomiting -Alcohol intake -uncontrolled diabetes

List medications that cause constipation and what should be done to prevent

-Ferrous sulfate - yes iron supplements -Opioids (oxycodone) - acetaminophen with oxycodone -Antacids (omeprazole) -avoid gas producing foods(cabbage, onions, cauliflower) -Daily use of laxatives can lead to chronic constipation -Limit use of above medications and increase fluids if necessary, continue to encourage high fiber diet (fruits, vegetables, whole grain, whole wheat, seeds (Quinoa, nuts, brown rice) Hydrate - 2-3 L (8-10 glasses of water a day to prevent constipation) Daily exercise to prevent constipation or repositioning every 2 hrs if patient is in bed or wheelchair bound -Include fruits and vegetables in your diet regularly

Causes of dehydration

-Not enough fluid intake -Taking medications such as diuretics and a side effect of docusate sodium - diarrhea - causes dehydration -Decreased thirst receptors -Taste bud changes -Decreased filtration rate in kidneys and glomerulus -vomiting/diarrhea

24 hour urine collection

24-hour urine collection Tests for amount of creatinine that passes through the kidneys - Wash Hands with soap and scrub for 20 seconds - Instruct the patient to urinate the first urine of the day in the toilet, flush then begin the 24hr collection. -Collect all urine for next 24hrs -Keep container cool and in refrigerator

•​Full liquid diet

Also designed for patients who are experiencing trouble chewing and swallowing, or prepping for/recovering from surgery. Examples: all clear liquids plus milk, pudding, custards, frozen dessert, eggnog, veggie juice. Food is blended into liquid form

Measures for infected wound

Best to put patient in private room if possible and do not post any signage up on door or at bedside, its an invasion of patient's privacy (HIPAA) -​Wear PPE (gown, gloves, mask, face shield) -​Wear sterile gloves when cleaning the wound -​Wear clean gloves when removing the old dressing -​Perform hand hygiene before and after contact with patient and scrub for 20 seconds wound -When irrigating the wound, make sure it is turned outside the body and that it falls into a collecting device

low iron levels

Can cause: anemia When your body doesn't have enough iron, it'll make fewer red blood cells. -Leads to lack of oxygen Give: -Vitamin B12 injections and supplement - RBC less than 4 million/uL Iron: -Red meat (beef, lamb, liver, etc), -Legumes(beans, lentils, mixed beans, chick peas), dark leafy green -veggies( spinach, broccoli, kale,)fortified bread, (nuts)

clear liquid diet

Doctors order clear liquids the first day and advance to a full liquid diet the second day, then to normal food consistency on the third day for patients who return from surgery diet that consists of foods that are liquid at room temperature and leave little residue in the intestine. Ex: Water, Sprite, Ginger Ale, all beverages without any residue, broth, Jello •​Clear Liquid diet: prepping for surgery or recovering from surgery or experiencing Examples: broth, coffee or tea with honey, strained apple juice, cranberry juice, grape juice, gelatin, popsicles. Patient

Procedure for inserting foley catheter in male and female Female

Female knock and introduce yourself - You need to explain to the patient what you are about to do - identify patient with 2 identifiers -Close door and draw curtain for privacy -perform hand hygiene -Position patient dorsal recumbent -Make sure to only expose area you are inserting catheter\ -Use clean gloves to clean perianal area with betadine -Use only sterile gloves for catheterization -lubricate the catheter with KY jelly -open labia with your hands already in sterile gloves and do not let go of the labia when you insert catheter -Insert catheter 2-3 inches into the urethra, when there is urine return, then you are in the bladder -Once you have reached patients bladder, advance another 2-3 inches -Inflate balloon with 10mL sterile water - gently pull til you feel resistance Secure the tubing to patient's thigh -Hang the drainage bag below patient's bladder on bed frame Male -knock and introduce yourself - explain what you are about to do - identify patient with 2 identifiers -Close door and draw curtain for privacy -perform hand hygiene -position patient supine with legs slightly apart -expose only the area you are inserting catheter, put a clean drape around the penis area -have patient lift bum and slide a waterproof pad under him -put on clean gloves and clean area with ph balanced cleanser and wash cloth -start to clean at the tip of the penis in a circular motion and start at the meatus moving outward - Wash the shaft in a downward stroke toward the public area and rinse clean - Remove clean gloves and perform hand hygiene - Attach the urine drainage bag to the bed frame -no not at this time - open sterile catheter tray - don sterile gloves - open sterile drapes and place it next to the leg and put catheter set up on the sterile drapes - place fenestrated drape over penis - if patient is uncircumcise

Procedure for putting on a condom catheter

First Wash Hands Take Condom Catheter roll it onto penis leaving a small space about 1-2 inches at the tip Assess for tightness because it restricts blood flow Assess skin and provide hygiene care every shift to prevent skin breakdown Make sure there is a 1-2" space kept between penis and tip of catheter to promote urine flow Prevent tubing from kinking

List signs and symptoms of UTI

Frequency, dysuria - burning during urination, urgency

stage 4 pressure ulcer

Full-thickness tissue loss with exposed bone, tendon, or muscle Alginate is used for infected wounds, copious amount of drainage - Also used for Stage III if infected & Stage IV. Absorbs Copious amount of exudate. Debridement of Eschar and slough. Helps to keep a moist environment. Needs secondary dressing.

Patient has potassium level 3.0

Give pt Potassium supplement IVPB on a pump or oral, never administer IM, SQ, or IV push- see the Potassium level is low 3.0 mEq/L Food- banana, avocado, potato, etc

Prevent wound healing

Lack of oxygenation, infection, age (older adults) and sex hormones, stress, diabetes, hypertension, obesity, medications, alcoholism, smoking, and nutrition

List characteristics of abnormal urine

List characteristics of abnormal urine •Dark amber, dark orange, red , dark brown •Foul-smelling odor - infection- assess further- check temperature, dysuria, burning - send urine C & S to lab test •Presence of microorganisms, glucose, ketones, and blood •pH greater than 8.0 or less than 4.5 - >8 (kidney stones/UTI) < 4.5 (starvation) •Specific gravity greater than 1.030 and less than 1.010 >1.030 (dehydration), <1.010 (too much water)

List side effects of each uti med

Phenazopyridine - yellow-orange, reddish-orange urine (this is a normal effect) - which is normal and which is abnormal? -Toxicity -reddish/Yellowish orange colored skin, little urine, having yellow, blue or purple skin, nausea and vomiting, diarrhea, hepatic damage (this is Abnormal effect) - - Nitrofurantoin - dark yellow or brown urine (this is a normal effect) - Ciprofloxacin - photosensitivity - explain this and what preventive actions when the skin is sensitive to sunlight easily burned by uv rays(may have skin rash, sunburn, redness

What medications used for UTI

Phenazopyridine, Nitrofurantoin, Ciprofloxacin

sterile field considerations

Preventive measure to avoid contamination of a sterile field -Make sure hands are washed - Do not reach over/under the field - The hand cleaning the wound is not supposed to touch the field - Wear sterile gloves - Make sure hand are kept above the waist - Do not place anything that is not sterile on the field -Never turn your back on the sterile field -Make sure that the sterile field is above the waist -​When opening the sterile drape, hold it using clean gloves only at the 1" nonsterile border -​Don't use any gauze that falls within the 1" boarder

Sign of infection

Redness, pain, swelling and pus -increased hr -fatigue -loss of appetite

Which type of wounds is at greatest risk for infection ?

Stab wound, unintentional

stage 2 pressure wound treatment

Stage 2- Hydrocolloid dressing is used for wounds with small to moderate amount of exudate, maintain moisture, -protect against contamination- -adhesive. -Provides cushion. -Some debridement. -Protects from bacteria. Debrides Eschar and slough. Keep 3-7 days helps with absorption of the drainage, maintain moisture, protects against contamination, helps with debridement, provides cushion.

List foods types of food to heal the pressure tissue injury

Strawberries, orange juice, red meat, chicken (poultry), organ meat, liver, kiwi Carbohydrates, Proteins. Healthy Fats, Vitamins, Veggies

urine culture and sensitivity (C&S)

Test for which bacteria is in the urine which antibiotic it is sensitive to and resistant to. Sensitive to means you can take those antibiotics. Resistance means that the antibiotic will not work against the bacteria present. Should be obtained from by sterile catheterization- -Taken from port of foley catheter or straight from straight catheter Steps for foley catheter: Always explain to the patient what you are about to do - Hand hygiene - use a sterile syringe and needle and collect urine from the port of foley catheter and put urine into sterile cup. - Hand hygiene after Steps for straight catheter: - Hand hygiene - Insert a straight catheter into the urethra and to the bladder and urine will flow into the catheter into the sterile cup. So place sterile cup at the end of the straight catheter to collect urine. - Hand hygiene after If no catheter then collect via mid stream clean catch method, see above for Urinalysis yes

urinalysis (UA)

Tests for if any abnormality of protein, blood, pus, bacteria or glucose in urine - Wash Hands with soap and water and scrub for 20 seconds, perform clean catch method of collecting urine for UA. - Wash perineal area from front to back with an obstetrical wipe - Instruct pt to urinate a small amount into toilet, then urinate about 10ml into specimen cup (catch the urine midstream), urinate the remaining in the toilet. - Advise pt to keep specimen cup away from labia or meatus to prevent contamination - Close lid of specimen cup tight - Hand hygiene

balanced diet

To increase the albumin levels eating a well-balanced diet full of protein would help. Foods like lean meats, fish, nuts and eggs. Carbohydrates like brown rice and bread. Foods such as yogurts and cheeses with some milk would assist with not only the albumin but the calcium levels. To aid in increasing potassium patient could eat potatoes, avocado, the dairy products and add some leafy greens, fruits and starchy vegetables to diet like spinach, broccoli, kale, bananas, oranges and orange juice-vitamin C. To aid in increasing RBC, patient can eat meat, poultry, eggs, fish, sausage, milk, cheese, and fortified food.

Vitamins

VitaminB12 deficiency symptoms: weak, short of breath while doing strenuous exercise (climbing stairs for example- doesn't have to be strenuous), dizziness, swollen tongue and red cracks at side of mouth Vit A for soft parts eyes, skin, nose, lungs Vitamin A deficiency symptoms: dry skin, dry eyes, night blindness, throat and chest infections Vit D to increase absorption of Calcium Calcium for strong bones and teeth Vitamin D deficiency symptoms: bones feel painful, back pain, hair loss - and Need vitamin D for Calcium absorption Vit E for reduces skin inflammation from Uc rays and strong immune system Vit K for helping reverse effects of blood thinning Vitamin K deficiency symptoms: excessive bleeding ,bruises easily Vit C for skin healing Calcium deficiency symptoms: muscle spasms, weak and brittle nails Vit B12 for energy, makes RBC, and to keep nerve healthy

Explain procedure for enemas

Wash Hands For Saline Fleet Enema- Position patient on left side- sims position and then insert tip into the rectum and then squeeze bottle to facilitate flow of solution into rectum -For Return flow or Harris Drip- position patient on left side- sims position and push in enema into patient's rectum raise bag 12 inches above the patient to facilitate flow of solution in the rectum and colon and then once the solution is in lower the enema bag below bed frame and with gravity, water will return back into the enema bag. -For fleet enema, soap/water, position patient in left side lying, sims position - Insert pre lubricated rectal tube about 2- 3 inches into rectum -Raise bag about 12 inches above the patient If pt experience abdominal cramps, lower the bag to prevent high flow of liquid and slow the rate of infusion- this is correct for any soap water enema but a fleet enema is not a soap water enema. Fleet is a small bottle that you squeeze the solution into the rectum. Patient holds it in and when there is an urge to defecate - provide the bed pan

What are the purpose of each medications above (Uti meds)

What are the purpose of each medications above Phenazopyridine- treats bladder pain, the urgency and frequency of urinating It is a bladder analgesic. Nitrofurantoin- Treats urinary tract infection Ciprofloxacin-Treats urinary tract infectio

➢ Which findings are of most concern to the nurse? Select all that apply Client received for routine checkup accompanied by mother with whom he lives. Client has paraplegia secondary to spinal cord injury. Client is alert and oriented X3. Denies pain or any problems. Mother is concerned about "red area on his left heel." VS: T - 97.9 F (36.6 C), P - 76, RR - 16, BP - 112/68. Lungs clear, S1S2 audible with no murmurs, gallops, rubs. Bowel sounds hypoactive. Client has full active range of motion in bilateral upper extremities with light touch sensation intact in fingers. No feeling or movement below waist. Full passive range of motion bilaterally in lower extremities. Open area right heel noted - copious pus drainage detected. Skin otherwise intact.

X Bowel sounds X Non-blanching area on heel X Copious pus drainage with semi-liquid slough Stage 3

normal urine characteristics

characteristics of normal urine •Pale yellow, straw-colored, or amber ( yellow -clear gold-orange) •Clear or translucent when on furosemide / increase intake water •Aromatic odor strong pleasant sweet smell •Absence of microorganisms in bladder urine sterile •Absence of glucose, ketones, or blood •pH 4.5-8.0 (average 6.0) •Specific gravity 1.010-1.030 - your text book change the normal range to 1.050 - 1.030 but we are still going by 1.010 - 1.030 •Solutes in urine: urea, uric acid, ammonia, vitamins, hormones, K+, NA+, Bicarbonate or H+, etc

complete protein

complete protein ‌Fish. ‌Poultry (chicken, duck, or turkey) ‌Eggs. ‌Dairy products (milk, yogurt, or cheese, for example) ‌Beef or pork, lamb Red meets are complete protein

Hypocalcemia

deficient calcium in the blood; depresses heart Calcium supplement with vitamin D - calcium below 9 mg/dL - Food: cheese, kefir, yogurt, milk

stage 1 pressure injury

non-blanchable erythema of intact skin 1- keeps the wound visible, helps with O2 flow, helps keep wound protected from the outside environment, maintain a moist environment. transparent film so we can increase visibility and keep the wound moisturized, increase O2 flow and protect the wound from external bacteria because it is adhesive.

Steps for cleaning surgical wounds

​Assess pain prior to providing wound care -​Perform hand hygiene -​Position patient and expose only the wound area before prepping supplies -​Prep the surgical field -​Put on clean gloves and remove the old dressing -​Remove clean gloves, put on sterile gloves -​Assess wound using TACO (type, amount, color, odor) -​Clean inside of wound first from top down using a sterile gauze each time, then clean the side farther away from you from top to down then clean the side closer to you from top to down -​Dry wound with sterile gauze -​Apply protective barrier cream around the outside of the wound (periwound) -​Apply treatment over the wound bed -​Hand hygiene -​Always cover all wounds with secondary dressings if non-adhesive

How should the nurse assess a patient if the patient did not have adequate urine output after surgery, such as urine output less than 500mL/day or 8 hours

•Assess lower abdomen - abdominal distended - assess light palpation •Assess volume (urine retention) using bladder scan - e. g., post surgical patient, removal of foley catheter - priority assess if patient voided and how much and color, odor, dysuria - burning, frequency, and urgency

List nursing interventions to prevent uti

•Schedule toileting & take patient to toilet upon urgent feeling to urinate •Women: wipe front to back •Exercise- ambulate, reposition Q2hrs- promotes urinary control & prevents urine stasis •Provide showers Avoid Baths - cause cystitis (lower bladder infection) •Urinate Q 2-4 hours •Wear cotton under garment •Drink 2-3 L H20 daily •Encourage 10 ounces cranberry juice daily •Avoid long use of catheters •Avoid touching the catheter drain bag spout on or inside urinal •Wash with pH balanced moisturizing cleanser and water •Diabetic patients: Keep blood glucose in normal range 70-110 •Sexually active: Void after, shower/wash

What are the names of infection in the lower urinary system

•cystitis (bladder infection) •Urethritis (Urethra infection

Describe the steps to cleaning a pressure tissue injury

•​Asses pain prior to providing wound care •​Wash hands •​Position Patient, expose only wound area before prepping supplies to prevent contamination of supplies and maintain patient privacy •​Using clean gloves, remove the old dressing and assess drainage/wound •​Change gloves from clean to sterile gloves- use hand sanitizer. •​Use a sterile gauze one time, use new gauze with each cleanse •​Clean in circular motion from inside wound bed to outside wound bed (peri wound) for pressure tissue injury​ •​Dry wound with sterile gauze •​Apply treatment • And apply skin barrier around peri wound to prevent maceration and protect the skin •​Place dressing at center of wound to 1 inch beyond wound​

low sodium diet

•​Low Sodium diet- designed for patients who needs to maintain a avoid salt intake. Such as cardiac patients and patients with HTN . Examples: avoid canned foods, salted meat/fish, frozen prepared foods, peanut butter. We want to encourage and provide fresh fruits and veggies.

purulent exudate

•​Purulent - pus, yellow or green in color. Sign of infection. notify MD and recommend to doctor put in an order for wound culture WBC, CBC labs, document TACO, wear PPE Always cover all wounds to prevent contamination