Chapter 32 and 36
Proteins (4kcal/gram)
> Tissue growth and repair > Provide energy when carbohydrate intake is inadequate > Continuously build new tissues > Protein tissues are in a constant state of flux > Tissues are continuously being broken down and replaced
Primary Intention Healing
> Tissue surfaces approximated (closed) > Minimal or no scarring > Little or no tissue loss > Heals rapidly > EX. Closed surgical incision with staples or suture or liquid glue to seal laceration
2 Major Processes of Inflammatory Phase
> Vasoconstriction, clot formation, hemostasis > Phagocytosis of microorganisms
A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?
An infant's skin and mucous membranes are easily injured and at risk for infection.
The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?
Apply saline solution-moistened gauze over the protruding area.
Puncture
Cause: Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional > Open wound
Penetrating Wound
Cause: Penetration of the skin and the underlying tissues, usually unintentional > Open wound
Incision Wound
Cause: Sharp instrument > Open wound, deep or shallow, once the edges have been sealed together as a part of treatment or healing, the incision becomes a closed wound
Principles of Wound Care
Include assessment, cleansing, and protection
Normal Healing
Promoted when the wound is free of foreign material
Improve Appetite
Provide familiar food, select appropriate portions, avoid unpleasant treatment immediately before or after meal, provide clean environment, encourage oral hygiene before meals (improve taste), reduce stress and relieve illness symptoms
Encourage
ROM and mobility as patient condition allows
Approximated
Tissues are together
Use 0.9% Normal Saline
To irrigate and clean the ulcer
Topics for Home Health Care Teaching
• Supplies • Infection prevention • Wound healing • Appearance of the skin/recent changes • Activity/mobility • Nutrition • Pain > Elimination
Regeneration of Tissue Occurs via Natural Body processes
• Type of wound healing influenced by amount of tissue loss • Phases of healing are same for all wounds, but rate and extent of healing differ
Collaborative Malnutrition Interventions
•Dietician, PCP, OT, PT •Surgery •Pharmacologic therapy •Enteral nutrition-through GI system •Parenteral nutrition
Effects of Applying Heat
•Dilates peripheral blood vessels •Increases tissue metabolism •Reduces blood viscosity and increases capillary permeability •Reduces muscle tension Helps relieve pain > Arthritis, contractures, low back pain > Hot water bags and bottles
Physical Activity
•Physical activity of moderate effort exercise for at least 150 min/week •Muscle-strengthening activities 2 times/week
Factors Affecting Nutrition and Metabolism
•Religious and cultural practices •Financial issues •Appetite •Negative experiences •Environmental factors •Disease and illness •Medications > Age •Developmental factors •Gender •State of health •Alcohol abuse •Drug abuse •Tobacco use •Megadoses of nutrient supplements
Diagnosis
•Risk for Pressure Ulcer •Risk for Impaired Skin Integrity •Impaired Skin Integrity •Impaired Tissue Integrity •Risk for Infection Acute Pain
The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound?
An alginate dressing
Regular Diet
Consists of ANYTHING!
When performing a dressing change, the home care nurse notes that the base of the client's leg wound is red and bleeds easily. What is the appropriate action by the nurse?
Document the findings.
Providing
Providing oral nutrition
A nurse is caring for a client with chronic anemia. What should be included in the diet of this client?
Red meat
Tissues Referred to
Skin, hair, and nails
The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?
a client sitting in a chair who slides down
The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?
elevating and supporting the stump
Main interventions for skin integrity
•Support wound healing •Prevent pressure ulcers •Treat pressure ulcers •Clean and dress wounds •Support and immobilize wounds •Apply heat and cold
Teaching
Teaching nutritional information
Wound Complications
> Infection > Hemorrhage > Dehiscence and evisceration
Phagocytosis
Cell eating
Structure of Skin
Changes as a person ages; the maturation of epidermal cell is prolonged, leading to thin, easily damaged skin
Healthy Eating Pattern
Choose my plate
RDA for Protein
0.8 g/kg of body weight, 10% to 35% total calorie intake
Greatest Risk for Hemorrhage
1st 48 hours after surgery
Secondary Intention Healing
> Extensive tissue loss > Edges cannot be approximated > Repair time is longer > Scarring is greater > Increase risk for infection > Heals by granulation > EX. Pressure ulcer left open to heal
Primary Prevention
> Healthy eating patterns > physical activity
Obesity for Wounds
Adipose tissue is poorly perfused
At what period of life do nutrient needs stabilize?
Adulthood
Physical Assessments
Anthropometric and clinical data
Circulation and Collagen Formation
Are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure
The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?
Assess when client generally eats meals.
Assisting
Assist with eating
Corticosteroid and Postoperative Radiation Therapy
Delay healing
History taking
Dietary, medical, socioeconomic data
Minimize
Direct pressure on the ulcer
TPN (total parenteral nutrition) VEIN
Highly concentrated, hypertonic lots of minerals less water Calories, fluids & nutrients Central venous access device required you have to have a central line not a peripheral line it would burn the tissue* also you will use a filter
Types of Heat therapy
Hot water bags or bottles Electric heating pads Aquathermia pads Hot packs Warm, moist compresses Sitz baths Warm soaks
Skin
Largest organ in body (20 square ft) > Sweating > Heat and Cold > Hair
Monitoring
Monitoring nutritional status
Shearing Forces
Occur when the skin moves one direction and the bone that lies underneath it moves in another direction.
Hypertrophic Scar (keloid)
Overproduction of collagen
Dehiscence
Separation or splitting open of layers of a surgical wound
Children under 2
The skin is thinner and weaker than it is in adults
A nurse is checking a client's capillary blood glucose level. Which nursing action is mostappropriate?
Touch the test strip directly to a drop of blood.
Clear Liquid Diet
Transparent to light and liquid at body temperature. Water, fruit juice (no pulp), broth, gelatin, popsicles, hard candy, coffee, tea
Regulate Body Processes
Vitamins, minerals, water
Penrose Drain
a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing
Evaluate, assess, treat
do not delegate
Stage 4
full-thickness skin and tissue loss
Age-related Changes
in metabolism and body compostion
A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:
Dehiscence
Local Factors Affecting Wound Healing
•Pressure •Desiccation (dehydration) •Maceration (overhydration) •Trauma •Edema •Infection •Excessive bleeding •Necrosis (death of tissue) •Presence of biofilm (thick grouping of microorganisms)
Imbalanced nutrition (less than body requirements)
> Insufficient dietary intake
Risk for Overweight
Excessive food intake in relation to physical activity > Sedentary > BMI 24; waist 39 in
Fiber
Forms crosslinks on top of skin
Water a day
2,500 mL/day
Clinical Manifestations of Malnutrition
-Skin (dry, scaly, brittle nails, rashes, hair loss) -Mouth (crusting & ulceration, changes in tongue) - Gums are spongy, swollen, inflamed; bleed easily -Muscle (decreased mass & weakness) -CNS (confusion, irritability) -Delayed wound healing -Anemia and immune system impairment
Nursing Management
1) EMERGENCY! Stay with patient, notify HCP 2)Cover wound/organs with saline soaked sterile towel/dressing 3)DO NOT re-insert organs 4)Position client supine with knees bent 5)Monitor VS for signs of shock 6)NPO to prepare for surgery
Infection Nursing Management
1) Prevent infection with aseptic/sterile technique! 2) Monitor closely for signs and symptoms 3) Administer antibiotics after collecting specimens for culture & sensitivity 4) Provide rest & adequate nutrition to promote healing
Use 30-60 mL syringe
5-8 psi of pressure
Proliferative Stage
> Lasts next 3-24 days; replacement of lost tissue with granulation tissue and collagen, wound contraction, wound resurfacing (with new epithelial) > If wound not sutured, marginal epithelial cells proliferate over granulation tissue to fill the wound (forming scar)
A-D-PLAN-I-E
> Maintain or restore optimal nutritional status •Patient consumes 50% to 60% of the contents of the meal tray. •Patient does not aspirate during or after the meal. > Promote healthy nutritional practices, adequate diet > Prevent complications associated with malnutrition > Attain and maintain ideal body weight, as indicated by BMI and waist circumference > Planning for home care •Provide aid with eating, purchasing food, and preparing meals •Instruct about nutrition therapy •Assess client and family's abilities for self-care, financial resources, and need for referrals
Foods High in Protein
> Meat and fish > Cheese > Eggs > Beans > Bread > Hummus > Nuts and seeds
Hemostasis
> Occurs immediately after initial injury > Involved blood vessels constrict and blood clotting begins > Exudate is formed, causing swelling and pain > Increased perfusion results in heat and redness
Type of Drainage Systems
> Open >> Penrose drain > Closed >> Jackson-Pratt drain >> Hemovac Drain
Vitamins
> Organic compounds needed by the body in small amounts > Most are active in the form of coenzymes > Needed for metabolism of carbohydrates, protein, and fat > Classified as water soluble or fat soluble > Absorbed through the intestinal wall directly into bloodstream
Psychological Effects of Wound
> Pain > Anxiety > Fear > Impact on activities of daily life > Change in body image
Bullimia Nervosa
A cycle of binge eating followed by purging. Lack of control during binges Average of one cycle of binge eating and purging per week for at least 3 months
Normal Weight
BMI 18.5-24.9
Diabetic Diet
Balanced intake of protein, fats, and carbohydrates.
Escar
Black, necrosis of the tissue (DEAD) > Debrid it
Sanguineous Exudate
Bright red, indicated active bleeding
Used in Caring for Wound
Careful hand hygiene
Yellow
Cleanse; remove nonviable tissue, drainage, and slough
Serous Exudate
Clear, watery plasma
Causes of Hemorrhage
Clot dislodgement, broken stitch, blood vessel damage Internal (swelling/distention/discoloration of wound area-hematoma) or external
A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?
Contusion
Red
Cover to protect healthy regeneration of tissue
Black
Debride; remove necrotic eschar to enable healing to occur
A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?
Diffuse dermatitis accompanied by pruritus
A nurse is working with a 46-year-old woman who is working to lose weight. Based on recommendations from the USDA regarding diet modification, which is not appropriate advice for this client?
Drink juice for majority of fluid intake.
Skin Inspection
Early inspection means early detection. Show patients and carers what to look for
Manifestations of Infection
Edema, redness, pain, purulent, drainage, fever, chills, odor, increased HR and RR, increase in WBC
Evisceration
Extrusion of viscera or intestine through a surgical wound
Low Residue Diet
Foods low in fiber and easy to digest. White rice, white bread, refined cereals and pasta.
A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?
Glucose levels will decrease with illness and stress.
Inflammation is
Good because it helps the body heal
Factors that Increase BMR
Growth, infections, fever, emotional tension, extreme environmental temperatures, elevated levels of certain hormones
Fewer Calories Required
In adulthood because of decrease in BMR
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?
Incision
Activity
Increases nutritional needs
Infections result from
Invasion of pathogenic, micro-organisms
Adequate Blood Supply
Is essential for normal body response to injury
Medical Adhesive-Related Skin Injury (MARSI)
It is caused by medical adhesive; trauma related; mechanical trauma
PPN (peripheral parenteral nutrition)
Less concentrated Short term Given in a peripheral IV nothing can be mixed with it, it has its own port and controlled with a pump tubing and bag is discarded every 24 hours
Nutritional needs
Level off in adulthood
Providing Also
Long-term nutritional support
Surface
Make sure patients have the right support
Pressure Ulcers are
Preventable; no longer covered by insurance
Increased Profusion
Results in heat and redness
Cold
Shivering
Stimulating
Stimulating appetite
The nurse is caring for a client receiving continuous tube feeding via a nasogastric tube. The client is slumped down in the bed with feet touching the footboard. Which action should the nurse take first before pulling the client up in bed?
Stop the enteral feeding pump.
Body responds
Systematically to trauma of any of its parts
Friction Injury
The force that one surface exerts on another when the two surfaces rub against each other
Hemostasis
The stopping of a flow of blood.
Purulent Exudate
Thick, yellow, green, tan, or brown (pus)
Consequences of Malnutrition
Undernutrition or overnutrition
BMI =
Weight (kg) / height (meters squared)
Friction
When skin rubs against another surface, like the sheets on a bed, it can become damaged. When skin is damaged this way, it's more likely to develop pressure ulcers.
High Fiber Diet
Whole grains, fruits and vegetables
At Risk for Infection
age extremes, impaired circulation & oxygenation, wound nature, immune function, malnutrition, chronic disease, infection control
Dyshagia can increase the risk of
aspiration
Eschar
dead matter that is sloughed off from the surface of the skin, especially after a burn
Malnutrition
faulty or inadequate diet
Jackson-Pratt Drain
hollow bulb-like device used to collect drainage
Incontinence
inability to control bladder and/or bowels
Wound Care
increasingly provided in home/community settings. Assess and involve family/caregivers in availability, skills, and responsiveness to task.
Supine
lying on the back
Goals:
maintain intact skin, promote healing, eliminate infection, manage pain
Stage 1
nonblanchable erythema of intact skin
Stage 2
partial-thickness skin loss with exposed dermis
Overnutrition
ØGrowth failure ØPoor wound healing ØSusceptible to infection ØMuscle loss Physical decline
Short term Nutritional Support (Less than 4 weeks)
•Using the nasogastric or nasointestinal route •Confirming NG feeding tube placement •Radiographic examination •Measurement of aspirate pH and visual assessment of aspirate •Measurement of tube length and tube marking •Carbon dioxide monitoring •Confirming nasointestinal tube placement
Independent Malnutrition Intervention
•Weekly weight, diet evaluation •Appetite stimulating measures •Assistance with meals Record intake
Evaluate
•Were the outcome of goals achieved? •Progress toward meeting nutritional outcomes? •Patient's tolerance and adherence to the diet? •Understanding of interventions? •If not, the nurse should explore the reasons. •Cause of problem identified? Outcomes realistic? •Family included and supportive? •Client's preferences considered? •Do symptoms cause loss of appetite? •Anything interfering with digestion or absorption?
Intact Skin
•the first line of defense against microorganisms.
Low Blood Albumin (below 3.5 g/dL)
May cause delayed wound healing
Do not delegate what you can EAT
> Evaluate > Assess > Teach
Overweight
25-29.9
Greatest Risk for Infection
3-11 days after injury/surgery
Keep bed less than
30 degrees for pressure ulcers
Pain Medication
30 minutes before dressing
Obesity, Class I
30-34.9
Obesity, Class II
35-39.9
Extreme Obesity
40.0+
Underweight
< 18.5 BMI
Dietary Data
> 24 Hour recall method > Food frequency > Food diary/calorie count > Diet history
Factors Affecting Wound Healing
> Age (very young or old) > Impaired nutrition (especially protein) > Lifestyle (activity, smoking, alcohol, drug use) > Immunocompromised- decreased immune function > Medications > Obesity > Chronic diseases- Anemia, diabetes, CV disease > Decreased perfusion- circulation is necessary
Nursing Management of Hemorrhage
> Apply pressure > Monitor vital signs > Notify provider
Inflammatory Phase
> Begins immediately after injury, lasting 3-6 days > Helps bring oxygen and nutrients to wound bed > Measures that impair inflammation put healing process at risk
Maturation/Remodeling Phase
> Day 21 up to 1 year: remodeling and strengthening of collagen tissue > Fibroblasts synthesize collagen, laying in more orderly structure > Wound contracted > Scar becomes stronger by repaired area is never as strong as original tissue
Tertiary Intention Healing (delayed primary intention)
> Initially left open 3-5 days >> Edema, infection to resolve, or exudate to drain > Closed with sutures, staples, or adhesive skin closures once edema/infection is resolved > Long time healing > EX. abdominal wound initially left open until infection is resolved then closed
Extent of Damage and Person's State of Health
Affect wound healing
Minerals
Elements found in food that are used by the body > Calcium, magnesium, iron, zinc, sodium, phosphorus
Exudate
Formed, causing swelling and pain
Children and Healthy Adults
Heal more rapidly
The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 550 mL. The previous residual was 200 mL. What action should the nurse take?
Hold the enteral nutrition and notify the primary care provider.
Types of Cold therapy
Ice bags Cold packs Hypothermia blankets Cold compresses to apply moist cold
A nurse is caring for a client with a gastrostomy tube in place. Which is an accurate guideline for care of the insertion site?
If the gastric tube insertion site has healed and the sutures are removed, use soap and water to clean the site.
Wound care is not
Independent nursing action; provider order and established protocol dictate type of cleansing agent, dressing, frequency of care
Growth
Infancy, adolescence, pregnancy, and lactation increase nutritional need
Pressure Ulcers
Injury to skin and/or underlying tissue usually over a bony prominence as a result of ischemia.
Friction Prevention Tip
Keep bed free from Wrinkles
Shearing Prevention Tip
Keep head of bed 30 degrees or lower
Hemovac Drain
Large portable would self-suction device with reservoir common after mastectomy
Clean Wound from
Least to most contaminated
Binge-eating disorder
Loss of control during binge, followed by guilt, shame, or depression Does not purge Episodes range from 1 to more than 14 times per week Clients often overweight or obese
Age
Loss of turgor, decrease in circulation, slower tissue regeneration, decreased absorption, decreased collagen production
Anorexia Nervosa
Low body weight for gender, age, developmental level. Fear of being fat Self-perception of being fat. Behaviour that prevents weight gain.
Nutritional Supplements
Most adults need at least 1,500 kcal/day
Use
Most current evidence-based practice
Infant's Skins
Mucous membranes are easily injured and subject to infection
Vasoconstriction
Narrowing of blood vessels
Impaired Swallowing
Neuromuscular impairment
Low Sodium Diet
No added salt or limited to 1-2 grams/day
NPO
Nothing by mouth
Contamination
Of wound surface with microorganisms, compete with new cells for oxygen and nutrition
Keep
Patients moving
Shearing Injury
Skin shear is an internal force caused when adjacent surfaces slide across each other, which results in stretching and tearing of the underlying blood vessels and leads localized tissue breakdown.
Exoriation
Skin sore or abrasion produced by scratching or scraping
Masceration
Softening of tissue due to moisture
Hemorrhage
Some escape of blood from wound is normal, hemorrhage is not
A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.
True
Blanchable
Turns white with pressure and then color returns; peripheral vascular system able to refill
do not
Use cornstarch or massage bony prominence
Clean Ulcer
With every dressing change using surgical asepsis
Stage 3
full-thickness skin loss; not involving underlying fascia
Unstageable
full-thickness skin and tissue loss
Deep Tissue Pressure injury
persistent nonblanchable deep red, maroon, or purple discoloration
Non-blanchable
press down or skin and it does not turn white
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?
preventing the client from sliding in bed
Undernutrition
ØGrowth failure ØPoor wound healing ØSusceptible to infection ØMuscle loss Physical decline
Purpose of Wound Dressings
• Provide physical, psychological, and aesthetic comfort • Prevent, eliminate, or control infection • Absorb drainage • Maintain moisture balance of the wound • Protect the wound from further injury • Protect the skin surrounding the wound • Debride (remove damaged/necrotic tissue), if appropriate • Stimulate and/or optimize the healing response Consider ease of use and cost-effectiveness
Pressure injury Assessment
• Risk assessment • Mobility • Nutritional status • Moisture and incontinence • Appearance of existing pressure injury • Pain assessment
Presence of Infection
• Wound is swollen. • Wound is deep red in color. • Wound feels hot on palpation. • Drainage is increased and possibly purulent. • Foul odor may be noted. • Wound edges may be separated, with dehiscence present.
Water
•Accounts for 50% to 60% of adult's total weight. •Required for cell function •Transports nutrients, wastes •Regulates metabolic processes, body temperature •Serves as solvent •Acts as a lubricant, cushion •Maintains blood volume •Assists to maintain healthy weight •Water intake for adults averages 2,000 - 2,500 mL/day
Long-term nutritional Support
•An enterostomal tube may be placed through an opening created into the stomach (gastrostomy) or into the jejunum (jejunostomy). •A gastrostomy is the preferred route to deliver enteral nutrition in the patient who is comatose. •Placement of a tube into the stomach can be accomplished by a surgeon or gastroenterologist via a percutaneous endoscopic gastrostomy (PEG) or a surgically (open or laparoscopically) placed gastrostomy tube.
Diagnostic Tests for Nutrition
•Cholesterol •Triglycerides •Hemoglobin •Electrolytes •Albumin •Prealbumin •Transferrin •Glucose HbA1c
Effects of Applying Cold
•Constructs peripheral blood vessels •Reduces muscle spasms •Promotes comfort •Can cause cell damage from prolonged use •Slowed bacterial growth •Decreased inflammation •Local anesthetic effect > Sprains, fracture, swelling
Complications of total Parenteral Nutrition
•Insertion problems •Infection and sepsis •Metabolic alterations •Fluid, electrolyte, and acid-base imbalances •Phlebitis •Hyperlipidemia •Liver and gallbladder disease
Phases of Wound Healing
> Hemostasis > Inflammatory > Proliferation > Maturation
Nursing Assessment
> History taking > Physical assessments > laboratory Data
Wound Assessment
> Inspect sight and smell > Palpation for appearance, drainage, and pain >> Serous drainage >> Sanguineous Drainage >> Serosanguineous drainage >> Purulent Drainage > Sutures, drains or tubes, and manifestation of complications
Patient Education
> Proper food handling, storage, and preparation. > Wash hands and food preparation surfaces frequently, before handling food. > Separate foods to avoid cross-contamination. > Cook foods to a safe temperature. > Refrigerate perishable food promptly and keep cold foods at or below 40° F. > Identify food allergies. > Be mindful of food-medication interactions.
Dehiscence/Evisceration Prevention
> Splinting for cough/sneezing > Stool softeners
Types of Wound Dressings
> Telfa > Gauze > Transparent dressings > Hydrocolloid > Hydrogel
Full Liquid Diet
All clear and opaque liquid foods. Ice cream, sherbet, pudding, milk, yogurt, thin hot cereal (cream of wheat).
Mechanical Soft Diet
Foods that require less chewing. Chopped and diced meats, fruits and vegetables
Pureed Diet
Foods that require no chewing. All clear & full liquid plus mashed potatoes, pureed meats, scrambled eggs
Serosanguineous Exudate
Pale, red, watery; picture of clear and red fluid
Heat
Peripheral vasodilation resulting in drop in blood pressure, fainting
Response to Wound is more effective if
Proper nutrition is maintained
Laboratory Data
Protein status, body vitamin, mineral, and trace element status
Nutrition for Wounds
Protein, vitamin A, minerals essential for tissue healing
Dysphagia diet
Pureed foods and thickened liquids.
Incontinence/ Moisture
Your patients need to be clean and dry
Evaluation of Wound (if not, why?)
•Has client's condition changed? •Risk factors identified? •Appropriate devices and techniques used? •Client compliant with instructions •Nutritional and fluid intake adequate? •Stringent asepsis used? Status of dressing appropriate?
Prevent Pressure Ulcer
•Identify patients at risk •Limit chair/wheelchair sitting •Advise client to shift weight q 15 minutes •Optimize nutrition: hydration and protein •Maintain skin hygiene •Do not massage bony prominences •Do not use powder / cornstarch •Avoid skin trauma, reduce friction & shear •Lift (vs. pull) patients up in bed. •Reposition Q 2 hrs..** Keep HOB <= 30 degrees
Risk Factors for Pressure Ulcers
•Immobility •Nutrition •Incontinence >> Maceration: Tissue softened by prolonged wetting >> Excoriation: Area of loss of superficial layers of skin •Decreased mental status •Diminished sensation •Age •Chronic Conditions- Diabetes, CV disease
Factors Affecting Basal Metabolic Rate (BMR)
•Males have a higher BMR due to larger muscle mass •BMR is about 1 cal/kg of body weight per hour for men •BMR is about 0.9 cal/kg of body weight per hour for women
Which nursing student statement regarding vegetarian diets requires further teaching from the nursing instructor?
"According to research, vegetarians have a higher incidence of obesity than others."
A client tells the nurse, "As long as I only eat 2,400 calories per day, it does not matter which foods I eat." Which response by the nurse is best?
"Can you share an example of what you ate yesterday?"
The nurse is providing care for an older adult client who is recovering from pneumonia on the hospital's medical unit. The nurse sets up the client's dinner tray on his overbed table. The client then states, "I won't be having any of this." What is the nurse's most appropriate response?
"Can you tell me why you don't want to have dinner tonight?"
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?
"I will put a layer of cloth between my skin and the ice pack."
A nurse is planning a high-energy diet for a client. Which statement by the nurse best describes the types of foods the client should include in the diet?
"Include plenty of grains, fruits, and vegetables in your diet."
The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?
"It provides a way to remove drainage and blood from the surgical wound."
A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching?
"My husband and I are ordering a product that has megadoses of vitamins."
The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?
"That is necrotic tissue, which must be removed to promote healing."
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?
"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."
The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?
"Your wound will heal slowly as granulation tissue forms and fills the wound."
The nurse is caring for four older adult clients. Which does the nurse identify at highest risk for cardiometabolic syndrome?
59-year old with bust, abdomen, and hips of similar proportion
Supply Energy
> Carbohydrates > Protein > Lipids
The nurse is teaching a client about ways in which to reduce sodium in the diet. Which foods will the nurse recommend that the client avoid? Select all that apply.
> Cured ham > Table salt > Bacon
MARSI Cause
> Epidermal stripping > Tension injury or blister > Skin tear > Dermatitis >> Irritant contact dermatitis >> Allergic dermatitis > Other >> Maceration from trapped moisture >> Folliculitis
Interrelated Concepts
> Perfusion > Oxygenation > Motion > Tactile sensory perception > Elimination > Nutrition > Pain
The nurse's assessment reveals that the client's gastrostomy tube feels slack and the site is leaking a significant amount of drainage. What should the nurse do?
Apply gentle pressure to the tube while pressing the external bumper closer to the skin.
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding?
As a stage I pressure injury
The nurse is concerned that a client is not eating the meals provided. Which interventions should the nurse implement to encourage eating?
Ask the client why he or she is not eating.
A nurse is caring for a client who has a nursing diagnosis of Risk for Aspiration. When preparing to assist this client with eating, how can the nurse best reduce this risk?
Assess the client's level of consciousness.
Prior to allowing a client to eat, which action is most important for the nurse to take?
Assess the client's level of consciousness.
Contusion (bruise)
Cause: Blow from a blunt instrument > Closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels
Abrasion
Cause: Surface scrape, either unintentional or intentionnal > Open wound involving the skin
Laceration
Cause: Tissues torn apart, often from accidents > Open wound; edges are often jagged
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?
Clean the wound from the top to the bottom and from the center to outside.
A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse?
Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab
Which intervention should the nurse take for a client who is receiving continuous tube feedings?
Elevate the head of the bed at least 30 to 45 degrees to prevent aspiration.
A woman consumes pasta, grains, and other carbohydrates for which purpose?
Energy
A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual?
Every 4-6 hours
The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?
Fish
A nurse in a clinic is caring for a female client who is of childbearing age. Which vitamins or minerals should the nurse recommend to prevent neural tube defects during pregnancy?
Folic acid
The nurse is caring for a client with an enlarged thyroid gland. Which nutritional deficiency will the nurse suspect is linked to the client's condition?
Iodine
A postmenopausal client wishes to increase the amount of vitamin D that she consumes to help keep her bones strong. Which food will the nurse recommend?
Milk
An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of:
Negative nitrogen balance
During a visit to the pediatrician's office, a parent inquires about adding solid foods to the diet of a 6-month-old infant. What does the nurse inform the parent?
New foods should be introduced one at a time for a period of 2 to 3 days.
A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in?
Overweight
A nurse is working with a 45-year-old construction worker. The nurse obtains his height and weight and calculates that his BMI is 28. How would the nurse best classify James?
Overweight
The nurse is performing a nutritional assessment of an obese client who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this client?
Psychological reasons for overeating should be explored, such as eating as a release for boredom.
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?
Rotate the swab several times over the wound surface to obtain an adequate specimen.
A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client's level of malnutrition?
Serum albumin
Which laboratory test is the best indicator of a client in need of TPN?
Serum albumin
A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?
Stage II
Tissue Integrity
Structural intactness and physiologic function of tissues and conditions that affect integrity
The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse would require intervention by the charge nurse?
The new nurse places the client in the left lateral recumbent position.
Nutrition
The science of optimal cellular metabolism and its impact on health, disease, and recovery from illness
A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?
The status of the client's tetanus immunization
A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?
Transparant
An older adult client informs the nurse that foods don't taste or smell the same and eating is a chore. What suggestion can the nurse provide to the client to address this age-related change?
Try eating foods that are attractive and at the proper temperature.
The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite?
Try to ensure that the client's food is attractive and sufficiently warm.
A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?
Vitamin K
The nurse is caring for four clients. Which client does the nurse assess to be at highest risk for cardiac and vascular disease?
client with total cholesterol of 210 mg/dL, HDL 40 mg/dL
The client, after undergoing an appendectomy for a ruptured appendix, has an open drain left in the wound. The health care provider prescribes removal of 2 in (5 cm) of drain every day. Which action will the nurse take?
reposition the safety pin or clip on the drain
A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document?
serosanguineous
The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk?
teenager who is in the second trimester of pregnancy
Which client's laboratory data indicates the need to include interventions in the nursing plan of care specifically aimed at cardiac and vascular disease?
total serum cholesterol of 180 mg/dL; HDL 32 mg/100 mg/dL
Fat (Lipids) (9 kcal/gram)
> Provide energy > Palatability > Satiety > Necessary for the absorption of fat-soluble vitamins > Body protection >> Provides structure >> Insulates the body >> Cushion internal organs
Carbohydrates (4 kcal/gram)
> Provide energy; spare protein > Prevent ketosis > Absorb water to Increase fecal bulk > Decease intestinal transmit time > Slow gastric emptying > Lower serum cholesterol level > Delay glucose absorption
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?
Assess the client's wound and vital signs.
The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the:
RDA Level
Dietary Guidelines for Americans 2015-2020
Recommends that individuals should limit intake of saturated fats and trans fats, with less than 10 % of calories per day from saturated fats and intake of trans fats to as low as possible.
A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason?
To rest the gastrointestinal tract and promote healing
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?
To splint the area when engaging in activity
A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?
Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown
A nurse is conducting client education with a woman who meets the diagnostic criteria for metabolic syndrome. The nurse is teaching the client about the MyPlate tool for promoting healthy food intake. According to MyPlate, the highest proportion of food in each meal should consist of what?
Vegetables
The client reports to the nurse that she feels as if her eyes are persistently dry. This symptom is consistent with a deficiency in which dietary element?
Vitamin A
A 16-year-old adolescent informs her nurse that she became a vegetarian 1 year ago. Lately she is reporting fatigue and has trouble concentrating. A quick blood test ordered by her licensed provider informs the nurse that she has pernicious anemia. This is a deficiency of what vitamin?
Vitamin B12
A 45-year-old client on the inpatient unit has just resumed eating a normal diet. The nurse checks a blood sugar with the morning labs and the result is 99.10 mg/dL (5.5 mmol/L). How would the nurse interpret this blood glucose?
Normal
A nurse is caring for a client receiving total parenteral nutrition (TPN). Which should the nurse educate the client about regarding TPN therapy? Select all that apply.
> TPN has a high glucose concentration. > TPN requires a PICC line or central venous access. > TPN has three primary components: proteins, carbohydrates, and fats.
A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.
> Warm hand > No finger numbness or tingling > Fingers with quick capillary refill
The nurse would recognize which client as being particularly susceptible to impaired wound healing?
An obese woman with a history of type 1 diabetes
A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?
Dehiscence of the wound
The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding?
Nonblanchable redness
