NU 273 - Test 2

Which wounds benefit from negative pressure wound therapy (NPWT)?

It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include stage 3 or stage 4 pressure injuries; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and full-thickness burns. NPWT is not considered for use in the presence of active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; wounds with exposed vessels, nerves, tendons and ligaments; allergy to any component; or with fistulas of unknown origin.

Steps for wound irrigation

(1) Assess the wound, (2) wound anesthesia (as needed), (3) wound periphery cleansing, and (4) irrigation with the solution under pressure. A 35 to 50mL syringe may be attached to an eye cup (to prevent splash back) or an 18 gauge plastic catheter. The syringe may be filled with the operator's choice of irrigation solution as discussed above. An assembly consisting of a 19-gauge plastic attached to a 35 to 50mL syringe produces a pressure of 25 to 40 PSI when pushing the barrel of the syringe with both hands. The upper limit of pressure where injury to tissues may occur is 70 PSI. Studies have used 250mL of irrigation fluid per 5cm of wound length or approximately 50mL per centimeter of wound length. Once the operator believes that the wound has been sufficiently irrigated and that no foreign material remains the clinician may proceed to either wound dressing or primary repair depending upon the situation.

Abdominal assessment (for general screening)

(1) Observe the coloration, vascularization, scars, rashes, and lesions of the abdominal skin. (2) Observe umbilicus. (3) Observe abdominal contour and symmetry. (4) Observe for aortic pulsations and peristaltic waves. (5) Auscultate bowel sounds. (6) Percuss tones over four quadrants of abdomen. (7) Lightly palpate four quadrants of abdomen.

What are the functions of the skin?

Barrier protection (including immune function), thermoregulation, sensation, vitamin D synthesis

How do you safely move a patient whose BMI is >40?

A BMI >40 is morbidly/extremely obese. Lifting a patient who is this large will often require a mechanical lift and/or a "lift team" (i.e. either a specialized lift team per hospital policy or multiple nurses/staff members to assist in moving/repositioning) to ensure patient and staff safety. The patient should also be positioned in a bariatric hospital bed and bariatric wheelchair as appropriate, as smaller equipment will increase the risk of patient and staff harm. NEVER attempt to move one of these patients with only one staff member.

Nausea

A feeling of sickness or discomfort in the stomach that may come with an urge to vomit.

Halitosis

A strong mouth odor or a persistent bad taste in the mouth, may be the first indication of periodontal disease.

Cachexia

A wasting condition of general ill health and malnutrition, marked by weakness and emaciation. This type of malnutrition is characterized by an abnormal metabolic rate, anorexia, muscle wasting, severe weight loss, and general decline in condition. Though this syndrome is not well understood, it is typically attributed to a combination of factors, including increased catabolism and interference with gastrointestinal function resulting from the cancer, anorexia, altered metabolism, treatment related and from psychological factors such as anxiety and depression. Often associated with severe / late stage chronic illness, such as cancer, AIDS, heart failure, advanced COPD.

Negative pressure wound therapy (NPWT)

Activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. In clinical practice, this device is commonly referred to as a wound V.A.C. (vacuum-assisted closure).

What do you do for perineal care for a heavily soiled, un-circumcised male?

Always proceed from the least contaminated area to the most contaminated area. Rinse the washed areas well with plain water. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis. Pull the uncircumcised male patient's foreskin back into place over the glans penis to prevent constriction of the penis, which may result in edema and tissue injury. It's important to immediately pull the clean foreskin back into place when the area is heavily soiled.

Intramuscular route for meds

An injection into deep muscle tissue, usually of the buttock, thigh, or upper arm.

Intravenous route for meds:

An injection of a solution into the vein.

Plaque

An invisible, destructive, bacterial film that builds up on everyone's teeth and eventually leads to the destruction of tooth enamel. Caries (decay of teeth ; aka cavities) result from failure to remove plaque.

Hydrocolloid dressings (e.g. Comfeel, DuoDERM, etc.)

Are occlusive or semiocclusive, limiting exchange of oxygen between wound and environment. Inner layer is self-adherent, gel forming, and composed of colloid particles. Outer layer seals and protects the wound from contamination. Minimal to moderate absorption of drainage. Maintain a moist wound environment. Thermal insulation. Provide cushioning. Facilitate autolytic debridement. May remain in place for 3-7 days, depending on exudate.

Undermining (in relation to pressure ulcers)

Area of destroyed tissue that extends under intact skin along the periphery of a wound; commonly seen in shear injuries; can be distinguished from sinus tract in that there is a significant portion of the wound edge involved, whereas sinus tract involves only a small portion of the wound edge

Infant skin considerations

At risk for diaper rash, minor abrasions from falls, poor decision making for environmental dangers (i.e burns). The premature infant is often born with immature organ systems and minimal energy stores but high metabolic requirements—a condition that predisposes to impaired wound healing.

Abdominal assessment - auscultation

Auscultate for bowel sounds. Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the client's abdomen. Apply light pressure or simply rest the stethoscope on a tender abdomen. Begin in the RLQ and proceed clockwise, covering all quadrants. Listen for at least 5 minutes before determining that no bowel sounds are present and that the bowels are silent. Normal: A series of intermittent, soft clicks and gurgles are heard at a rate of 5-30 per minute. Hyperactive bowel sounds referred to as "borborygmus" may also be heard. These are the loud, prolonged gurgles characteristic of one's "stomach growling." "Hyperactive" bowel sounds that are rushing, tinkling, and high pitched may be abnormal indicating very rapid motility heard in early bowel obstruction, gastroenteritis, diarrhea, or with use of laxatives. "Hypoactive" bowel sounds indicate diminished bowel motility.

Hydrocolloid dressing use

Available in sheets and in gels, hydrocolloids are a good choice for both exudative and acute wounds. Easy to use and comfortable, hydrocolloid dressings promote debridement and formation of granulation tissue. Most can be left in place for as long as 7 days and can be submerged in water for bathing or showering. Hydrocolloid dressings are more effective than saline gauze or paraffin gauze dressings in completely healing chronic wounds. As the dressing absorbs water, it produces a foul-smelling, yellowish covering over the wound. This is a normal chemical interaction between the dressing and wound exudate and should not be confused with purulent drainage from the wound.

Factors to consider when administering TPN (2)

Avoid blood sampling via the venous access device used for PN when feasible. Change site dressings according to facility protocol. Transparent semipermeable dressings are changed once per week. Gauze dressings do not allow for inspection of exit site without dressing removal and should be changed every 48 hours. In addition, change dressings immediately if they become wet, soiled, or nonocclusive. Check that all connections are securely taped, catheter is clamped before opening the system, and insertion site is covered with sterile dressing. Compare the patient's daily weight to fluid intake and output. Total weight gain should not be greater than 3 lb per week. Weight gain greater than 1 lb per day indicates fluid retention. Assess serum protein and electrolyte levels for signs of imbalance.

Dorsiflexion

Backward bending of the hand or foot. Example: A person's foot is in dorsiflexion when the toes are brought up as though to point them at the knee.

How do you properly store dentures at night while the patient sleeps?

Brush dentures twice a day and rinse with cool water; remove and rinse dentures and rinse mouth after meals. Fully clean before storing at night. Store dentures in a denture cup/container filled with water and labelled with the patient's name and room number.

Wound prevention for patients with COPD who are typically in tripod position

COPD reduces quantity and quality of oxygen available to the wound site, which negatively affects would healing. To promote prevention of the development of wounds, assess pressure points (e.g. if hands are resting on knees, assess both the hands and knees), encourage repositioning, encourage adequate nutrition, encouraging activity/mobility (as possible), prompt changing if incontinent (and good peri care regardless), proper nutrition (including sufficient protein, carbs, vitamin C, vitamin A, calories, etc.), keeping skin clean and dry, minimizing risk factors (e.g. maintaining adherence to nutrition and medication recommendations if diabetic, etc.)

ROM exercises

Can be passive, active-assistive, or active. Range-of-motion exercises should be done at least twice a day. During the bath is one appropriate time. The warm bath water relaxes the muscles and decreases spasticity of the joints. Also, during the bath, areas are exposed so that the joints can be both moved and observed. Another appropriate time might be before bedtime. The joints of helpless or immobile patients should be exercised once every eight hours to prevent contracture from occurring. Joints are exercised sequentially, starting with the neck and moving down. Put each joint needing exercise through the range of motion procedure a minimum of three times, and preferably five times. Avoid overexerting the patient; do not continue the exercises to the point that the patient develops fatigue. Some exercises may need to be delayed until the patient's condition improves. Support the extremity when giving passive exercise to the joints of the arm or leg. Stretch the muscles and keep the joint flexible. Move each joint until there is resistance, but never force a joint to the point of pain.

Debridement

Cleaning away devitalized tissue and foreign matter from a wound

What materials will be found in purulent drainage?

Comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria.

Purulent drainage

Contains pus, has a milky texture, and is gray, yellow, or green in color. Comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria

Which factors influence personal hygiene practices?

Culture (e.g. typical habits and behaviors, use of particular products, frequency of bathing, etc.), socioeconomic class (e.g. finances may impact a person's ability to afford certain hygiene products), spiritual practices (e.g. bathing at particular times or on particular occasions), developmental level, health state (e.g. disease, surgery, or injury impacting a person's ability to perform hygiene), personal preferences.

What to consider when interviewing a patient regarding their skin care?

Daily and weekly bathing habits, types of products used (soap, lotion, deodorant, shampoo, etc.), factors that may interfere with hygiene practices (e.g. sensory, cognitive, endurance, mobility, or motivational issues), exposure to sun and chemicals history, any history of skin problems, any changes in skin, any piercings or tattoos that may impact skin care, etc.

What should you do when the patient is attempting to ambulate and states they feel weak?

Discontinue ambulation. Ask them to sit down to avoid a fall/injury.

Serosanguineous drainage

Drainage that contains a mixture of serum (primarily clear and watery) and red blood cells. Has a light red or pink tinge to it, although it may be clear in some cases (it depends upon how much clotted blood is mixed with the serum)

Sanguineous drainage

Drainage that contains blood (common with deeper wounds), red or pink in color. The drainage is typically syrup-like and thicker than regular blood.

Necrosis - eschar

Dry, black, leathery tissue. Healing of the wound will not take place with necrotic tissue in the wound. Removal of the dead tissue must occur for healing to begin.

Chachexia nursing education to improve intake

Educate patient to avoid unpleasant sights, odors, and sounds in the environment during mealtime. Suggest foods that are preferred and well tolerated by the patient, preferably high-calorie and high-protein foods. Respect ethnic and cultural food preferences. Encourage adequate fluid intake, but limit fluids at mealtime. Suggest smaller, more frequent meals. Promote relaxed, quiet environment during mealtime with increased social interaction as desired. Encourage nutritional supplements and high-protein foods between meals. Encourage frequent oral hygiene, particularly prior to meals. Collaborate with dietician to provide nutritional counseling; instruct patient and family regarding enteral tube feedings of commercial liquid diets, elemental diets, or other foods as prescribed.

Bed bath procedure - prep and head (1)

Fill a disposable bowl with warm water and ask the patient to check the temperature is comfortable. If the patient is wearing a watch, hearing aid or glasses, remove them. Place a towel under the patient's chin and cleanse the patients eyes according to local policy. Wash the face, neck and ears, checking whether the patient likes soap on their face. Clean hearing aids and glasses if worn, and return them to the patient to facilitate communication during the procedure.

Hemostasis phase

First phase of wound healing. Hemostasis is the process of the wound being closed by clotting. Hemostasis starts when blood leaks out of the body. The first step of hemostasis is when blood vessels constrict to restrict the blood flow. Next, platelets stick together in order to seal the break in the wall of the blood vessel. Finally, coagulation occurs and reinforces the platelet plug with threads of fibrin which are like a molecular binding agent. The hemostasis stage of wound healing happens very quickly. The platelets adhere to the sub-endothelium surface within seconds of the rupture of a blood vessel's epithelial wall. After that, the first fibrin strands begin to adhere in about sixty seconds. As the fibrin mesh begins, the blood is transformed from liquid to gel through pro-coagulants and the release of prothrombin. The formation of a thrombus or clot keeps the platelets and blood cells trapped in the wound area. The thrombus is generally important in the stages of wound healing but becomes a problem if it detaches from the vessel wall and goes through the circulatory system, possibly causing a stroke, pulmonary embolism or heart attack.

Steps for negative pressure wound therapy (NPWT) - Prep through bandage removal

First, all the regular stuff (review records, hand hygiene, PPE as needed, identify patient, get materials, close curtains, assess for pain before wound care, adjust bed as needed, make sure pt is comfortable, have waste bag nearby, etc.). Using sterile technique, prepare a sterile field and add all the sterile supplies needed for the procedure to the field. Pour warmed, sterile irrigating solution into the sterile container, as indicated. Put on a gown, mask, and eye protection. If NPWT is currently in use, turn off the negative pressure unit. Put on clean, disposable gloves. Loosen the tape on the old dressings by removing in the direction of hair growth and the use of a push-pull method. Push-pull method: lift a corner of the dressing away from the skin, then gently push the skin away from the dressing/adhesive. Continue moving fingers of the opposite hand to support the skin as the product is removed. Carefully lift the adhesive from the surrounding skin to prevent medical adhesive-related skin injury (MARSI). Remove the sides/edges first, then the center. If there is resistance, use an adhesive remover. Carefully remove the soiled dressings. If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to help loosen and remove it.

Maturation / Remodeling / wound contraction phase

Fourth phase of wound healing. This phase begins approximately 3 weeks after injury with the development of the fibrous scar and can continue for 6 months or longer, depending on the extent of the wound. During this phase, there is a decrease in vascularity and continued remodeling of scar tissue by simultaneous synthesis of collagen by fibroblasts and lysis by collagenase enzymes. As a result of these two processes, the architecture of the scar is capable of increasing its tensile strength, and the scar shrinks so it is less visible.

Unstageable pressure ulcer

Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.

Stage 3 pressure ulcer

Full-thickness tissue loss. Subcutaneous fat may be visible; however, bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Depth of a stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; stage III ulcers can be shallow in these areas. Areas of significant adiposity can develop extremely deep stage III pressure ulcers.

Stage 1 pressure ulcer

Has intact skin. Nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching. Color may differ from surrounding area. Area may be painful, firm, soft, and warmer or cooler as compared to adjacent tissue.

Bed bath procedure - Upper body (2)

Help the patient to remove their upper clothes and use a sheet to cover the patient. Only expose the part of the body that is being washed. Starting with the arm farthest away, wash and dry the upper body, including the arms, hands, axilla and torso. Moving across the body in this way ensures the patient is clean and dry by the end of the procedure. Always wash down the body, for example from axilla to hands. Ask the patient if they would like to soak their hands in water.

What stage of wound healing occurs first in a stage 4 pressure injury?

Hemostasis (which is always the first phase for any wound)

What are the two major processes involved in the inflammatory phase of wound healing?

Hemostasis and Phagocytosis. Hemostasis is the arrest or cessation of bleeding resulting from vasoconstriction, retraction of injured blood vessels, the deposition of fibrin, and blood clot formation. Phagocytosis is when macrophages begin to engulf microorganisms and cellular debris.

Risk factors for skin injuries

Immobility, incontinence, reduced sensory perception, poor nutrition and hydration, conditions negatively affecting blood flow / perfusion, weight (either being excessively thin or excessively overweight/obese), wearing adaptive equipment (braces, etc - particularly when they apply pressure), age, exposure to chemicals, excessive exposure to UV/sun

Who may need special consideration prior to perineal care?

Individuals with incontinence issues, if they have a catheter, if they douche, if they've had rectal or genital surgery, if they have a UTI, diabetes, STI/STDs, if they have pressure ulcers (or are at risk for them), if they are obese, etc.

Intrathecal route for meds

Injected into the spinal canal, or into the subarachnoid space so that it reaches the cerebrospinal fluid.

Subcutaneous route for meds

Injection into the subcutaneous tissue that lies between the epidermis and the muscle.

Anorexia

Lack or loss of appetite for food.

Abduction

Lateral movement of a body part away from the midline of the body. Example: A person's arm is abducted when it is moved away from the body.

Adduction

Lateral movement of a body part toward the midline of the body. Example: A person's arm is adducted when it is moved from an outstretched position to a position alongside the body.

Supine position

Laying flat in bed with face upward

Semi-Fowler's position

Laying in bed with bed raised between 15-45 degrees (with 30 degrees being the most frequently used angle).

Necrosis - slough

Moist, yellow, stringy tissue. Healing of the wound will not take place with necrotic tissue in the wound. Removal of the dead tissue must occur for healing to begin.

Management of NG tube (after placement)

Monitor electrolytes (sodium, potassium, magnesium, and phosphorus) whether he or she is receiving tube feedings or placed on suction. In patients receiving tube feedings, electrolytes are lost due to the osmolality of the tube feeding and the way the electrolytes move across the pressure gradient. With suction, these electrolytes will be lost with the gastric contents that are removed. You'll also want to monitor your patient's daily weight and maintain strict intake and output; this will ensure that he or she is receiving the right amount of nutrients and water. Monitor your patient's skin, especially the nares. NG tubes can cause skin breakdown of the nares if not monitored and repositioned frequently. You should change the position of the NG tube slightly every 24 hours to reduce the risk of skin breakdown. Remember that tube placement should be verified before use if intermittently being used and every 4 hours if being continuously used.

Child skin considerations

More at risk for abrasions/lacerations from active play. Wound healing in children is similar to that in the adult population.51 The child has a greater capacity for repair than the adult but may lack the reserves needed to ensure proper healing. A lack in reserves is evidenced by an easily upset electrolyte balance, a sudden change in temperature, and rapid spread of infection. The neonate and small child may have an immature immune system with no antigenic experience with organisms that contaminate wounds. The younger the child, the more likely the immune system is not fully developed. Successful wound healing also depends on adequate nutrition. Children need sufficient calories to maintain growth and wound healing.

Older adult skin considerations

More at risk for skin tears. A number of structural and functional changes occur in aging skin, including a decrease in dermal thickness, a decline in collagen content, and a loss of elasticity. The observed changes in skin that occur with aging are complicated by the effects of sun exposure. Because the effects of sun exposure are cumulative, older adults show more changes in skin structure. Wound healing is thought to be progressively impaired with aging. Older adults have reduced collagen and fibroblast synthesis, impaired wound contraction, and slower reepithelialization of open wounds. Although wound healing may be delayed, most wounds heal, even in the debilitated older adult undergoing major surgical procedures. Older adults are more vulnerable to chronic wounds, especially pressure, diabetic, and ischemic ulcers, compared to younger people, and these wounds heal more slowly. However, these wounds are more likely because of other disorders such as immobility, diabetes mellitus, or vascular disease, rather than aging.

Granulation tissue

New tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

Do we still use injectable air into NG tube to confirm placement?

No. Per American Association of Critical-Care Nurses website: "Nurses should not use the auscultatory (air bolus) or water bubbling method (holding tube under water) to determine tube location." (This method only has a specificity of 61% and is considered unreliable: https://pubmed.ncbi.nlm.nih.gov/24731474/) It was however, used often in the past, and continues to be used occasionally currently.

Steps for negative pressure wound therapy (NPWT) - After taking off bandage

Note the presence, amount, type, color, and odor of any drainage on the dressings. Note the number of pieces of wound contact material removed from the wound. Compare with the documented number from the previous dressing change. Remove your gloves and put them in the receptacle. Perform hand hygiene. Put on sterile gloves. Using sterile technique, clean or irrigate the wound, based on wound care plan and prescribed wound care. Clean the area around the wound with normal saline or prescribed skin cleanser. Dry the surrounding skin with a sterile gauze sponge. Assess the wound for appearance, stage, presence of eschar, granulation tissue, epithelialization, undermining, tunneling, necrosis, sinus tract, and drainage. Assess the appearance of the surrounding tissue. Measure the wound. Remove gloves and perform hand hygiene.

Risk factors for poor oral health / hygiene

Older individuals (due to several factors, including reduced dexterity that may limit the person's ability to bruss or floss), dependent individuals who require assistance for oral care, cognitive impairment, mental illness, individuals with poor diets (excessive sugar, including sugary drinks), oral cancer, HIV w/ oral manifestation (e.g. fungal, bacterial, or viral infections), oro-dental trauma, tobacco use (all forms, including chewing tobacco).

Management of dehiscence and evisceration

Once dehiscence occurs, the wound is managed like any open wound. Dehiscence and evisceration of an abdominal incision is a medical emergency. Place the patient in the low Fowler's position and cover the exposed abdominal contents, as discussed previously, being sure to keep the exposed viscera moist. Do not leave the patient alone, and be sure to provide reassurance and intravenous pain medications as appropriate. Notify the primary care provider immediately. This situation is an emergency that requires prompt surgical repair, so the patient should be kept NPO

What are post op priorities in regards to resumption of activities?

Once patient is stable after surgery (vitals, awake, bowel sounds), beginning oral intake, and then mobility are strongly encouraged. Much better outcomes with early physical activity following surgery. Initially focusing on sitting up, but soon increasing activity level to transfers between bed and chair, and then to walking (with assistance that gradually decreases over time). The quicker this whole process *safely* happens, the better.

Total parenteral nutrition (TPN)

PN is a highly concentrated, hypertonic nutrient solution and is sometimes referred to as total parenteral nutrition (TPN). PN provides calories; restores nitrogen balance; and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. PN can also promote tissue and wound healing and normal metabolic function. It provides the bowel a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine. PN may be used to improve a patient's response to surgery. PN meets the patient's nutritional needs by way of nutrient-filled solutions administered intravenously through a central venous access device, such as a multilumen, nontunneled catheter into the subclavian vein, or a peripherally inserted central catheter (PICC).

TPN infusion process

PN is administered using an electronic infusion device with anti-free-flow protection, via continuous or cyclic infusion. Physical incompatibility between the intravenous nutrition formula and other intravenous solutions, especially medications, is a potential problem that must be addressed. If the patient has a multilumen catheter in place, dedicate one lumen for the administration of the PN. Do not use that lumen or administration set for any other purpose, to prevent incompatibility problems. If the patient's intravenous catheter has only one lumen, attempt to obtain a peripheral intravenous access for the administration of additional solutions. Consider discussing the potential for a midline or peripherally inserted central catheter with the patient's health care team.

Stage 2 pressure ulcer

Partial thickness loss of dermis, presenting as a shallow open ulcer with red-pink wound bed without slough. May present as an intact or open/ruptured serum-filled blister. May present as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. Does not include skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

Partial care

Patient can safely perform some portions of a task (e.g. self hygiene) (<75%), but require assistance for other portions of the task. Encourage independence as appropriate, but assist where needed.

Full care

Patient is unable to safely perform any part of a task (e.g. self hygiene) and requires full assistance to complete the task.

Minimal assist

Patient requires a small amount of help, or intermittent help, to complete a task (but can do 75% or more of the task on their own).

Periodontitis

Periodontitis, or periodontal disease, is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone. Symptoms include bleeding gums; swollen, red, painful gum tissues; receding gum lines with the formation of pockets between the teeth and gums; pus that appears when gums are pressed; and loose teeth. If unchecked, plaque builds up and, along with dead bacteria, forms hard deposits called tarter at the gum lines. The tartar attacks the fibers that fasten teeth to the gums and eventually attacks bone tissue. The teeth then loosen and fall out.

Dumping syndrome

Physiologic response to rapid emptying of gastric contents into the small intestine, manifested by nausea, weakness, cramping, sweating, palpitations, syncope, and possibly osmotic diarrhea. This can lead to dehydration, hypotension, and tachycardia. Patients fed by the small intestinal route vary in the degree to which they tolerate the effects of high osmolality; the nurse needs to be knowledgeable about the patient's formula and take steps to prevent this undesired effect. The small intestines may be able to adapt to a formula of high osmolality if it is initiated at a low hourly rate that is advanced slowly.

What are the essential nutrition components that are necessary for wound healing?

Protein (wound repair, clotting, immune response to injury), carbohydrates (supplies energy necessary for healing), vitamin C (membrane integrity), vitamin A (collagen synthesis, epithelialization), vitamin K (collagen synthesis, clotting), iron (hemoglobin synthesis), zinc (cell proliferation, enzyme cofactor), copper (collagen cross-linkage), B vitamins (specifically pyridoxine, riboflavin, thiamine), arginine, and glutamine

Evisceration

Protrusion of wound contents. Serious surgical complication. Abdominal example: When the wound edges separate slowly, the intestines may protrude gradually or not at all, and the earliest sign may be a gush of bloody (serosanguineous) peritoneal fluid from the wound. When a wound ruptures suddenly, coils of intestine may push out of the abdomen. The patient may report that "something gave way." The evisceration causes pain and may be associated with vomiting.

Steps for negative pressure wound therapy (NPWT) - After assessing and measuring the wound

Put on sterile gloves. Wipe intact skin around the wound with a skin protectant/barrier wipe and allow it to dry. If the use of a wound contact layer (impregnated porous gauze or silicone adhesive contact layer) is indicated, use sterile scissors to cut the wound contact layer to fit the wound bed. Apply wound contact layer to the wound bed. Fit the wound contact material to the shape of the wound. If using foam wound contact material, use sterile scissors to cut the foam to the shape and measurement of the wound. Do not cut foam over the wound. More than one piece of foam may be necessary if the first piece is cut too small. Carefully place the foam in the wound. Ensure foam-to-foam contact if more than one piece is required. If using gauze wound filler, carefully place in wound to fill cavity. Note the number of pieces of wound filler placed in the wound. Do not under- or over-fill.

Proper mechanics for moving a patient up in bed: preparation

Raise the bed to a level that reduces strain on your back. Make the bed flat. Roll the patient to one side, then place a half rolled up slide sheet or draw sheet against their back. Rolling the patient onto the sheet and spread the sheet out flat under the person. Make sure the head, shoulders, and hips are on the sheet.

Normal albumin level

Range: 3.4 to 5.4 g/dL. Patients with cachexia are typically low in albumin. Albumin is a group of plasma proteins that aids in the transport of substances in the body.

Erythema

Redness of the skin

Is it a good idea to use baby powder?

Recommendation from our text: Discourage parents from using any type of baby powder to avoid the risk of aspiration; inhalation of talcum-containing powders may result in pneumonitis. Prevention is the best management of diaper dermatitis. Topical products such as ointments or creams containing vitamins A, D, and E; zinc oxide; or petrolatum are helpful to provide a barrier to the skin. Change diapers frequently. Change stool-soiled diapers as soon as possible. Avoid rubber pants. Gently wash the diaper area with a soft cloth, avoiding harsh soaps. Use baby wipes in most children, but avoid wipes that contain fragrance or preservatives. Once a rash has occurred, allow the infant or child to go diaperless for a period of time each day to allow the rash to heal (or blow dry area on warm (not hot) setting for 3-5 min.

What are some interventions to prevent pressure injuries in patients?

Regular skin assessments, repositioning, encouraging activity/mobility (as possible), prompt changing if incontinent (and good peri care regardless), proper nutrition (including sufficient protein, carbs, vitamin C, vitamin A, calories, etc.), keeping skin clean and dry, minimizing risk factors (e.g. maintaining adherence to nutrition and medication recommendations if diabetic, etc.)

Bed bath procedure - Lower body (3)

Remove clothing from the lower body, then wash and dry the legs and feet, starting with the leg farthest away and working from the top of the leg to the foot. Check feet for any problems such as calluses and dry skin. Change the water and wash cloth and, if required, apply non-sterile gloves before washing the patient's genitalia. If appropriate, ask the patient if they wish to wash their own genitalia, or gain consent to continue with the procedure. Dispose of water - and gloves if used. Decontaminate your hands and fill a disposable bowl with warm water, checking the temperature again with the patient. With help from a colleague (who has decontaminated their hands and put on an apron), roll the patient onto one side using appropriate equipment. Assess if gloves are required for washing the sacrum. Using a clean wash cloth and towel, wash and dry the back then the sacral area, moving from top to bottom. Then change sheet, help patient get dressed, clean nails if needed, brush teeth/dentures, hair, etc.

Inflammatory phase

Second phase of wound healing, but happens with hemostasis (the first phase). Inflammation is the second stage of wound healing and begins right after the injury when the injured blood vessels leak transudate (made of water, salt, and protein) causing localized swelling. Inflammation both controls bleeding and prevents infection. The fluid engorgement allows healing and repair cells to move to the site of the wound. During the inflammatory phase, damaged cells, pathogens, and bacteria are removed from the wound area. These white blood cells, growth factors, nutrients and enzymes create the swelling, heat, pain and redness commonly seen during this stage of wound healing. Inflammation is a natural part of the wound healing process and only problematic if prolonged or excessive.

Dehiscence

Separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound. Serious surgical complication. An abdominal binder can provide support and guard against dehiscence and may be used along with the primary dressing, especially in patients with weak or pendulous abdominal walls or when rupture of a wound has occurred. Evisceration is the most serious complication of dehiscence. In evisceration, the abdominal wound completely separates, with protrusion of viscera (internal organs) through the incisional area.

How to reduce the likelihood of dumping syndrome?

Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. Advise the patient to remain in semi-Fowler position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time.

Epithelialization

Stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of "ground glass" to pink

If wounds are in the subcutaneous tissues, what stage would that be?

Stage 3

Extension

The state of being in a straight line. Example: A person's cervical spine is extended when the head is held straight on the spinal column.

Trendelenburg position / Reverse Trendelenburg

The Trendelenburg position requires lowering the upper torso and raising the feet. It is commonly used in minimally invasive surgery of the lower abdomen or pelvis. The displacement of the abdominal viscera toward the head decreases diaphragmatic movement and respiratory exchange; blood pools in the upper torso, and blood pressure increases; and hypotension can result with return to the supine position. Shearing with resultant tissue damage is also a significant risk in this position. Reverse Trendelenburg position (which has the feet down and the head up) provides the space to operate on the upper abdomen by shifting the intestines into the pelvis. A padded footboard and other supportive cushioning preserve a safe environment for the patient.

Pronation

The assumption of the prone position. Example: A person is in the prone position when lying on the abdomen; a person's palm is prone when the forearm is turned so that the palm faces downward.

Proper mechanics for moving a patient up in bed: pulling

The goal is to pull, not lift, the patient toward the head of the bed. The 2 people moving the patient should stand on opposite sides of the bed. Grab the slide sheet or draw sheet at the patients upper back and hips on the side of the bed closest to you. Put one foot forward as you prepare to move the patient. Put your weight on your back leg. On the count of three, move the patient by shifting your weight to your front leg and pulling the sheet toward the head of the bed.

How do you calculate BMI?

The person's weight in kg divided by their height in meters squared. BMI = kg/m2. (1 kg = 2.2 lbs, 1 meter = 39.37 inches).

Flexion

The state of being bent. Example: A person's cervical spine is flexed when the head is bent forward, chin to chest.

Suspected deep tissue injury

There may be a purple or maroon localized area of discolored intact skin or blood-filled blister. The area may be preceded in appearance by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

Serous drainage

Thin, watery, composed of clear, serous portion of the blood and from serous membranes. May occasionally have a slight yellow/brownish tinge, but is primarily clear. Small amounts are normal during the first stages of healing.

Proliferative phase

Third phase of wound healing. The primary processes during this phase focus on the building of new tissue to fill the wound space. The key cell during this phase is the fibroblast, a connective tissue cell that synthesizes and secretes the collagen, proteoglycans, and glycoproteins needed for wound healing. Fibroblasts also produce a family of growth factors that induce angiogenesis (growth of new blood vessels) and endothelial cell proliferation and migration. The final component of the proliferative phase is epithelialization, during which epithelial cells at the wound edges proliferate to form a new surface layer that is similar to that which was destroyed by the injury.

Cachexia nursing interventions

Treat the underlying conditions that are contributing to the cachexia. Physician may recommend appetite stimulants. Education re: diet and encouraging increased nutritional intake with the focus of stabilizing weight, improving comfort, lowering the risk of infection, keeping up strength and energy, minimizing distress, and improving quality of life. Assess and address factors that interfere with oral intake or are associated with increased risk of decreased nutritional status. Initiate appropriate referrals for interdisciplinary collaboration to manage factors that interfere with oral intake.

Steps for negative pressure wound therapy (NPWT) - After filling the wound

Trim and place the transparent adhesive drape to cover the wound contact material and an additional 3 to 5 cm border of intact periwound tissue. Avoid stretching the transparent adhesive drape tight over the wound. Choose an appropriate site to apply the connector pad/tubing port. Pinch the transparent adhesive drape and cut a hole through it. Apply the connector pad/tubing port and connective tubing over the hole. Position tubing away from the periwound area and anchor. Remove the drainage collection canister from the package and insert into the negative pressure unit until it locks into place. Attach the connective tubing to the canister and check that the clamps on the tubing are open, if present. Remove gloves and discard. Perform hand hygiene. Turn on the power to the negative pressure unit. Select the prescribed therapy settings (suction and cycle type) and start the device. Assess the dressing to ensure seal integrity. The dressing should be collapsed, shrinking to the wound contact material and skin (Figure 5). Observe drainage in tubing. Label dressing with date and time. Remove all remaining equipment; place the patient in a comfortable position, with side rails up as indicated and bed in the lowest position. Check all wound dressings at least every shift.

Tripod position

Tripod positioning (sit or stand leaning forward with the arms supported, often supported on the knees when sitting) forces diaphragm down and forward, stabilizes chest while reducing work of breathing. If shortness of breath worsens with arms raised, support arms during ADLs. Leaning forward enhances use of accessory muscles to aid breathing. Loosening waistband or belt reduces abdominal constriction. There is tension in the sternocleidomastoid muscles.

Perineal care (anal area)

Turn the patient on his or her side and continue with cleansing the anal area. Continue in the direction of least contaminated to most contaminated area. In the female, cleanse from the vagina toward the anus. In both female and male patients, change the part of the washcloth being used with each stroke until the area is clean. Rinse and dry the area.

How do you manage a feeding tube if the residual is >100 cc?

Typically, you give the feeding as scheduled unless the patient is uncomfortable. If pt is uncomfortable, notify the provider (and expect to hold the feeding and probably resume at a lower rate later on). It varies from facility to facility, but often 200cc of residual is the point when you don't immediately give the feeding. Typically, they recommend that you re-check in an hour and if 200cc is still present, hold until next scheduled feeding.

Stage 4 pressure ulcer

Ulcer presents with full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound. Often includes undermining and tunneling. Depth of a stage IV pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; stage IV ulcers can be shallow in these areas. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule); osteomyelitis is possible. Exposed bone/tendon is visible or directly palpable.

Sitting position

Upright between 60-90 degrees (angle of back in relation to the surface the patient is on). Aka High Fowler's position.

Perineal care (female)

Use a small amount of a mild nonsoap cleaning agent and water, or disposable cleaning cloths. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area to prevent carrying organisms from the anal area back over the genital area. Always proceed from the least contaminated area to the most contaminated area. Use a clean portion of the washcloth for each stroke. Rinse the washed areas well with plain water. Dry the cleaned areas and apply an emollient as indicated. Avoid the use of powder. Powder may become a medium for the growth of bacteria.

Perineal care (male)

Use a small amount of a mild nonsoap cleaning agent and water, or disposable cleaning cloths. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. Wash the shaft of the penis using downward strokes toward the pubic area. Always proceed from the least contaminated area to the most contaminated area. Rinse the washed areas well with plain water. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis. Pull the uncircumcised male patient's foreskin back into place over the glans penis to prevent constriction of the penis, which may result in edema and tissue injury. It is not recommended to retract the foreskin for cleaning during infancy and childhood, as injury and scarring could occur. Wash and rinse the male patient's scrotum. Dry the cleaned areas and apply an emollient as indicated. Avoid the use of powder. Powder may become a medium for the growth of bacteria.

How do you confirm that an NG tube is properly placed?

Use either a radiography/x-ray to confirm placement OR two of the following: measurement of tube length and measurement of tube marking, measurement of aspirate pH (stomach <5.5, intestines >7.0, respiratory tract 6.0 or higher), visual assessment of aspirate (stomach: grassy green, tan, off-white; intestines: clear or straw colored; respiratory tract: off-white to tan), and monitoring of carbon dioxide. Radiographic confirmation is the standard way to confirm initial placement of a tube, although is not often not practical for subsequent checks to verify continued placement.

Factors to consider when administering TPN (1)

Use the same catheter lumen for administration of parenteral nutrition each time the tubing is changed. Use an electronic infusion device to administer infusion of parenteral nutrition. Infusion rate changes are made incrementally to avoid severe hyperglycemia or hypoglycemia. Taper infusion rates gradually. Discard unused parenteral nutrition solution within 24 hours of starting its administration. Check vital signs every 4 hours to monitor for development of infection or sepsis. Monitor blood glucose levels as appropriate based on the patient's clinical status. Use aseptic technique when changing solution, tubing, filter, or dressings according to facility policy. Infusion administration sets should include an in-line filter. Change infusion administration sets every 24 hours.

Prior to changing a dressing, what does the nurse need to do first?

Wash hands, look up the orders, note previous time/date it was changed, collect supplies (incl. stuff to clean wound, measure wound, etc.), create a sterile field IF it is a sterile dressing change. Look at dressing - is it saturated? Note appearance. (Wound contamination occurs through a moist medium). Ask patient if they're in pain - do they need meds prior to dressing change? Remove dressing and look at / assess the wound and make sure it looks good before changing the dressing.

Emaciation

Wasting. An extreme weight loss and unnatural thinness due to a loss of subcutaneous fat and muscle throughout the body. Usually chronic and progressive. (Cachexia is a more severe, end-stage version of emaciation associated with severe chronic illness).

Tunneling (in relation to pressure ulcers)

When the wound progresses to form passageways underneath the skin (can be short, long, shallow, or deep)

Wound irrigation

Wound irrigation is a directed flow of solution over tissues. Sterile equipment and solutions are required for irrigating an open wound, even in the presence of an existing infection. Sterile 0.9% sodium chloride or sterile water, a commercially prepared wound cleanser, an antiseptic, or an antibiotic solution may be used, depending on the condition of the wound and the primary health care provider's order. A sterile, large-volume syringe is used to direct the flow of the solution. After irrigation, open wounds may be packed and dressed with appropriate materials to absorb additional drainage and allow healing by secondary intention to take place (see Table 32-5). Nonsterile solutions are generally used to clean the skin surface if the wound edges are approximated.

Caries

aka cavities. Decay of teeth resulting from a failure to remove plaque

Skin changes in older adults

changes are reflected in decreased mitosis in the stratum basale, leading to a thinner epidermis. The dermis, which is responsible for the elasticity and resilience of the skin, exhibits a reduced ability to regenerate, which leads to slower wound healing. The hypodermis, with its fat stores, loses structure due to the reduction and redistribution of fat, which in turn contributes to the thinning and sagging of skin. The accessory structures also have lowered activity, generating thinner hair and nails, and reduced amounts of sebum and sweat. A reduced sweating ability can cause some elderly to be intolerant to extreme heat. Other cells in the skin, such as melanocytes and dendritic cells, also become less active, leading to a paler skin tone and lowered immunity. Wrinkling of the skin occurs due to breakdown of its structure, which results from decreased collagen and elastin production in the dermis, weakening of muscles lying under the skin, and the inability of the skin to retain adequate moisture.