Week 5 I&O, Fluid Status, IV Therapy, and Skin Integrity and Wound Care

QUESTION: Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied? a.Pinning the tubing to the patient's hospital gown b.Compressing the bulb while replacing the port cap c.Emptying the drainage container only when it is 90% full d.Placing the drainage container below the wound site

-B -Compressing the bulb while replacing the port cap recharges the drainage system by reestablishing a vacuum. Pinning the tubing to the patient's hospital gown would not affect suction but rather would minimize tension on the insertion site. Emptying the drainage container has no effect on suction. Keeping the drainage container below the wound site encourages drainage by gravity but does not affect the level of suction

nursing interventions

-goal: prevention for patients at risk, patient education -focus: preventing infection, promote wound healing, preventing further injury or alteration in skin integrity

IV solutions

-isotonic: same osmolality as body fluids D5W/NS/LR -hypotonic: osmolality less than body fluids 0.45% NACL -hypertonic: osmolality greater than body fluids D10W/TPN

types of wound drains

-jackson pratt: closed suction, common for post op -hemovac: placed under skin during surgery -penrose (open): tube -wound VAC: removes pressure and fluid -t-tube: bile drain

line maintenance

-keeping system sterile -change solutions, tubing, site dressing per policy -assist client with self care activities -integrity of system must always be maintained -do not disconnect -stopcock parts should be capped -injection ports must be prepped prior to access -use snap gowns -when removing apply pressure with 2X2 gauze, hold longer when on blood thinners (plavix or heparin)

measurement of volume

-recorded in mL -cc=mL -1 tsp = 5 mL -1 tbsp = 15 mL -1 oz = 30 mL -4 oz = 120 mL -8 oz = 240 mL

wound drainage

-sanguineous: looks like blood (bright red or darker) -serosanguineous: light pink to blood tinged -serous: clear an watery -purulent: thick, milky fluid, indicates infection

body water

-single greatest constituent of the body is water, body water movement and distribution are influenced by fluid intake, fluid pressure, and osmolality -water distributed among 3 types of compartments: cells, blood vessels, and tissue spaces between vessels and cells -extracellular: intravascular and interstitial fluid

measuring wounds

-size: length, width, and diameter -depth: use sterile applicator -wound tunneling: determine direction and depth

I&O

-the measurement and recording of all fluid intake and output during a 24 hour period -provides important data about a patients fluid and electrolyte balance -will be recorded for an 8hr shift then totaled for 24 hrs -ex: 7am-3pm intake 600mL, 3pm-11pm intake 400mL, 11pm-7am intake 100mL (600+400+100=1100mL/24hrs)

output

-urine -vomitus and liquid stool -tube trainage (jackson-pratt, hemovac, T-tube, and penrose

hyperosmolar imbalance

-water excess- extracellular fluid, can be caused by renal failure or congestive heart failure -signs and symptoms: rapid weight gain, neck vein distention, increased blood pressure, dependent edema, crackles in lungs

QUESTION: What is the best way to prevent infection and conserve resources when terminating an IV piggyback medication infusion in a patient who also has a primary fluid infusion? a.Remove the tubing from the primary line Y-site port, and cap the end. b.Leave both the piggyback tubing and the bag attached to the primary line Y-site port until the next scheduled dose. c.Place an unopened secondary setup at the bedside, and discard the used one. d.Change both the primary and secondary tubing upon terminating the piggyback infusion.

-B -Leaving the piggyback tubing and bag attached will help maintain tube sterility while conserving supplies and nursing time. -Although the tubing can be removed from the port and capped, it is better to leave the tubing and bag in place until the next scheduled dose. Secondary tubing can be reused for up to 72 hours. Changing the tubing with each piggyback infusion is expensive. It is unnecessary to change the primary and secondary tubing when terminating an infusion of IV piggyback medication.

basic metabolic profile: chem-7 normal levels

-BUN: 7-20 mg/dL (blood urea nitrogen) -CO2: 20-29 mmol/L -glucose: 64-128 mg/dL -serum chloride: 101-111 mmol/L -serum potassium: 3.7-5.2 mEq/L -serum sodium: 136-144 mEq/L

basic metabolic profile test meanings

-BUN: check kidney function -CO2: changes suggest loss/retain fluid causes imbalance in electrolytes -creatinine: evaluate kidney function, if abnormal creatine levels increase in blood (because less released in urine) -glucose: used to monitor patients who have diabetes, also for first time seizure, strange changes in behavior, fainting -serum chloride: if patient has disturbance in bodys fluid level or acid-base balance -serum potassium: kidney disease common cause of high K+ levels -serum sodium: represents balance between Na+ and water in food and drinks you consume and amount in urine, small % loss through stool and sweat

complications: infiltration

-IV fluids enter the subcutaneous space at venipuncture site -signs and symptoms: swelling, pallor, decreased rate of flow, pain may be present, pressure sensation

PICO in practice questoin

-IV teams: to have or not have, that is the question -in adult patients, ages 30-65in an acute care setting who need peripheral IV therapy, does incorporating an IV therapy team decrease the rate of infections and complications to peripheral infusion sites? -population: adults ages 30-65 in an acute care setting -intervention: IV team to initiate peripheral infusion site -comparison: staff nurse initiated of peripheral infusion sites -outcome: having an IV team will decrease infections and complications to peripheral IV sites (phlebitis, bacteremia, sepsis, trauma to hospital) and will decrease cost to patient and hospital

regulating IV fluids

-SMART pumps: volume control device, programs mL/hr on pumps -most facilities all IV therapy have to be on a pump (ER being exception) prevents accidental overloading of fluid if roller clamp fails, helps control rate and keep track of intake -pumps usually require tubing specific to device -if necessary, manually calculate drip rate start with 15sec, count for 1min -burritol: volume controlled device (pedi or critical care)

wound VAC

-VAC treatment applies localized negative pressure to draw the edges of the wound to the center of the site -negative pressure is applied to a special dressing positioned within the wound cavity or over a flap or graft -by applying pressure directly to the wound, able to remove fluid that causes swelling, stimulate cellular growth, increase blood flow, and promote an increased healing response

topical wound care products

-antibiotic ointment -antibacterial agents -anti fungal agents -chemical debridement gels/ointments -barrier creams (prevention) -skin cleanser -wound fillers (paste, gels, beads, powders) provide moist healing environment under dressing

wound assessment

-appearance of wound -type of drain (if present) -drainage -sutures, stapes, and steri-strips -pain assessment

preventing pressure injuries

-assess skin of patients at risk on daily basis -cleanse skin routinely and whenever any soiling occurs -protect skin from moisture -avoid massaging over bony prominences -turn and reposition at least every 2hrs -positioning devices such as pillows, wedges, pressure reducing devices, gel cushions, mattresses, or foam -minimizing skin injury from friction and shearing forces

complications: sepsis (systemic infection)

-bacteria enters bloodstream via IV site -symptoms: fever, shortness of breath, tachycardia -nursing care: notify primary care clinician, culture IV tip (cut tip off and put in sterile cup), monitor vital signs, treatment as prescribed (broad spectrum antibiotics)

unstageable injuries

-base covered by eschar (black, brown, tan) -base covered by slough (yellow, gray, tan, green, or brown) -stable eschar on heels should not be removed as it serves as bodys natural cover

medical terminology

-blanching: paling/whitening of skin, press on red pink or darkened area with finer, area should go white, remove pressure, return red/pink indicating blood flow, if not blood flow has been impaired, damage has begin -erythema: redness (impaired blood flow) -slough: dead skin cells separated from wound, whitish/yellowish (can indicate infection) -undermining: separation of tissue from surface under edge of wound, like the wound is spread out underneath skin that surrounds visible part of sore, wound may be bigger than what appears at first glance, use cotton tipped applicator to feel under wound edges to see if tip will go "underneath" skin, if yes=undermined

homeostasis

-body normally maintains a state of equilibirum between water taken in and amount of water lost -when body water is insufficient and kidneys are functioning normally, urine volume diminishes and individual becomes thirsty -normal pattern of water intake and loss is 2000-2500mL

intravenous equipment

-catheters: either plastic tubes mounted on needles -needles: guided by flexible sheath catheter, smaller # larger needle (larger for patient receiving blood/blood products, smaller used for pediatrics/elderly) -extension tubing w cap: if not continuous, small extension tubing with cap attached -IV tubing: primary, secondary, blood -drops per minute gravity flow: macrodrip (10,15,20gtts/mL), microdrop (60 gtts/mL)

central venous access devices (CVAD)

-central venous catheter (CVC) -portacaths: placed by surgeons, incision in skin, placed under skin, not visible, but may see bump (often used for chemo) -hickman catheters: similar to central line but only has 2 ports -picc lines: peripheral inserted central catheter, inserted with use of fluoroscopy into the brachial artery to the subclavian then SVC, commonly used in homecare and long-term facilities -most stay in 6-8 weeks -usually have 3 ports, one for IV fluids, second for meds or IV, and one for blood draws

IV fluid administration requires

-correct solution -correct equipment -correct infusion rate -correct method of maintaining the line or system: identify problems, correct problems, discontinue infusion if necessary

moist wound healing

-dried exudate impairs wound healing -moist environment promotes wound healing -injured tissues are repaired by physiologic mechanisms that regenerate functioning cell and replace connective tissue cells with scar tissues

types of dressings

-dry sterile dressing (DSD) -wet-to-dry -chemical -foam -hydrofiber (absorptive) -transparent -hydrogel (autolytic debridement) -hydrocolloid (provide a moist healing environment) -wound closure material (staples, sutures, synthetic glue) -tape (pressure dressing) -dressing around a drain site (drain sponge) -irrigating a wound -packing a wound -binders (montgomery straps)

blood transfusions and reactions: circulatory overload

-dyspnea, dry cough, pulmonary edema -slow or stop transfusion, monitor vital signs, notify PCP, place in upright position with feet dependent

IV prep and insertion

-evaluate extremities/veins then apply tourniquet of BP cuff (older adult) above insertion site to compress venous blood flow -once needle removed put into sharps asap -catheters must be flushed to maintain patency and prevent clot formation -use SAS for flushing: 3mL saline, admin, 3mL saline

blood transfusions and reactions: bacterial reaction

-fever, HTN, dry/flushed skin, abdominal pain -stop infusion immediately, obtain culture of patients blood, monitor vital signs, notify PCP

common IV site

-forearm: cephalic vein, basilic vein, median cubital, radial -hand: superficial dorsal, dorsal venous arch, basilic vein, cephalic -avoid bend such as ante cubital or wrist -dont start IV on same side as mastectomy or lymphoma -use arm boards if necessary -start distal, work proximal, start lower, move up -avoid hands if possible (more painful) -IVs placed in foot need HCP order

deep tissue injury

-form of a pressure ulcer -purplish/maroon area -intact skin -blood filled blister -boggy -cool to touch -described as purple pressure ulcers, ulcers that are likely to deteriorate and bruises on bony prominences -result of injury to subcutaneous tissues under intact skin -has potential for rapid deterioration

stage III pressure injury

-full thickness -subcutaneous fat may be visible (no tendon, muscle, or bone exposed) -slough may be present (does not obscure depth of tissue loss) -may include undermining or tunneling -depth varies depending on location -

stage IV pressure injury

-full thickness loss -exposed bone, tendon, and muscle (visible and palpable) -slough or eschar may be present -undermining and tunneling common -high risk for osteomyelitis

basic metabolic panel (7)

-group of blood tests that provides information about bodies metabolism -also called: SMAC7, sequential multi-channel analysis with computer-7, SMA7, CHEM-7 -venipuncture: blood sample needed -test can be done to evaluate kidney function, blood acid/base balance, and levels of blood sugars, and electrolytes; depending on lab can also check levels of calcium and albumin -dL = 0.1 L

weight pt. 2

-have the patient void before weighing -avoid weighing any equipment attached to the patient -record in lbs or kg -to convert lbs to kg divide by 2.2 -to convert kg to lb multiply by 2.2

blood transfusions and reactions: allergic fever or hemolytic

-hives, itching anaphylaxis, fever, chills, headache, facial flushing, malaise, shock -stop transfusion immediately -keep vein open with normal saline -notify primary care provider (PCP)

risk for pressure injury development

-immobility -cast, splints, or braces -moisture and incontinence -nutritional status -hydration -age -mental status -pain -braden scale can be used for predicting pressure injury risk

wound complications

-infection -hemorrhage -dehiscence: wound seperates -evisceration: underlying tissue (organs) protrufe -fistula formation: pathway b/w one area to another

complications: phlebitis

-inflammation of a vein -causes: catheter, additives, position -signs and symptoms: pain, skin warm to touch, erythema streak, palpable cord (hard distended vein) -interventions: discontinue infusion, remove IV, apply moist heat, notify provider -irritants: additives like KCl, position of catheter (bend)

stage I pressure injury

-intact skin -blanching (white/pale) -non-blanchable erythema (redness) -may be painful, warm or cool, firm or soft, may indicate "at risk" patient

fluid and electrolytes

-intracellular: fluid in cell -intravascular: fluid in blood vessels -homeostasis: (equilibrium of internal environment) in relation to body fluids, homeostasis is process of maintaining equilibrium to the physical and chemical properties of the body -regulators of fluid balance: thirst, electrolytes, protein and albumin, hormones, lymphatics, skin, and kidneys

wound dressings

-location and size -type and depth -presence of infection -need for debridement -amount and type of drainage -condition of surround skin -cost -hydrocolloid: occlusive dressing that swells in the presence of exudate, forms a seal at the wound surface to prevent evaporation of moisture from the skin (maintains granulating wound bed) -hydrogel: promotes autolytic debridement and cooling

drips

-macro: larger drop 15 drops (per min) used for routine IV adult administration -micro: smaller drops 60 per min, used when more exact measurements are needed (critical care, pedi, meds)

characteristics of an ideal dressing

-maintains moist healing environment -high absorbency to regulate moisture -thermally insulates to keep wound warm -does not shed fibers/reduces need for debridement -protects from external contaminants -flexible and conforming provides protection and coverage -easy delivery system reduces changing time -semi-occlusive enables wound inspection without removing the dressing -pain-free removal reduced medication and wound trauma -allows gaseous exchange to prevent maceration

weight

-method to monitor fluid status -standing scale, bed scale, chair scale, and wheel scale -ensure the scale is properly balanced before having the patient stand or sit on it or before rolling the wheelchair onto the scale -use the same scale each time -weigh in the same clothes each day -weigh before breakfast or at the same time each day -take shoes off

wound care and wound management

-open to air (no dressing or protective covering) -closed wound care: uses dressings to keep the wound moist, promoting healing -purpose of dressings: absorb drainage, prevent/eliminate/control infection, maintain a moist environment, provide physical/psychological/ and aesthetic comfort -wounds left open to air are exposed to more environmental factors and potential injury, wounds left open to air also dry more slowly because wound drying produces a dried eschar or scab

intake

-oral liquids -ice chips -tube feedings -parental (IV) -intravenous medications -catheter or tube/drain irrigants

stage II pressure injury

-partial thickness skin loss involving epidermis/dermis (most times epidermis) -superficial open ulcer -red or pink wound bed -abrasion, blister, or shallow crater

methods to assess fluid status

-physical exam (edema, oral mucosa, skin turgor) -lab work- electrolytes -

collecting a wound culture

-position patient (ease of access to wound, comfort of patient, and to allow run off if irrigation -cleanse wound -swab wound surface (collect specimen from wound center, avoid touching wound edges)

local factors affecting wound healing

-pressure -desiccation -maceration: soft, wet, mushy -trauma -edema -necrosis -co-morbidity, age, obesity, mobility, infection, smoking, nutrition (protein-albumin), medications like cortico steriods, thinning skin, poor tissue perfusion

different IV tubing

-primary: used to attach IV soln. container to patients venous access, includes spike to access IV soln. (careful not to puncture bag), drip chamber for observing fluid drops, slide clamp to stop flow, roller clamp to manually regulate rate of flow, filter, and several injection ports for admin of meds or additional fluids, connector at end to connect to venous access, extension added to line to help protect site when tubing and dressing needs to be changed -secondary: shorter, connected to primary, used to piggy back another solution or med -y-tubing: for blood, larger, larger filter in chamber -package indicates how many drops per mL

intravenous therapy (parenteral)

-providing fluid replacement, electrolytes, or nutrients -providing blood/blood components -supplementing fluid intake -administering medication -quickest route of absorption but also has greatest risk for complications and requires careful monitoring -IV therapy involves administering fluids via intravenous catheter -as a nurse may be responsible to initiate, monitor and discontinue IV therapy

care of IV dressings

-purpose: reduce entrance of bacteria into injection site -two types: transparent (allows continuous visual inspection), gauze -dressing changes: when damp, loosened or soiled, according to policy -remove tape or dressing by pulling toward insertion site

documenting

-record amount and route of all fluids at least every 8hrs -fluids will be totaled for 24hr period -record ice chips at their half volume -if irrigating tube (nasogastric tube, foley catheter) subtract amount instilled by total output (ex. if irrigating a foley catheter with 30mL of normal saline and patient had 500 mLs of urine output; total 500-30=470mLs) -measure output in calibrated container -observe at eye level

complications: fluid volume excess

-results from rapid infusion of fluid -symptoms: shortness of breath, crackles in the lungs, tachycardia -nursing care: slow rate, notify primary care clinician, raise head of bed, monitor vital signs, take pulse ox, listen to lungs, inspect skin, chest x-ray (if ordered), diuretic (such as lasix if ordered)

tonicity

-solute or concentration of solution outside cell -iso: prevents fluids from shifting in and our of cell, maintains balance, used to treat patients with dehydration/fluid loss/hypernatremia -hypo: allows fluid to shift into cell, treats dehydration but use fluid with less salt -hyper: allows fluid to move out cells, replaces electrolytes and keeps patient hydrated (surgery, unable to orally eat) -if continuous IV 1000mL bag used -medication IV may be mixed in 50mL bad -check bag for leaks, clear solution, expiration date

nursing care for infiltration

-stop fluids -remove IV -elevate extremity on pillow -warm compresses -notify physician -reinsert IV in another extremity/above site -extravasation: infiltration of caustic or irritating medication which may cause tissue destruction, treat with cold compress and call provider

results of PICO

-study done at 330 bed acute care hospital med-surg wards where IVs were inserted by the intravenous therapy team -results showed that intravenous bacteremias decreased from 4.6/1,000 patient discharges after institution of an intravenous therapy -an IV therapy team improved quality of care for patients and reduced hospital costs -study implies decreasing # of infections or complications from IVs: -patients may have shorter stays -patients may have increased satisfaction -decreased hospital costs -staff are freed to attend other aspects of their job

complications: thrombophlebitis

-the formation of a blood clot in the site of a phlebitis -symptoms same as phlebitis (painful) -may result in emboli (clot that travels, be life threatening)

medical terminology pt. 2

-tunneling: channel runs from wound edge through to other tissue -dehiscence: separation of edges from wound -eschar: thick leathery scab or dry crust that is dead tissue (necrotic, black) -exudate: fluid leaking -granulation: healing process, new pink tissue forms around wound -maceration: softening of skin and breakdown (prolonged moisture) -debride: removing unhealthy tissue -irrigate: -ecchymosis: bruising -edema: fluid swelling -decubitus ulcer: pressure ulcer -osteomyelitis: infection of bone -pressure injury -skin tear

how to use central venous access device

-used on patients in all settings -inserted into superior vena cava, chest wall, need xray to confirm placement -provide access for IV fluids, medications, TPN, blood products, hemodynamic monitoring and for blood samples -dressing changes are done using sterile technique (sterile kit, mask, and gloves), usually changed every 3-5 days

pressure injuries

-wound with localized area of tissue necrosis, must be over bony prominence -underlying cause is pressure -pressure sore, bedsore, and decubitus ulcer also used -factors in development: external pressure, friction and shear (friction can damage superficial blood vessels under skin, caused from wrinkled sheets, shear may occur when patient is pulled up in bed) -pressure results in occluded blood capillaries and poor circulation to tissues, can lead to ischemia, hypoxia, edema, inflammation, necrosis -may form in as little to 1-2hrs -sacrum and coccyx most common, followed by trochanter and calcaneus -tissue tolerance test

QUESTION: What can the nurse do to help protect the patient from infiltration of IV medication? a.Use the most proximal insertion port on the existing primary tubing. b.Ensure that the syringe has been securely loaded into the mini-infusion pump. c.Set the pump to deliver the medication over the prescribed time period. d.Check the IV site for placement before and after the infusion.

D -:Assessing placement and patency of the IV site is essential and will minimize the risk of infiltration. -Using the most proximal insertion port will not prevent infiltration. -Making sure the syringe has been securely loaded will not prevent infiltration. -Setting the pump to the correct infusion rate will not prevent infiltration.

QUESTION: Which device is used for wound irrigation? a.19-gauge needle attached to a 10-mL syringe b.19-gauge needle attached to a 35-mL syringe c.Sterile container held 30.5 cm (12 inches) above the wound d.Foley irrigating syringe

B -A 19-gauge needle attached to a 35-mL syringe will release a sufficient quantity of solution at the correct pressure for wound irrigation. A 19-gauge needle attached to a 10-mL syringe will not supply enough solution for wound irrigation, nor will it release it at the recommended pressure. Holding a container of solution above the wound would yield an unpredictable result and would probably be ineffective for wound irrigation. A Foley irrigating syringe will not release a sufficient quantity of solution at the right pressure for wound irrigation

QUESTION: The nurse is preparing equipment to administer a unit of blood to a patient. Which type of fluid would the nurse piggyback with the blood transfusion? a.0.45% normal saline b.0.9% normal saline c.Dextrose 5% and 0.45% normal saline d.Dextrose 5% and 0.9% normal saline

B. -Blood and blood products can be administered only with 0.9% normal saline. -No other solution is to be administered or piggybacked with blood or blood products. Only 0.9% normal saline solution, not 0.45% normal saline, can be used to administer blood. No other solution is to be administered or piggybacked with blood or blood products. Solutions that contain dextrose cause blood to coagulate and must not be administered or piggybacked with blood or blood products.

QUESTION: Which task might the nurse delegate to nursing assistive personnel (NAP) caring for a patient receiving IV medication via mini-infusion pump? a.Assessing the IV site frequently for signs of infiltration b.Notifying the nurse if the pump alarm sounds c.Informing the physician that the patient is allergic to the prescribed medication d.Ensuring that the medications being delivered intravenously are compatible

B. The nurse may delegate to NAP the task of reporting when a pump alarm sounds. -The skill of patient assessment may not be delegated to NAP. Physician notification may not be delegated to NAP. No aspect of the skill of preparing or administering medication may be delegated to NAP.

QUESTION How would the nurse safely apply an enzyme debridement ointment? a.Daub ointment on dead tissue at the wound edges. b.Put ointment on a tongue blade, and gently spread it on the center of the wound. c.Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin. d.Apply a gauze dressing to ensure contact with the ointment.

C -Avoiding contact with surrounding skin prevents tissue damage. Contact with surrounding skin needs to be avoided with an enzymatic debridement product. The middle of the wound may not need the product. Applying a gauze dressing to ensure contact with the ointment does not address safety when applying the enzymatic product.

QUESTION: When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves? a.After performing hand hygiene at the start of the procedure b.Before removing the inner dressing c.After removing the original dressing materials and performing hand hygiene a second time d.Just before cleansing the wound with sterile water

C -The nurse would wear clean gloves to remove the contaminated original dressing, and he or she would then perform hand hygiene again. Only then would the nurse apply sterile gloves. Applying sterile gloves at the start of the procedure or before removing the inner dressing would compromise the sterility of the gloves. The nurse would apply sterile gloves before performing any step that requires sterile technique, rather than wait until it is time to cleanse the wound with sterile water.

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? a. 1+ pitting edema b. 2+ pitting edema c. 3+ pitting edema d. 4+ pitting edema

C. 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. -1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. -2+ is a 4-mm pit that lasts longer than -1+ with fairly normal contour. -4+ is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.

QUESTION: Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound? a.Cleansing the wound with sterile water b.Blotting the incision with dry gauze c.Wearing sterile gloves to cleanse the wound d.Using a new gauze pad for each stroke while cleansing the wound

D -Using a new gauze pad for each stroke minimizes the risk for cross-contamination by preventing contaminated gauze from introducing microorganisms into other areas of the wound. Using sterile water and drying a wound after cleansing it does not minimize the risk for cross-contamination. Wearing sterile gloves minimizes the introduction of pathogens to the wound, not the cross-contamination of pathogens already found within the wound.

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. a. Serous drainage is composed of the clear portion of the blood and serous membranes. b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. d. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. e. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f. Serosanguineous drainage can be dark yellow or green depending on the causative organism.

a, b, c, d. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. -Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. a. 5% dextrose in 0.9% NaCl b. 0.9% NaCl (normal saline) c. Lactated Ringer's solution d. 0.33% NaCl (⅓-strength normal saline) e. 0.45% NaCl (½-strength normal saline) f. 5% dextrose in Lactated Ringer's solution

d, e. 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. -5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. -0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. -Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. - 5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? a. Using sterile dressing supplies b. Suggesting dietary supplements c. Applying antibiotic ointment d. Performing careful hand hygiene

d. Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? a. Recording intake and output. b. Testing skin turgor. c. Reviewing the complete blood count. d. Measuring weight daily.

d. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury? a. Keeping the head of the bed elevated as often as possible b. Massaging over bony prominences c. Repositioning bed-bound patients every 4 hours d. Using a mild cleansing agent when cleansing the skin

d. To prevent pressure injuries, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.

preventing accidental disruption of IV system

nursing interventions: -assist with ADLs -IV pole for ambulation, client holds pole with involved arm -instruct client to report: blood in tubing, stoppage in the flow, discomfort

discontinuing an IVF

1. clean gloves 2. move roller clamp to closed position 3. place 2x2 gauze over site 4. withdraw catheter by pulling straight back 5. apply pressure to site for 1-3min -consider additional time for patient on anticoagulant therapy (blood thinners) or who is have clotting times

phases of wound healing

1. hemostasis (coagulation) 2. inflammatory 3. proliferation (granulation) 4. maturation (epithelialization)

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. a. Use standard precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c. Clean the wound in full or half circles beginning on the outside and working toward the center. d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e. Clean to at least 1 in beyond the end of the new dressing if one is being applied. f. Clean to at least 3 in beyond the wound if a new dressing is not being applied.

a, b, e. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least 1 in beyond the end of the new dressing, and (6) clean to at least 2 in beyond the wound margins if a dressing is not being applied.

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. a. "Try to drink at least six to eight glasses of water each day." b. "Try to limit your fluid intake to 1 quart of water daily." c. "Limit sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." e. "Temporarily increase foods containing caffeine for their diuretic effect." f. "Weigh yourself daily and report any changes in your weight."

a, c, d, f. In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. a. Hemostasis occurs immediately after the initial injury. b. A liquid called exudate is formed during the proliferation phase. c. White blood cells move to the wound in the inflammatory phase. d. Granulation tissue forms in the inflammatory phase. e. During the inflammatory phase, the patient has generalized body response. f. A scar forms during the proliferation phase.

a, c, e. Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood components out into the injured area. -White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. -New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. -New collagen continues to be deposited in the maturation phase, which forms a scar.

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? a. Document the findings and continue to monitor the patient. b. Administer antipyretics, as prescribed. c. Increase the frequency of assessment to every hour and notify the patient's primary care provider. d. Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.

a. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. b. Draw the shape of the wound and describe how deep it appears in centimeters. c. Gently insert a sterile applicator into the wound and move it in a clockwise direction. d. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.

a. To measure the depth of a wound, the nurse should perform hand hygiene and put on gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin; and remove the swab and measure the depth with a ruler.

A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply. a. The patient takes time to think about responses to questions. b. The patient is 86 years old. c. The patient reports inability to control urine. d. The patient is scheduled for a hip arthroplasty. e. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL). f. The patient reports increased pain in right hip when repositioning in bed or chair.

b, c, d, f. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. -The skin of older adults is more susceptible to injury; -incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; -hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. -All these factors are related to an increased risk for pressure injury development. -Apathy, confusion, and/or altered mental status are risk factors for pressure injury development. - Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development.

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as: a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

b. A stage 2 pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister.

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? a. Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. b. Keeping fluids readily available for the patient. c. Emphasizing the long-term outcome of increasing fluids when the patient returns home. d. Planning to offer most daily fluids in the evening.

b. Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

The nurse uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound? a. Irrigate the wound. b. Provide gentle cleansing of the wound. c. Debride the wound. d. Change the dressing frequently.

b. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires debridement (removal) before the wound can heal.

A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. a. Notify the health care provider of the situation. b. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. c. Place the patient in the low Fowler's position.

c, b, a. Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position (to prevent further physical damage), cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). Note that the interprofessional team may be completing the activities simultaneously in the clinical setting, but the priority identified above is important to understand.

The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. a. Enhanced healing due to the presence of sugars and proteins b. Delayed healing due to dead tissue present in the wound c. Decreased effectiveness of antibiotics against the bacteria d. Impaired skin integrity due to overhydration of the cells of the wound e. Delayed healing due to cells dehydrating and dying f. Decreased effectiveness of the patient's normal immune process

c, f. Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient -Necrosis (dead tissue) in the wound delays healing. -Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. -Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

c. A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.

A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? a. The therapy is used to collect excess blood loss and prevent the formation of a scab. b. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. c. The therapy provides a moist environment and stimulates blood flow to the wound. d. The therapy irrigates the wound to keep it free from debris and excess wound fluid.

c. Negative pressure wound therapy (NPWT) 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. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? a. "I can expect to have more discomfort in the area where the cold is applied." b. "I should expect more drainage from the incision after the ice has been in place." c. "I should see less swelling and redness with the cold treatment." d. "My incision may bleed more when the ice is first applied."

c. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.

A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? a. PainImpaired b. Skin Integrity c.Disturbed Body Image d. Disturbed Thought Processes

c. Wounds cause emotional as well as physical stress.