Wound Care
Define:
Granular tissue
Slough
Necrotic tissue
new cells move to wound bed; red, delicate tissue
yellow, stringy tissue
result of cell death; black tissue
what might you use secondary tubing for?
electrolytes and IVPB medications (may need to back-prime tubing)
signs of a not working gut
- absent or hypoactive bowel sounds
- constipation
- distention
- gastroparesis
- vomiting
position for male catheter insertion
supine
give an example of a Hypotonic and Hypertonic enema
hypo: tap water enema
hyper: fleet enema
for what type of wound would you use a foam dressing? (ie Mepilex)
drainage: minimal to heavy exudate
wounds: post-op and traumatic wounds, minor burns, diabetic ulcers, pressure ulcers, venous insufficiency ulcers
give a brief description of:
infiltration
phlebitis
extravasation
inadvertent leakage of non vesicant IV solution into surrounding tissue - insertion site will appear swollen and cool to touch
inflammation of the wall of the vein - reddened streak along the vein may be visualized and will feel warm to touch
inadvertent leakage of vesicant IV solution into surrounding tissue
potential complications from enteral feedings
- aspiration
- migration/dislodgement
- gastric intolerance (feeding intolerance)
- clogged tubing
- skin breakdown
- infection
- dumping syndrome
position for female catheter insertion
dorsal recumbent
what should you do if you meet resistance when admin a large volume enema
slow down rate of solution, allow some to flow, have pt take deep breath and try again
purpose of heat and cold therapy
heat: increase blood flow, reduce muscle tension, relieve pain, increased O2 and nutrients to area, venous congestion decreased, increased cap permeability, prolong clotting time
cold: constricts periph blood vessels, reduces muscle spasms, promote comfort, decreases release of histamine/serotonin/bradykinin, facilitate control of bleeding, reduce edema formation, alter tissue sensitivity
recognize s/s of:
sepsis
speed shock
air embolism
extremity fluid overload
breathlessness, fever, AMS, clammy skin, increased HR
flushed face, headache, tight chest, irregular pulse, LOC, edema in extremities and face, cramping/bloating, HTN, dyspnea, tachycardia
sudden headache, slurred speech, gait imbalance, vertigo, dyspnea, chest pain, confusion
rapid weight gain, edema in extremities and face, swelling in abdomen, cramping, SOB, HTN, dysrhythmias
how long should you listen when confirming absent bowel sounds?
additional 2 mins per quadrant
when might you suspect the need to irrigate a catheter?
clots in collection bag, not draining, bladder scanned for significant volume but no output, bladder distended
how does stool from an ileostomy differ from a colostomy
ileostomy stool will be more of a liquid consistency
[RYB classification]
give a brief summary of interventions indicated by color of wound bed
red: protect (keep wound bed moist to facilitate formation of granulation tissue)
yellow: cleanse (must remove slough and exudate to promote healing)
black: debride (for wounds to begin to heal non-viable tissue must be removed)
how to prevent or minimize infection risk related to IV therapy
- keep IV spike and connection port sterile
- always clean with alcohol before accessing ports
- change tubing per protocol
- assess IV site regularly
when should you flush for intermittent and continuous feedings?
intermittent: after checking residual and after feedings
continuous: every 4-6hrs
*flush with 30-60 mL of water or sterile saline
to what point do you insert a male catheter?
to the Y fibrication
how should the pt clean the skin around their stoma
soap and water - dry COMPLETELY
give a brief description of the 5 pressure injury stages
1: intact skin with localized area of non-blanching
2: partial thickness loss of skin, wound bed is pink or red, moist (exposed dermis)
3: full-thickness loss of skin, adipose is visible with granulation tissue and rolled wound edges
4: full thickness skin and tissue loss with directly palpable fascia, muscle tendon, ligament, cartilage, or bone
5: unstageable: full thickness loss of skin and tissue loss where extent of damage cannot be confirmed - obscured by slough or eschar
what is the IV gravity flow rate equation
flow rate (drops/min) =
[VTBI * drop factor] / [time in mins for infusion]
interventions upon excessive gastric residuals
- check tube placement
- check tube patency
- check pt position
- check bowel sounds and distention
to what point do you insert a female catheter
once you see urine return, advance another 2-3 inches
how will you know if vagal nerve stimulation has occurred during digital removal of stool
drop in HR- stop immediately (check HR and BP)