Tissue Integrity
Primary lesions
Secondary lesions
intentional wounds
unintentional wounds
and their examples
What are common alterations to skin integrity?
-includes macules, patches, papules, nodules, tumors, vesicles, pustules, bullae, wheals
-changes to primary lesions
-venipuncture, surgical incision
-trauma
a persistent curiosity and desire to learn and ask questions
What is Spirit of Inguiry?
A nursing care plan
What is a guideline that organizes information about and individual or family plan of care?
control severe bleeding, prevent infection, control swelling and pain, and assess for shock with severe or internal bleeding
What are the guidelines for an untreated wound?
sensory perception, moisture, activity, mobility, nutrition, friction and shear
What are the categories of the Braden scale?
A way to identify new knowledge, improve professional education and practice, and use resources effectively.
What is the purpose and benefit of nursing research?
elements of evidence-based research
What is the abstract, introduction, literature review, clinical article, nursing research, outcomes research, and scientific method?
modifiable skin risk factors
What are impaired peripheral artery circulation, corticosteroids, poor nutrition, multiple wounds, hypoxia, tissue necrosis, and foreign bodies in a wound?
Pressure ulcer nursing diagnosis and prevention
strong current evidence, client perspectives, clinical expertise
What are the three components of evidence-based practice?
characteristics of servant leadership
What are listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to other's growth, and community builders
nursing diagnosis for skin integrity alterations
What is impaired skin integrity, infection, imbalanced nutrtion, risk for compromised dignity, low self esteem?
complications of wound healing and their signs and symptoms
hemorrhage (bleeding at site, hematoma, shock)
infection (change in wound color, pain, or drainage, culture confirmed, fever and elevated WBC)
dehiscence (rupture of sutured wound)
evisceration (protrusion of internal viscera through incision)
Evidence based practice vs research vs quality improvement
What is the difference between using info from research to determine safe, effective nursing care with the goal of improving patient care and outcomes vs systematic inquiry to answer questions and solve problems or contribute to general knowledge base without the specific goal of improving patient care, vs improving local work processes to improve patient outcomes and health system efficiency but not usually for a generalizable result.
the guidelines for writing a nursing plan of care
customize plan to patient cultural and spiritual preferences
preventative and restorative care aspects included
ongoing assessment aspects included
collaborative practices
plans for discharge and health teaching needs
must be dated, signed, have nursing process for headings, shrt specific and concise, approved abbreviations, and use facility resources. Initiated on admission and constantly being revised as needed.
polymeric, films(if superficial)
hydrocolloid
foams
alginate, hydrofiber
hydrogels
What are the different types of semiocculsive dressings for wound with:
mild exudate,
abrasion/burn/postop/pressure injury,
mild to moderate exudate,
moderate to high exudate,
and dry wound or deb-rid necrosis/eschar? (respectively)
Stage 1, stage 2, stage,3, stage 4, and unstageable
what is nonblanchable erythema w/ skin intact, partial thickness skin loss (dermis) open ulcer, full thickness skin loss deep crater and subcut tissue damage, full thickness skin loss with exposed muscle tendon or bone, and full thickness tissue loss with slough or eschar obscuring depth.
Steps of evidence based practice (including PICOT)
0.cultivate spirit of inquiry
1. ask clinical PICOT (population, intervention, comparison, outcome, time)
2. search for most relevant evidence
3. critically appraise evidence
4. integrate evidence w/ clinical expertise and pt preferences and values
5. evaluate outcomes of practice decisions or changes
6. share outcomes with others
formats for developing a plan of care
What is a colomn plan where top row shows nursing process and columns outline specific findings for each nursing process aspect.
What is a concept map where a key is used to outline shapes and colors used, client name is centered on the paper, significant assessment cues are given their own boxes to find priority nursing diagnosis, priority nursing diagnosis is added in its own box and lines are drawn to connect each topic.
What is a clinical pathway (type of standardized plan) where it is organized by day and timeframes and include multidisciplinary team or organized by risks/diagnosis for protocols.
risk factors other than pressure injury for neonates and children, older adults, immobility/paralysis, obesity, cancer, and chronic illness/other conditions.
skin tears, diaper rash
itchy dry flaky skin, skin infections and tears
skin tears and infection, incontinence-associated dermatitis
skin tears, diabetic ulcers, moisture lesions, skin-fold rashes
delayed wound healing, skin infections, radiation-induced dermatitis
skin tears and infections, moisture associated lesions