Oxygenation/circulation
-bradypnea
-bradycardia
-confusion and stupor
-cyanosis
-hypotension
-cardiac arrhythmias
-metabolic acidosis
late stage hypoxia symptoms
what happens if a wound that is healing via primary intention becomes infected?
it will need to heal via secondary intention
Learning the system, knowing how to correct errors, and maintaining security
challenges of ehr/emr
Widely separated wound is later brought together with some type of closure material; may be closed at a later time; LONG healing time; deep and extensive damage; high risk of infection and dehiscence
tertiary intention (wound healing/closure)
-age
-chronic illness/wellness
-immunity
-nutrition
-perfusion
-weight (obesity)
-chronic stress
-smoking
-wound stress (stress on suture from coughing)
-infection
-med use
-necrosis
-presence of biofilm
-pressure
-maceration
-desiccation
factors that affect wound healing
-tachypnea
-tachycardia
-restlessness
-pallor
-increased BP
-use of accessory muscles
-nasal flaring
-tracheal tugging
-adventitious lung sounds
-dyspnea
early hypoxia s/sx
WBC come to site
-wound will present with pain, heat, swelling, and redness may also see system response from body (elevated temp, increased WBC)
inflammatory stage
maintains PHI among care agencies
HIPPA
Wounds involve tissue loss; edges are approximated; widely separated; healing occurs by secondary intention -from the inside out; longer to heal; increase likelihood of scar; healing time is longer; can see the wound; if there is a chance if infection, they will do this; large wounds, burns, and trauma
secondary intention (wound healing/closure)
-change in surface area (removal of a lung)
-atelectasis (collapse of the alveoli--prevents the exchange of gas by diffusion in the lungs)
-thickening of the membrane (pneumonia, pulmonary edema)
-partial pressure changes (high altitudes=lack of O2)
factors influencing the diffusion of gases in the lungs
immediately after injury; blood clotting, platelets, exudate collect causing swelling and pain
-heat and redness are NORMAL in this stage
hemostasis wound healing stage
date, make corrections promptly, follow procedure for error correction, sign docs with name/title, reflect assessment, interventions, and eval.
legal concepts surrounding the EMR/EHR
Little tissue loss; edges approximate (close); heals rapidly with minimal scaring; low risk of infections; surgical wounds (sutured, staples, steri-strips); if a wound healing via primary intention becomes infected, it will need to heal via secondary intention
primary intention (wound healing/closure)
fluid loss/dehydration
loose skin
perspiration
skin diseases
things that contribute to skin breakdown
-level of health (chronic illnesses)
-development stage
-medication (opioids decrease respiratory drive)
-lifestyles (occupation, smoking)
-environment (pollution)
-psychological health (stress, hyperventilation)
factors affecting cardiopulmonary functioning
replacing lost tissue with connective tissue or granulation tissue
-forms the foundation for a scar
-granulation tissue is beefy red, highly vascular and bleeds easily and very fragile
-needs adequate oxygen and nutrition
-resurfacing of epithelial cells
-collagen synthesis
proliferation phase
confidential, permenant, legal documentation, that is admissible in court
must factual, concise, current, and complete
failure to document is illegal
concepts of the medical record
full thickness skin loss; not involving underlying fascia
stage 3 PU
• Have you developed any new moles or lesions? Have any of the moles or lesions changed in any way (color, borders, size)?
assessment for skin cancer
-use the lowest setting of oxygen to maintain adequate O2 sat
-monitor ABGs
-dc oxygen as soon as possible
-monitor for respiratory distress
-monitor LOC
nursing interventions for safe oxygen delivery
involves strengthening of the scar and resumption of a normal appearance
-can take more than 1 year to complete
-scar is 80% as strong and less elastic than regular skin
maturation phase
a major component of HIPAA that promotes the use of standard methods of maintaining the privacy of protected health information among health care agencies
the Privacy Rule
full thickness skin and tissue loss
stage 4 PU
too dry, drying out
Over hydration
dessication
maceration