I'm Smart
20 on the braden scale is what level of risk?
low risk
What is the difference between an actual and potential nursing diagnosis?
actual is something they are currently experiences
potential is something that could occur
Ex. Acute Pain VS Risk for impaired skin integrity
disruption in skin integrity
wound
how do you insure pt privacy?
Making sure those in the room are appropriate, following HIPAA, closing doors/curtains
dressing type for IV
transparent
Locations to develop pressure injuries
genetalia, coccyx, ears, nares, head, shoulder, hip, back, heels, sacrum, elbow
dry, leathery, tan layer of dead tissue
eschar
How do you create an advance directive?
Have social work be involved, the RN can't witness the signing of the paperwork
Stages of Wound healing
hemostasis
inflammatory
proliferation
maturation
Name 3 ways to prevent pressure injuries
Turn every 2 hours, keep skin dry, avoid wrinkly sheets, change incontinence pads frequently, assess pressure points, roll from side to side, adequate fluid and nutrition, use specialty devices and mattresses
Nurse role in a hemmhorrage
Direct Pressure, Fluids, O2, Prepare for OR
one layer slides over another layer
Shearing
S/S of infection
Purulent Drainage, Necrotic Tissue, Erythema, Increased Warmth, Edema, Pain, Odor, Drainage, Inc WBC count
Name 2 ways a wound can be closed
sutures
staples
steristrips
adhesive glue
What are nursing considerations with cold therapy
Assess integrity, sensation, temperature, and color of the skin. Negative signs: mottling, broken skin, can they feel it?
Leave cold packs in place no longer than 20 to 30 minutes.
Use a barrier between ice pack and skin
Assess for pallor or mottling every 10-15 minutes
Evaluate the effects of the cold therapy.
what are risks for heat injury?
appendicitis, bleeding wound or injury, newly injured joints, large areas on cardiac patients, peripheral neuropathy
Risk factors for pressure injuries
Age, Immobility, malnutrition, incontinence, spinal cord injuries, traumatic brain injuries, neuromuscular disorders, tissue compression, ischemia
Name 3 functions of the skin
Protection, Body Temp Regulation, psychosocial, sensation, vitamin d production, immunologic, absorption, elimination
What's the difference between Hemovac, Jackson-Pratt, and Penrose Drain?
Hemovac- closed drain with larger output
JP Drain- closed drain with smaller output
Penrose- open drain with minimal output
Name 4 factors that can affect wound healing.
Pressure, Desiccation, Maceration, Trauma, Edema, Infection, Excessive Bleeding, Necrosis, Biofilm, Age, Circulation, Oxygenation, Nutritional Status, Wound Etiology, Medications, Health Status, Immunosuppression, Adherence to treatment plan
What are the steps to empty a JP drain?
Wash hands and put on Gloves
Strip the tubing
Empty the bulb
Compress the bulb and recap
Measure drainage and note amount/color
Remove gloves and wash hands
Describe the 4 stages for pressure injuries
Stage 1: nonblanchable erythema of intact skin
Stage 2: partial-thickness skin loss with exposed dermis
Stage 3: full-thickness skin loss; not involving underlying fascia
Stage 4: full-thickness skin and tissue loss- bone showing
A wound dehisced- what does the RN do?
Call for help
Sterile gauze with NS
Relieve pressure off wound
Prepare for OR
what is the difference between primary, secondary, tertiary intention wound healing
primary- edges remain close together, clean wound
secondary- wound gaping, granulation occurs
tertiary- purposely left open to heal
Name 5 types of wounds
Incision- surgical
Contusion- blunt instrument, closed
Abrasion- top layer of skin abraded
Laceration- Tearing of the skin
Puncture- puncturing skin
Penetrating- Foreign Object entering the skin and lodging
Avulsion- Tearing structure from normal anatomic position
Chemical- toxic agents
Thermal- high or low temperatures
Irradiation- UV or Radiation Exposure
Pressure Ulcers- compromised circulation due to pressure
Venous Ulcers- poor venous return
Arterial Ulcers- underlying conditions
Diabetic Ulcers- Underlying diabetic disease process