Wound Drainage Assessment
Clear or amber; thin and watery
Serous drainage
Pink, pearly white;
wrinkled when touched
Epithelial Tissue
Nonblancheable (does not turn white w/ pressure)
Erythema caused by pressure typically over bony prominence
Stage 1
What is nectar thickened
Thicker than water, can be sipped through a straw
Which drug increases insulin sensitivity
Biguainide class
Metformin
Reddish, thin and watery
Sanguineous
Red & moist; bleeds easily
Granulation tissue
Full thickness tissue loss w/ exposed muscle or bone; possibility of undermining or tunneling; sometimes eschar
Stage 4
What is dysphagia
Difficulty swallowing
What is the biggest risk for a patient taking Warfarin?
Bleeding
Clear, pink, thin, watery
Serosanguineous
Yellow, brown, or gray;
made of dead cells or debris
Slough Tissue
Full thickness tissue loss w/out exposed muscle or bone
Stage 3
When someone has dysphagia, what are nursing considerations while feeding.
Note for pocketing of food
Ensure pt is awake, alert
Pt is in an upright position
don't rush!
Alternate solids and liquids
Oral care
Important patient education detail for someone on Levothyroxine
Take in a.m. on empty stomach, 60 min before coffee or breakfast
Opaque, yellow, green, or milky
"pus"
Purulent
Hardy, dry, and black
prevents further healing
Necrotic Tissue
partial thickness skin loss with visible injury or fluid filled blister
Stage 2
What is Enteral Nutrition
Providing nutrition through GI tract via a feeding tube
Common side effect of Albuterol
slight tremor
Increased heart rate
Reddish, milky, and viscous
(mixture of blood and pus)
Hemopurulent
Red, uneven, overgrowth of tissue
Hyper Granulating Tissue
How do we help prevent pressure ulcers
4 methods
Heel protectors/ egg crate cushions - redistribute weight
Low air-loss mattress - provides air flow
Air fluidized beds surface - redistributes weight
Lateral rotations
Nursing considerations for feeding with a PEG tube
Before opening feeding tube or removing syringe, clamp or kink tube so stomach contents do not come out.
The higher you hold syringe, the faster it goes in - be careful.
Important side effect and patient education regarding
Doxycyline
photosensitivity
can get sunburned
wear sun block