Wound Care
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Describe the differences in wounds healing by primary, secondary and tertiary intention; and the phases of wound healing o Wound- disruption of the integrity and function of tissues in the body; can be partial thickness (epidermis)- shallow, heal w/ regeneration or full thickness (dermis)
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Acute/trauma OR Chronic/DM
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Clean- no trauma, inflammation i.e. abrasion
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Clean-contaminated- surgical, uncomplicated
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Contaminated- trauma and complicated i.e. MVA, fistula
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Dirty- infected & purulent o
Wound Healing process
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Hemostasis by epinephrine
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Inflammatory response
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Proliferation, granulation (red beefy tissue and contraction ) & epithelialization
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Maturation/Remodeling migration from margins to center & reestablishment of epidermal layers w/ collagen increased tensile strength, but scar is only 80% strength of surrounding tissue o Primary Intention- closed wound, i.e. surgical incision, stapled or sutured, heals w/ epithelialization, quickly, minimal scarring o
Secondary Intention- edges not approximated, left open until fills w/ scar tissue move base of wound bed up i.e. pressure ulcers, surgical wounds w/ tissue loss, heal w/ granulation, contraction then epithelialization o Tertiary Intention- wound left open for several days, then edges are approximated, i.e. contaminated wounds requiring observation, closure is delayed until infection risk subsides
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Describe complications of wound healing and the usual time of occurrence o Hemorrhage w/i 24-48 hrs signs: low BP, inc HR, inc RR, low pulse ox, alt LOC s/s: distension, bruise, swelling, tender, hard abdomen. Cause: suture break, dislodged clot, FB erodes vessel, infection o
Infection 2-3 days post op to 30 days s/s: purulent, fever, tachycardia, warm, inc WBCs, red odor. @ risk if imunocompromised, dirty wound. 2 nd most common HAI o Dehiscence 3-11 days wounds breaks open i.e. surgical incision s/s: inc drainage @ risk if obese d/t fat o Evisceration dehiscence w/ bowel in wound total separation & protruding organs. Emergency, call doc, NPO * o Fistula abnl connection causes: radiation, Chron’s, pocket of fluid @ risk if dehydrated
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Explain the factors that impede or promote wound healing o Promote- young, good nutrition, low fat, edu, vascularity, drugs, o Impede- chronic dz, altered O2, DM, immobility, smoke, ETOH, infection
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Identify different types of wound drainage, wound drainage systems and how to empty a wound drainage device o Serous-clear, purulent-yellow green brown, serosaginous-pink watery red, sanguineous-dark red bleeding
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Should stop after 3 days, no odor, necrosis, edges should epithelialize o Use medical asepsis to empty & COCA
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Jackson-Pratt- inside wound & compressed drain w/ constant suction, Hemovac, Penrose
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Identify various types of dressings, their purpose, and how to apply and secure various types of dressings o Purpose- protect, hemostasis, healing, thermoregulation, aesthetic o Primary layer- contact w/ wound, absorbent layer, secondary layer- outer, protection layer ABD pad o
Moist- promote granulation o Wet to dry- debridement, remove FB o Dry- protection o Telfa- protect and won’t stick to wound o
Transparent- moist environment, visual, barrier and breath o Hydrocolloid- adhesive, molds to wound, auto debridement o Hydrogel- debride, sooth and reduce pain, conforms to wound size
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Determine what is appropriate and inappropriate to delegate regarding dressing changes and wound management o Apply supportive device, appearance, level of pain, drainage, mobility level
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Discuss the risks and contributing factors to pressure ulcer formation o Shearing forces, bony prominence, pressure, low blood flow, low mobility, elderly, low sensation, altered LOC, incontinence, poor nutrition, chronic dz
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List the four stages of pressure ulcers o Stage I- redness w/ skin intact, non blanching o Stage II- partial thickness o
Stage III- full thickness o Stage IV- full thickness with bone, tendon and muscles visible o Unstageable- cannot see wound bed
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Identify prevention strategies for pressure ulcers o @ risk population, assess skin (Norton or Braden scale), attention to pressure points, document, no delegation, edu
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Sterile Technique

o Medical asepsis- “clean” , hand hygiene, standard precautions V.S surgical asepsis- sterile & eliminate
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Skin cannot be sterilized
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Flap away, banana peel, don’t reclose, don’t reach over, drop from 6 in o Sterile touch sterile, only sterile on field, out of vision or field is contaminated, prolonged exposure to environment is contaminated, moisture son field is contaminated, fluid flows down, 1 inch border unsterile
Ostomies
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List medical conditions requiring ostomy surgeries o Colon, bladder or rectal CA, IBD, Chron’s, ulcerative colitis, defects, trauma, perforation, MS
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Review the major parts of the GI and GU systems and their functions o
LI- absorbs water, secretes bicarbonate and K+, eliminate waste o SI- reabsorb nutrient and electrolytes o Anus- release feces and flatus o Stomach- store, mix and empty food, HCL for digestion, mucus for protection and pepsin for protein, Vit B12 o Kidney- filter o Ureter- bring urine to bladder o Bladder- store urine o Urethra- expel urine
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Discuss the different kinds of ostomies o Can be temporary or permanent o Colostomy- large intestine brought to stoma i.e. ascending & transverse (liquid/semi solid, gas and odor) OR sigmoid & descending (semi-formed to solid, gas, odor o Ileostomy- small intestine brought to stoma liquid or paste, containing digestive enzymes, no odor, 500-750mL output, NO irrigating o Urostomy/ureterostomy-ureters brought to stoma i.e. ileal conduit usually stoma on right, may contain mucus.
Hematuria expected 24-48 hours after surgery.
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Identify possible stomal and peristomal skin problems and management o NL: budded 1 in, red, moist, painless, bleeds easily, no voluntary control, edema x 6-8wks o ABNL: dark red, purple, black, dry, excess blood in stool, stomal separation, infection, excoriation of health skin
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Discuss the preoperative and postoperative care of the patient undergoing bowel surgery o Pre op- edu, ET nurse consult, stoma selection, NG tube, bowel prep o Post op- assess dressing, stoma, output (function 2-4days later), skin integrity, pain, empty before ¼ to ½, home health, fluid and electrolyte balance
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List products used in ostomy pouching o Flat wafer for firm abdomen or convex wafer for soft abdomen with folds, one or two piece pouches with closed or drainable ends, barrier paste or powder, skin prep, belt @ 9:00-3:00 to support bag
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Discuss steps and teaching involved in care of stoma/ostomy o Balanced, low fiber diet, 8 glasses H2O (no straw, chewing gum, talking while eating/drinking) o 5-6 small meals/day o 1 new food @ a time
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Lists foods that can cause odor, gas, and blockage for patients with ostomy o Gas- broccoli, beans, fried, greasy, cauliflower o Odor- asparagus, brussel sprouts, onions
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Decrease odor-parsley, tomato, yogurt, OJ, spearmint, buttermilk o
Blockage from high fiber- seeds, nuts, popcorn, hot dogs
Bowel Elimination
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Discuss normal age-related changes in the GI tract o
Infant- small stomach capacity, less enzymes, food passes quickly, rapid peristalsis, unable to control elimination
(neuromuscular dev’t @ 2-3yrs) o Elderly- decreased chewing & salivation, reduced esophageal motility in lower 1/3, reduced stomach secretions
(mucus, acid), delayed gastric emptying, low vit B12 absorption, reduced absorption in SI, increased pouches and diverticulosis, LI constipation, missing defecation signals causing incontinence, decreased liver size (low protein synthesis)
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Discuss physiological /psychological factors that influence the elimination o Hydration (1400-2000ml), fiber for bulk, dietary intolerance (lactose, gluten), celiac dz, privacy, personal habits, physical limitations, comorbidities, medications and Polypharmacy
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Describe the nursing implications for common diagnostic examinations of the GI tract o Fecal occult blood- hemoccult or blood in stool o Blood tests
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Pancreatic dz- elevated amylase
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Carcino-embryonic antigen
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Liver dz- elevated bilirubin, alkaline phosphate

o Radiology, Barium swallow/enema, ultrasound, CT, SRI, enteroclysis o
Endoscopy- oral, esophagus, stomach o Colonoscopy- rectum to LI o Sigmoidoscopy
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Describe common physiological alterations in elimination and care to clients with alterations in bowel elimination o
Constipation- infrequent, hard, diff elimination. Causes: inadequate diet, fluids, chronic dz, laxative abuse, bad bowel habits
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Avoid straining post op because inc IOP and ICP o Impaction- unrelieved constipation s/s distention, dec appetite. Digital removal may stimulate CNX, need an order. o
Diarrhea- inc # of stool and liquid. @ risk for impaired skin integrity and fluid/electrolyte imbalance
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Clostridium difficile- acute, profuse, watery stringy stools secondary to disrupted flora r/t antibiotics. Treat w/ Vancomycin o Incontinence- unable to control passing feces. Causes: muscle/neuro, low sensation, chronic constipation
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Nursing implications- routines, stool softeners, warm fluids, activity, assess skin o Flatulence- gas accumulation o Hemorrhoids- painful, swollen veins in anus.. Causes: inc venous pressure, pregnancy, straining
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Discuss indications for a NG tube; the various types of NG tubes; and how to insert and maintain an NG tube for gastric decompression o Indications- decompression, compression, lavage, enteral feedings, med admin o Contraindications- head, face, neck or nose surgery or hx of alcoholism o D/C NG tube- verify order, assess for bowel sounds*, turn off suction, pt should hold breath o
Types
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Salem Sump- gastric decompression & lavage, double lumen, doesn’t stick to gastric mucosa, air vent
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Levin Tube- gastric decompression & enteral feeding, single lumen, no pigtail air vent
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Sengstaken-Blakemore Tube- balloons in esophagus and stomach to stop bleeding o Insertion: measure nose to earlobe to xiphoid
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mark it
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sit up 45 degrees
 nares
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turn 180 degrees
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pass nasopharynx
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swallow
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pass through esophagus
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stomach
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x-ray
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aspirate & measure pH nl<4
 auscultate
 elevate above stomach
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NPO & monitor I/O
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assess nares, GI and resp status
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Discuss indications and proper method of administering a cleansing enema o Indications- promote defecation after constipation, impaction or surgical prep o Isotonic o Hypertonic- H2O from tissue into feces promoting defecation o Hypotonic-H2O absorbed into tissue from feces solidifying stool o Soap suds o Oil retention- adds lubrication o Medicated *cannot delegate
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Kayexalate treats hyperkalemia
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Neomycin reduces bacteria prior to surgery
Nutrition
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Carbs & protein- 4kcal/g, fat=9kcal/g, 60-70% H2O in body, ADE&K=fat soluble vitamins, C&B complex= water soluble vitamins
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Breast feed until 4-6mos then introduce cereal (most imp non milk source of protein)
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Discuss nursing diagnoses related to nutritional problems o Risk for aspiration o Diarrhea o Deficient knowledge
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Medication interactions:
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> Appetite- steroids, antidepressants, antipsychotics
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< Appetite- Theophylline, digitalis
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Altered med absorption- diuretics
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Coumadin- vit K
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Grapefruit o Imbalanced nutrition: less/more than body requirements o
Risk for imbalanced nutrition: more than body requirements o
Readiness for enhanced nutrition o Feeding self-care deficit o Impaired swallowing o @ risk population is the elderly d/t
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GI changes, chronic dz, meds, alt in nutritional needs, cognitive alterations, social and financial changes
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Compare and contrast various therapeutic and diet progressions o High fiber, LAS/NAS, low cholesterol, diabetic, regular, snap

o Adaptations for clients with DM, HTN, cardiac dz, GI malabsorption
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Discuss the nursing care for the client with dysphagia o Difficulty swallowing d/t neuro, myogenic, obstruction
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@ > risk if low LOC, no gag reflex, no cough reflex, unmanageable saliva
 s/s: cough, vocal change, grimaces, throat clearing, runny nose, tears, > secretions, pocketing
 complications- aspiration, pneumonia, dehydration, weight loss, impaired nutritional status o Clear liquid
 full liquid
 puree
 mech soft
 soft/low residue or advanced
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regular o Thin
 nectar
 honey
 spoon thick liquids
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Compare and contrast various types of gastro-intestinal tubes o
Naso-enteric/Nasogastric Tube- nares to stomach, short term o Naso-intestinal Tube- nares to intestine, risk for aspiration o Percutaneous Endoscopic Gastrostomy (PEG)- percutaneously placed through abd wall into stomach, long term o Jejuenostomy Tube- surgically connecting jejunum to abd wall via stoma o Percutaneous Jejeunostomy Tube- percutaneously placed through abd wall into jejunum, long term o Feeding port for meds and food, flange attaches to skin, inflated balloon inside pt
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State the indications for enteral nutrition o
Supplemental or primary nutrition, physiologically efficient, less expensive, ease of delivery, cancer, GI dz, inadequate intake, dysphagia, trauma, neruo/muscular disorders
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Discuss EBP to determine NG tube feeding tube placement o Ask pt to talk, inspect pharynx for coils, x-ray, air bolus, aspirate, measure pH, gastroccult o
Verify before feedings (continuous or intermittent) and med admin
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Describe the risks and complications of enteral feedings o Aspiration pneumonia, diarrhea, constipation, cramps, delayed gastric emptying (ck residual), fluid/electrolyte imbalances (overload or dehydration), tube obstruction, tube displacement
Urinary Elimination
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Bladder capacity 600mL, 150-200mL=urge to void can ignore it (voluntary), nl=1200-1500mL/day
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Identify factors that commonly influence urinary elimination and common GU alterations o
Acute: Dehydration, obstruction, acute blood loss, hypovolemia shock, o Chronic: HTN, DM, kidney dz o Neuromuscular: MS, Parkinson’s, spinal injury o Continence: dementia, Alzheimer’s, decreased sensation
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Pre-renal- impaired blood flow to kidney
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Renal-kidney dz (dialysis and transplant)
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Post-renal- obstruction, trauma to urinary tract, BPH, UTI
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*Hemolytic uremic shock starts as GI then goes to kidney and causes end stage renal dz/ ESRD
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Meds: diuretics > urine, antihistamines retain urine, anticholinergics help w/ retention BUT cause overflow retention
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Privacy, ETOH, caffeine, anxiety, stress
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Explain how to obtain a nursing history for a client with urinary elimination problems o
Hx: factors affecting output i.e. pregnancy, obesity, episiotomy, trauma; void patterns i.e. frequency and changes, physical assessment (hydration, flank pain, distention discharge), lab values >BUN and creatinine =impaired renal fx
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Describe characteristics of normal and abnormal urine o
Dysuria- difficulty o Hesitancy- hard to start flow o Nocturia- at night o
Polyuria- a lot of voiding episodes o Anuria- no urine o Frequency- how often o Hematuria- blood in urine o
Retention- holding in urine and can’t fully empty o Incontinence- inability to control voiding; involuntary o Oliguria-decrease in urinary output o Dribbling- if have retention they overflow or release a little at a time o Stress incontinence- sneezing, coughing, lifting can cause incontinence
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Specimen collection o 30-60mL, < 30 mL/hr =abnl, >500-1000mL @ time of cath insertion=abnl o COCA o
U/A- clean container, nl void, <2 hrs old, 1 st void in a.m., dipstick, CAN delegate o Clean catch- “mid stream”, sterile container o C&S- straight cath, indwelling cath, clean catch

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Specific gravity b/w 1.005-1.030 concentration of urine compared to = vol of H2O
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Hematuria- anticoagulants, UTI
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Describe the nursing implications of common diagnostic tests of the urinary system o Consent, allergies to shellfish/iodine, dye into veins, I/Os, client edu, fluid restrictions,
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Identify nursing diagnoses appropriate for clients with alterations in urinary elimination and measures to promote normal micturition and reduce episodes of incontinence o Disturbed body image o Urinary incontinence o
Functional, stress, urge, overflow o
Pain o Risk for infection o Toileting self-care deficit o Impaired skin integrity o Impaired urinary elimination o Urinary retention
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Promote micturition: edu, maintain nl elimination, adequate fluids, complete bladder emptying, acidify urine (cranberry’s flavonoids)
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Discuss nursing measures to reduce urinary tract infection o UTI- bacteria/E.coli in ascending urethra, *most common HAI (40%) o Hand hygiene, peri care 4in <q8h, sterile tech, nurse, promote micturition
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Explain technique for inserting and caring for sterile urinary catheters, and how to obtain urine specimens o Condom cath- non invasive, external, spontaneous complete bladder emptying o Straight cath- single use for intermittent bladder drainage o Indwelling- remains in place, continuous drainage, empty q8h
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Coude tip- stiff, easy to guide, less trauma
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French tip: Infant 5-6, child 8-10, young female 12, women 14-16, men 16-18 Fr
Oxygenation
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Intrapleural pressure is less than atmospheric pressure (760 mm Hg) Air to flow into the lungs when IPP is more – causing a pressure gradient. Inspiration is active & stimulated by chem receptors, expiration is passive o Ventilation- gas into/out of lungs o Perfusion- CV sys pumps O2 blood into tissue and back to lungs o Diffusion- gas exchange in alveoli and capillaries; slowed by thick membranes in COPD pt
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Hemoglobin carries O2 (97%) and CO2
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During cardiopulmonary arrest
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C.B.A. (compression x30, airway x3 breaths, breathing)
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4 factors influencing oxygenation
1.
Physiological- dec O2 carrying capacity, hypovolemia (low blood flow = low O2), dec inspired O2, inc metabolic rate, pregnancy, obesity, neuromuscular dz, musculoskeletal abnl, trauma, CNS changes, chronic dz
2.
Dev’t- infacts get URI & congestion; school-age get 2 nd hand smoke and exposure to infections, young/middle-age adults have lack of exercise, stress, smoking, OTC and drugs; elderly-calcification of valves, SA nodes, costal cartilages, OP, atherosclerosis, enlarged alveoli, trachea and bronchi, TB test is UNreliable
3.
Lifestyle- nutrition, exercise, smoking, drugs, stress, birth control,
4.
Environment- smog, urban areas, occupation (asbestos)
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Hyperventilation- ventilate in excess to eliminate CO2. Eliminating CO2 faster than it’s produced by cellular metabolism.
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Hypoventilation- inadequate alveolar O2. Book: Administration of excess oxygen.
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COPD: O2 >24-28% (1-3L/min) is BAD bc accustomed to high CO2 levels & pt stops breathing
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Hypoxia- inadequate tissue oxygenation @ cellular level (can cause cyanosis
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late sign of hypoxia)
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Causes: anemia, CO2 poisoning, septic shock, cyanide, atelectasis, trauma (head/spine), cardiomyopathy o Spirometry measures the volume of air entering or leaving the lungs.
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Identify nursing care interventions in the primary care, acute care, and restorative and continuing care settings that promote oxygenation. o Primary care: Vaccinations (Flu: >6mos, chronic dz, imunocompromised), eliminate risk factors, reduce exposure to environmental pollutants, exercise, reduce occupational hazards (mask) o
Acute care: hydration, humidification, nebulizer, RT, CPT o Restorative: controlled physical exercise, nutrition counseling, relaxation and stress-management techniques, and prescribed medications and oxygen

Identify clinical indications that suggest the need for oral or tracheal suctioning. o Inc vital signs, dyspnea, adventitious sounds dec O2 sat, behavior change, pallor/cyanosis, secretions (nasal, oral, vomitus)

o Risks: can lower O2 sat, reduce O2, hypoxemia, hypotension, irritate mucous membranes, arrhythmias, bronchospasms, gagging, aspiration o Oro/naso-pharyngeal suctioning when can cough (oro) w/o expectoration, non-sterile o Oro/naso-tracheal suctioning when can’t cough, sterile

Identify 3 parts of a tracheostomy tube. o
Outer cannula- keep stoma open, NEVER REMOVED, secure w/ ties o Inner cannula- removed for cleaning, disposable o Obturator- used to insert trach tube, ALWAYS KEEP AT BEDSIDE

Differentiate between cuffed and uncuffed tracheal tubes. o
Cuffed- inflated in trachea to hold position; prevent aspiration, ck pressure (nl=20mmHg) to avoid over inflation o Uncuffed- no inflatable portion in trachea used in children

Discuss safety precautions for the client with a tracheostomy. o
Replacement tube nearby, obturator at bedside, O2 and manual resuscitator, assistance to change ties o Emergency: HELP, HOB 45 degrees, Obturator into new trach/dislodged trach, lubricate, insert at 45 degrees, if unsuccessful put suction cath into stoma for air entry OR bag valve mask w/ stoma covered
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Explain sterile open tracheal suctioning *check off*
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Differentiate between various oxygen delivery masks and describe proper use and remaining interventions to promote oxygenation. o Face mask- short term 35-50% FiO2
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Reservoir/partial non rebreather requires 6-10L/min to avoid inhaling CO2 40-70% FiO2 w/ bag 1/3 to ½ full
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Non rebreather w/ 1 way valves removes CO2 minimum 10L/min 60-80% FiO2 o Nasal cannula- 4L/min up to cL/min 20-40%FiO2 q8h assess nares for breakdown >4L/min causes drying need humidifier o Venturi mask- 24-55% FiO2 2-14L/min w/ flow control meter