Exam 4 Study Guide

Wounds
 Stage 1: Pressure injury
- The only stage where there’s no opening in the skin.
- Nonblanchable redness discoloration of the skin that does not turn white when pressed
- Darker skin – may appear blue/purple

 Stage 2: Pressure injury

- Skin is not intact but shallow, no visible bone
- Partial thickness loss of dermis
- No fatty tissue is visible
- Superficial ulcer

 Stage 3: Pressure Injury

- Skin is not intact
- Full thickness skin loss
- Damage to subQ of tissue (cell damage of fat)
- No bone, muscle or tendon exposed
- Ulcer extend down to the underlying fascia but not through it
- Deep crater w/t or w/o tunneling

 Stage 4: Pressure Injury

- Skin is not intact
- Full thickness tissue loss
- Destruction of tissue
- Bone, muscle, or tendon exposed
- Deep pockets of infection & tunneling

 Deep Tissue Injury (DTI)

- Skin is intact (Unbroken)
- Tissue beneath the surface is damaged
- Appears purple or dark red

 Unstageable
- Stage cannot be determined due to eschar (black, brown necrotic tissue) or slough
covering the visibility of the wound

 What’s important for wound healing?

- High protein intake
 - Adequate hydration
- good nutrition
 Wounds; Healing Process
Primary Intention
- Little or no tissue loss
- Heals rapidly
- Low risk of infection
- No or minimal scarring
Example: closed surgical incision w/t staples
Secondary Intention
- Loss of tissue
- Wound edges widely separated
- Longer healing time
- Scarring
- Heals by granulation
- Un approximated (pressure injury open burn areas)
Example: Pressure injury left open to heal
Tertiary Intention
- Widely separated
- Deep
- Risk of infection
- Closed later
- Longer healing time
- Extensive drainage and tissue debris
Example: Abdominal wound initially left open until infection is resolved and then closed.

 Classifications of Wounds
- Open/closed - wound open, break in skin. Abrasions, lacerations, puncture wounds, and
surgical incisions.
- Acute/Chronic - acute wounds are short duration, they heal spontaneously w/o
complications in a healthy person. Chronic wounds => wounds that exceed the expected
length of recovery.
- Clean/Contaminated/Infected - clean = uninfected, minimal inflammation.
Contaminated = open, traumatic wounds, major break in asepsis occurs. The risk for
infection is high. Infected => when bacteria count in wound tissue is above 100,000
organisms per gram of tissue.
 - Superficial/partial or full thickness – superficial wounds = only epidermal layer of the
skin. Injury due to friction, shearing or burning. Partial-thickness wounds = extend into
the subQ tissue and beyond.
- Penetrating – indicated the wound involved internal organs.
 What’s the difference b/t Dehiscence vs. Evisceration?
Dehiscence:
- Rupture (separation) of one or more layers of a wound.
- Most likely to occur in the inflammatory phase of healing.
- An increased risk occurs from incisions that begin draining within 5-7 after surgery.
- Causes: poor nutritional status | wound infection | increased tension on the suture line | Obesity
- Associated with abdominal wounds
- Patients would report feeling “pop” or tear w/t sudden straining – coughing, vomiting, standing,
changing positions.
Nursing Interventions: Dehiscence
- Notify provider of dehiscence ASAP
- Maintaining bedrest w/t head of bed elevated at 20 degrees and knees flexed
- Applying a binder, to prevent evisceration

vs.
Evisceration:
- A total separation of the layers of a wound w/t internal viscera protruding through the incision.
(Surgical Emergency!!)

Nursing Interventions: Evisceration

- Immediately cover the wound w/t sterile towels or dressings soaks in sterile saline to prevent
organs from drying out & becoming contaminated w/t environmental bacteria.
- Have the patient stay in bed w/t knees bent to minimize strain on the incision
- Do not put binder on the patient
- Notify the surgeon and ready the patient for surgery

 Braden Score
- Predicts the chances of developing a pressure sore
- The higher the score the better
- Look at: sensory perception, moisture, activity, mobility, nutrition, friction & shear.
High risk: 18 or less
Moderate Risk: 19 – 21
Low Risk: 22 – 23
 Major Cultural Groups
Judaism: against suicide, no post-modem care, only kosher food & they support organ donation.
Islamic: no pork, or pork by products, only eat meat from animals sacrificed in the name of
Allah, no abortions, no end-of-life care (palliative care)
Christianity: from Ash Wednesday – 40 days period fasting. (Sundays are excluded)
Buddhism: Believes illness is from nonhuman spirits invading body. No euthanasia, see meds as
harmful, prefer treatment from health care worker of the same gender, some are vegetarians, fast
on holy days, prefer death to occurs at the home, body must be prepared by a male, allow
cremation, mourners may only touch head and stand nearby praying no touching body.
Asian: disrespectful to look in the eye while they are talking.
 Cultures
Socialization – learning to become a member of a society or a group
Acculturation – learning process through which immigrants assume the characteristics of that
culture.
Assimilation – Occurs when new members gradually learn and take on the essential values,
beliefs and behaviors of the dominant culture.
Ethnocentrism – tendency to think that your own group is superior to others and view beliefs that
differ from your own as wrong.
Dominant Culture – The group that has the most authority or power to control values, and reward
or punish behaviors.
Subcultures – groups within a larger culture or social system that have some characterisits that
are different from those of the dominant culture.
Minority Groups – mad eup of individuals who share race, religion, or ethnic heritage.
 Scientific method + Evidence based practice
Scientific process steps:
- select & define the problem
- Select research design
- Collect data
- Analyze data
- Use the research findings
 What do you do if a patient speaks a different language?
- Call for a translator

 What does the nursing research and evidence based practices always concern?
- To improve healthcare quality and improve patient outcomes.

 What’s evidence based practice to a nurse?

-
  Maslow's Hierarchy of Needs

 Erikson 8 stages of development

1. Trust vs. Mistrust – 0-18 months – safety w/t mother, trust in environment and caregiver
2. Autonomy vs. Shame & doubt – 18 mo. – 3 yrs – independent from parents
3. Initiative vs. Guilt – 3-6yrs – purpose, ability to start activities and goals. Exploring.
4. Industry vs. Inferiority 6-12 yrs – school age – competence in intellectual, social, and
physical skills
5. Identity vs. Role confusion – 12-18 yrs – adolescence – fidelity, fitting into the world as
own person.
6. Intimacy vs. Isolation – 19-40yrs – Early adulthood – Love, finding & losing self in
others & career.
7. Generativity vs. Stagnation – 40-65 yrs – Adulthood – Care guidance & teaching new
generation
8. Ego Integrity vs. Despair – 65 years+ – Maturity – Wisdom fulfillment & satisfaction.

 Causes of death for each age groups

Newborn -
- Automobile accidents
- Falls
- Burn
- Chocking
- Drowning
- SIDs
Toddlers -
- Drowning
Pre-schoolers -
- Poisoning
  Physiological Developmental stages
Infants & Toddlers - Walking,
- Taking solid foods
- Talking, controlled bowel
- Bladder elimination
- Learning sex differences
- Sexual modesty
- Acquiring psychological stability
- Forming concept; Learning language
- Getting ready to read
Preschool & School Age - Learning physical skills necessary for
ordinary games
- Looking to get along with age-mates
- Achieving personal independence

 Developmental Changes in Older Adults -

Musculoskeletal Decreased muscle strength, body mass, bone mass, increased fat deposit
Cardiovascular Decreased cardiac output, Increased peripheral resistance,
Respiratory Decreased elasticity of chest wall, Intercostals muscle strength, cough
reflex
Gastrointestinal Decreased saliva production, GI motility, gastric acid production
Integument Decreased skin elasticity, nail growth, Increased dryness of skin, nail
thickening, hair thinning
Genitourinary Decreased glomerular filtration rate, Blood glow to kidneys, bladder
capacity, vaginal lubrication, hardness of erection.
Nervous Decreased nerve cells, neurotransmitter, REM sleep, blood flow to CNS
Endocrine Decreased insulin release, thyroid function, estrogen and testosterone
Sensory Decreased visual acuity, changes in pain sensation
Cognition Decreased short-term memory, Increased reaction time
Personality Increased cautiousness Retirement, Widowhood, Grandparenthood

Health risk for young adults -

- Sexually Transmitted infections
- Substance abuse
- Obesity
- Unplanned pregnancies
- Traumatic injuries
- Suicide attempts
- Domestic violence
  How to adjust nursing care for younger adults?
 Normal sensory changes in older patients
 How to approach a patient who is taking herbal medicine?

 Tactile Deficit - Alteration in the ability to feel & interpret touch, pressure, temperature
- Exercise Promotion – Strength Training
- Exercise Therapy: Balance
- Peripheral Sensation Management
- Change position often to relieve pressure on bony prominences
- Report signs of impaired circulation
- Inspect for wounds, abrasions, erythema

 Gustatory Deficit – lack of sense of taste | Causes nutritional deficit and weight loss
- Environmental Management: safety
- Feeding
- Nausea Management
- Nutrition Management

 Sensory Deprivation
- Encourage patient to do as much self-care as possible
- Using physical exercise & additional stimulation by means of a telephone, radio, or Tv.
 Sensory Overload
P – Population/patient - “Do“
I – Intervention/indicator - “Who are”
C – Comparison/Control - “Demonstrate”
O – Outcomes - “as compared to”
T – Time - “During”
Cellulitis
- A bacterial infection of the skin & subQ tissue usually following a break in the skin.
(lower extremities)

- Complications: Bacteremia | Osteomyelitis |

- Therapies: antibiotics (penicillin)

Dermatitis
- Nursing diagnosis: Impaired skin integrity

- Nursing Interventions: apply topical lubricants after bathing, avoid aggravating factors,
Bathe using lukewarm water and mild soap.
 - Goals: To restore the normal skin barrier and protect the skin from another occurrence.
Data base – clinical guidelines – are there to provide a basis for sound clinical practice guidelines
and recommendations.
Santyl ointment:
- Used to remove damaged tissue from chronic skin ulcers and severe burned areas.
- Slight redness may occur in places outside of the wound area.
- Common side effects: pain/burning at the affected area.