Skin and Wound Assessment

Skin and Wound Assessment Notes

• Minimum skin assessment is once per day; high-risk patients require assessment every four hours.
• Assess bony prominences like heels and elbows and skin around devices.
• Note whether the skin is blanchable or non-blanchable
• Moisture is a primary cause of decreased skin integrity.
• Darker skin may not visibly blanch; inflammation may appear purplish or blue.
• Assess wound location, depth, tissue involvement, dimensions (L, W, depth, undermining), exudate, periwound, and drains in a well-lit area.

Color or Appearance

• Granulation tissue indicates healthy, normal healing.
• Slough is white-yellow and stringy and must be removed.
• Eschar is a scab that must be removed, except on the foot, where it protects thin skin.

Exudates

• Serous exudate consists of clear, watery plasma.
• Purulent exudate indicates infection and is thick, yellow, green, or tan.
• Serosanguineous exudate is blood mixed with plasma; pale and watery.
• Sanguineous exudate indicates acute bleeding; bright red.

Wound Classification

• Primary intention wounds are closed with sutures or staples and heal quickly with minimal scarring.
• Secondary intention wounds have edges that cannot be approximated due to tissue loss or contamination and heal with granulation.
• Tertiary intention wounds are left open for several days and then approximated; closure is delayed due to infection risk.

Stages of Wound Healing

• Hemostasis is the initial stage involving blood loss control.
• The Inflammatory stage occurs within 24 hours, activating inflammatory responses with mast cells and WBCs.
• The Proliferative stage lasts 3-24 days, involving angiogenesis, filling with tissue, resurfacing, and epithelialization.
• Maturation can take over a year.

Wound Complications

• Hemorrhage is a potential complication; check for internal blood pooling.
• External hemorrhage is more easily detected.
• Infection is a risk in any wound.
• Dehiscence is when a wound pulls apart.
• Evisceration is the protrusion of organs, most commonly the intestine, requiring covering with sterile wet gauze and immediate surgical notification.

Pressure Ulcers

Stage 1

• Non-blanchable redness
• Intact skin
• Warmth and hardness

Stage 2

• Skin loss limited to dermis
• Shallow open ulcer with shiny bed
• No slough or bruising and blistering

Stage 3

• Full-thickness skin loss involving to subcutaneous fat
• No visualized bone, tendon and muscle are not present.
• Slough may be present.

Stage 4

• Deeper tissue loss
• Exposed, palpable bone, tendon, or muscle
• Undermining and tunneling due to pressure
• Risk of osteomyelitis

Unstageable Pressure Ulcer

• Obscured, requiring debridement

Suspected Deep Tissue Injury

• Localized purple or maroon area with intact skin
• Caused by soft tissue damage from pressure or shear force
• Depth unknown

Factors Affecting Wound Healing

• Adequate protein and caloric intake
• Tissue perfusion
• Absence of infection
• Age/comorbidities
• Psychosocial well-being

Patient Care

• Cultures before dressings
• Bed and chair support surfaces
• Wound irrigation, if needed
• Abdominal splinting
• Elevate the bed to max 30 degrees
• Turn the patient every 1.5 to 2 hours for lateral position, every 15 mins for upright position

Wound Management

• Schedule around current pain regime
• Moist dressings for dry wounds + gauze/saline
• Dry dressing for moisture wicks
• Self Adhesive dressing for moisture control
• packing is for those tunnelling
• Use analgesic at least 30 minutes prior
• Clean gloves for old dressings, clean gloves for the wound
• Use non-cytotoxic cleaning solution
• Never use the same gauze twice
• Sterilize and least contaminate areas prior

GI Intubation and Nutrition Notes

Diet & Health History During nutritional assessment

• Review nutrition knowledge to tailor education.
• Social history is taken as well to determine things that are in the pt's control vs not
• Sociocultural and socioeconomic factors are assessed
• Monitor nutrition with a 3-7 day food diary

Religious Restrictions influence Diet

• No pork, alcohol, caffeine is restricted in Islam. You must practice Ramadan fasting
• Some Christians practice minimal alcohol, or fast during Lent/ meatless Fridays
• Hinduism prevents eating meat
• Judaism does not allow park or dairy products
• Latter day saints exclude caffeine, alcohol consumption

Types of Therapeutic Diets

• Clear Liquid: clear/fat-free broth, tea, and jello
• Full Liquid: anything smooth eg ice cream and pudding
• Pureed/thick: foods scrambled, mashed meats/pots
• mechanical soft: ground meat, cheese, rice
• Soft/Low Residue: low fibre foods, pasta
• high fibre: raw fruits, steamed veg
• low-sodium: 4g/2, 1g limits
• Low cholesterol: 300mg
• Diabetic: balances of carbs, fats and protein

Dysphagia Notes

• Dysphagia means difficulty in swallowing

• Caused by disorders obstructing the upper and lower portions of the throat Warning signs of dysphagia:

• Coughing during eating

• Change in voice tone

• Abnormal tongue/mouth

• Slow, weak speech Be aware of aspiration

• Aspiration risk include those with a poor gag reflex, and suction at bedside

Dysphagia management

• Upright seated position
• Tuck chin in
• Position in stronger side of mouth- unilateral weakness
• Feed in 0.5/1 teaspoon

GI Intubation

Types:

• Naso(gastric, jejunostomy, duodenal, permanent tubes) Indications: (enteral feeding, decompress, lavage(irrigating)

GI Feeding Safety

Placement: pH or chest XR Discomfort: oral care Procedure: high fowler Meaure: nose to earlobe to xiphoid process to sternum Coughing? stop feeding

Gastric Notes

• if over 500ml or 250ml, stop feeding!
• check every 4hrs

Respiration & Oxygenation Notes

Factors Affecting Oxygenation

Physiological

• Decreased oxygen carrying (anemia)
• Decreased inspired oxygen (hypoventilation)
• Neuromuscular disorders

Development

• Infants and toddlers with immature immune system
• Adolescents with smoking habits
• RI in older adults

Assessment History Inspection

Level of Consciousness Earliest sign: restlessness Wall movement with use of muscle usage Tripod position with hands on thighs Nail clubbing means it's late

• kussmaul- metabolic acidosis
• Cheyne-strokes, apneas and brain injury

Pleuritic Chest Pain

• Sharp knife in the chest while breathing

Airway Management

• Coughing and suction
• Hydration
• Humidification to prevent mucosa from drying out Necessary for patient getting 4L of oxygen

Airways

Open airways for those getting surgical procedures

Lung Expansion Promotion

Semi-Fowlers Encourage deep breathing

Oxygen Delivery

• Nasal Cannula: 6,24 (flow and range), humidifiers required
• Simple Face: 4,40 CO2, retention contraindicated, no more than 2L
• non breather: minimum 10, valve between the bag prevents released air.
• venturii: 24, depends on setting

Respiratory disorders

• Atelectasis: deep breathing
• Asthma: triggers, wheezing, chest

Legal & Ethics Notes

Ethical Principles

• Autonomy: independence, patient choice
• Beneficence: promote health, patients rights
• non-maleficence. Do no har
• Justice: fairness of treament
• Fidelity: Keep promises

Nursing Actions for Ethical Duties

• Respect all obligations and follow patients, respect, advocate, answer etc
• Protect client info

delegation

• Only give people things you are 100 percent certain they can carry out

Scope of Practice UAP: (VS, ROM and Urine Spec) LVN: Everything that UAPs can do while adding dressing changes and medication RN: Nursing process and development of care Student: No phone or written orders

Hypertension and Vital Signs Notes

• Cardiogenic risk factors linked to high BP include heart rate, contractility, and conductivity

• Sympathetic Nervous System in relation to high BP is due to Adrenergic receptors

Factors that contribute and don't are

• age, gender, ethnic are unmodifiable
• diet, alch, smoking are modifiable

Electronic BP measurements:

• if any irregularity or low value, avoid.
• Cuff should fit and line the forearm
• take 3 heart rate readings, positive if: heart rate increases or mmHg decreases
• if arm is above the heart it underestimates.
• repeat the high
• smoking results in vasoconstriction

Fluid & Electrolytes Notes

Electrolytes and Normal Ranges

• Sodium: 135-145, prevalent in ECF
• Chloride: 98-107
• Pottasium: 3.5-5 mEq/L
• calcium and ionized 4.5 for calcium
• phosphate and magnesium 2.5

Osmolality: water and tonicity

• imbalance result in:
• volume isotonic
• hyper and hypo natremai /volemic

Hyponatermia Causes

• diuretics, burns and vomiting and dehydration, signs: (seizures, lethargy, muscle

Hypernatremia Causes

• diarrhea and diuretics signs: (seizures, arrhythmia)

Potassium Imbalance

• Kalemia: 3.5-5 mEq/I

Signs and symptoms of hyperkalemia: abdominal cramps, anxiety, diarrhea, muscle

• force K+ from the cell. Prevent

Signs and symptoms of hypokalemia: muscle, constipation, weak

• NEVER BOLUS

Calcium level: 8.6-10.2

Signs of hypercalcemia: constapation, N/V

• give diuretic for calcium execess

Signs of Hypo:

• spasms, trousseau's sign

Magnesium Level: 1.5

Signs of hyper low respiration rate

signs of level

• dyspepsia and high blood pressure
• avoid for people on Admin: glocunate