Wound Healing Stages PDF

"Care for Patients with Alterations in Skin Integrity Wound Assessment and Prevention Strategies 1\. Describe the stages of wound healing, including the inflammatory, proliferative, and maturation/remodeling stage. (CO1) +-----------------------------------+-----------------------------------+ |...

"Care for Patients with Alterations in Skin Integrity Wound Assessment and Prevention Strategies 1\. Describe the stages of wound healing, including the inflammatory, proliferative, and maturation/remodeling stage. (CO1) +-----------------------------------+-----------------------------------+ | Stages of wound healing | | +===================================+===================================+ | Hemostasis (immediate) | --involved blood vessels | | | initially constrict for blood | | | clotting ̶blood vessels then | | | dilate and capillary permeability | | | increases (exudate) --response: | | | localized pain, heat, redness, | | | swelling | +-----------------------------------+-----------------------------------+ | Inflammatory | Inflammatory phase (lasts 3-6 | | | days) | | | | | | ̶ WBCs (leukocytes, macrophages) | | | move to wound | | | | | | ̶ response: localized (pain, heat, | | | redness, swelling); generalized | | | (elevated temperature, | | | leukocytosis, malaise) | +-----------------------------------+-----------------------------------+ | Proliferative | Proliferation phase (3 -24 | | | days) | | | | | | ̶ new tissue (granulation tissue) | | | built to fill wound space through | | | action of fibroblasts | | | --capillaries grow across wound | | | ̶collagen synthesis and | | | accumulation | +-----------------------------------+-----------------------------------+ | Maturation/remodeling stage | Maturation phase (starts around | | | day 21 & lasts for months to | | | years) | | | | | | --collagen deposited in wound | | | remodeled to make healed wound | | | stronger and more like adjacent | | | tissue | | | | | | --new collagen continues to be | | | deposited | | | | | | --scar tissue | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | Intentional or Unintentional | intentional: created for | | | therapeutic reasons - | | | unintentional: occurs from | | | unexpected trauma - | | | considerations: wound edges, | | | bleeding, risk of infection | +===================================+===================================+ | Open or Closed | -open: skin surface broken, | | | portal of entry for | | | microorganisms; risks: bleeding, | | | tissue damage, infection, delayed | | | healing | | | | | | \- closed: skin surface not | | | broken, soft tissue damaged; | | | risks: hemorrhage, internal | | | injuries | +-----------------------------------+-----------------------------------+ | Acute or Chronic | \- acute: healing time within | | | days to weeks | | | | | | \- chronic: healing time delayed | | | (\>30days) | | | | | | \- considerations: wound edges | | | (approximation), risk of | | | infection | +-----------------------------------+-----------------------------------+ 2\. Identify factors that affect wound healing. (CO1, CO4) +-----------------------------------+-----------------------------------+ | Factors that affect wound healing | **Local (wound)** - pressure - | | | desiccation - maceration - trauma | | | - edema - infection - excessive | | | bleeding - necrosis - biofilm | | | | | | **Systemic (body)** - age - | | | circulation and oxygenation - | | | nutritional status - wound | | | etiology (cause) - medications | | | and health status - | | | Immunosuppression and | | | proinflammatory conditions - | | | adherence to treatment plan | | | | | | **Nutritional Status:** Poor | | | Nutritional Status or Fluid | | | Imbalance Phases of wound | | | healing are slowed or inadequate | | | Proteins, Carbohydrates, Fats, | | | Vitamins, Minerals Protein: | | | Rebuild cells & tissue Serum | | | albumin | | | | | | Age:Increased age delays | | | healing.·Loss of skin turgor·Skin | | | fragility·Decrease in peripheral | | | circulation and | | | oxygenation·Slower tissue | | | regeneration·Decrease in | | | absorption of nutrients·Decrease | | | in collagen·Impaired immune | | | system function·Dehydration due | | | to decreased thirst sensation | | | | | | Overall wellness: A wound in a | | | young, healthy client that heals | | | faster than a wound in an older | | | adult who has a chronic illness | | | | | | Decreased leukocyte count: Delays | | | wound healing because the immune | | | system\'s function is to fight | | | infection by destroying invading | | | pathogens | | | | | | Infection: Prolongs healing and | | | can result in further tissue | | | destruction | | | | | | Some medications | | | (anti-inflammatory and | | | antineoplastic): Interferes with | | | the body\'s ability to respond to | | | and prevent infection | +-----------------------------------+-----------------------------------+ 3\. Demonstrate removal of staples and sutures. (CO4) +-----------------------------------+-----------------------------------+ | Removal of staples | Staples: stainless steel or | | | plastic that close skin incisions | | | in areas hard to stitch or during | | | quickly performed procedures | | | | | | Place the lower part of the | | | sterile staple remover under the | | | center of the staple. Squeeze | | | the handles of the staple | | | remover, which bends the staple, | | | pulling the ends out of the skin. | | | Gently lift the staple out and | | | dispose of it in a biohazard | | | container. Continue removing | | | staples one at a time, working in | | | an alternating pattern (removing | | | every other staple) if instructed | | | to avoid disrupting the wound. | +===================================+===================================+ | removal of sutures | Sutures: black silk, synthetic | | | material, or fine wire that hold | | | tissue and skin together | | | | | | Use sterile forceps to gently | | | hold the knot of the suture. | | | Using sterile scissors, cut the | | | suture just under the knot. | | | Gently pull the suture out in | | | the direction of the knot | | | (parallel to the skin) to avoid | | | reopening the wound. Continue | | | removing each suture one at a | | | time, alternating removal if | | | instructed. | +-----------------------------------+-----------------------------------+ 4\. Differentiate between primary, secondary, and tertiary intentions with wound healing. (CO4, CO5) +-----------------------------------+-----------------------------------+ | Primary intentions with wound | Primary intention | | healing | | | | ̶ wound edges well approximated, | | | skin quickly regenerates | | | | | | ̶ example: intentional wounds with | | | minimal tissue loss | | | | | | · Little or no tissue loss | | | | | | · Edges approximated, as with a | | | surgical incision | | | | | | ·Heals rapidly | | | | | | ·Low risk of infection | | | | | | ·No or minimal scarring | | | | | | Example: Closed surgical incision | | | with staples,sutures, or liquid | | | glue to seal laceration | +===================================+===================================+ | Secondary intentions with wound | Secondary intention | | healing | | | | ̶ wound edges not well | | | approximated, longer healing time | | | | | | ̶ examples: large, open, | | | contaminated wounds (require more | | | tissue replacement); wound | | | healing by primary intention that | | | becomes infected | | | | | | ·Loss of tissue | | | | | | · Wound edges widely separated, | | | unapproximated(pressure injury, | | | open burn areas) Longer healing | | | time | | | | | | ·Increase for risk of infection | | | | | | ·Scarring·Heals by granulation | | | | | | Example:Pressure injury left open | | | to heal | +-----------------------------------+-----------------------------------+ | Tertiary intentions with wound | Tertiary intention (delayed | | healing | primary closure) --wounds left | | | open for several days to allow | | | edema or infection to resolve or | | | fluid to drain, then closed | | | | | | ·Widely separated | | | | | | ·Deep | | | | | | · Spontaneous opening of a | | | previously closed wound | | | | | | · Closure of wounds occurs when | | | they are free of infection and | | | edema | | | | | | ·Risk of infection· Extensive | | | drainage and tissue debris·Closed | | | later·Long healing timeExample: | | | Abdominal wound initially left | | | open until infection is resolved | | | and then closed | +-----------------------------------+-----------------------------------+ 5\. Accurately assess (appearance and drainage) and document the condition of wounds. (CO1, CO4) +-----------------------------------+-----------------------------------+ | Assess (appearance and drainage) | Appearance | | | | | | -location: describe in relation | | | to nearest anatomic landmark | | | ̶measurements: size (length, | | | width, depth -- mm, cm); presence | | | of undermining, tunneling, or | | | sinus tracts | | | | | | -color, odor, approximation of | | | wound edges, wound tissue, and | | | signs of dehiscence or | | | evisceration | | | | | | -presence of medical equipment | | | (drains, tubes, sutures, staples) | | | | | | Drainage (exudate) ̶assess | | | wound, dressing, drain: amount, | | | color, odor, and consistency | +===================================+===================================+ | Document the condition of wounds | Communicates wound status and | | | tracks progression of healing | | | | | | --continuity, evaluation, and | | | changes of wound care | | | | | | --skin and wound assessment | | | tools: record assessment findings | | | and treatment interventions | | | | | | --color photographs of wounds: | | | assessment documentation and | | | measurement of changes | +-----------------------------------+-----------------------------------+ 6\. Describe how to identify wounds related to abuse and neglect. (CO4, CO5, CO6) +-----------------------------------+-----------------------------------+ | How to identify wounds related to | Physical indicators: Bruises, | | abuse and neglect | lacerations, fractures, burns, | | | pressure injuries and grip marks. | | | Sexual abuse: genital injuries, | | | new STDs, and bruises on breasts | | | or buttocks | | | | | | Neglect: dehydration, poor | | | hygiene, inappropriate clothing, | | | poor dental health, and worsening | | | medical conditions | | | | | | **Abuse & Neglect** Common | | | Perpetrators: 90% of abuse cases | | | are committed by family members, | | | and many go unreported. Risk | | | Factors: Caregiver stress, | | | substance abuse, and financial | | | dependence. Interviewing | | | Techniques: use open-ended | | | questions and private | | | conversations. Nursing Actions: | | | Documentation, photography of | | | injuries, and following reporting | | | protocols. | +-----------------------------------+-----------------------------------+ 7\. Identify patients at risk for pressure injury/ulcer development. (CO4) +-----------------------------------+-----------------------------------+ | Patients at risk for pressure | Development of pressure injuries | | injury/ulcer development | | | | --soft tissue compressed between | | | bony prominence and external | | | surface for prolonged time period | | | | | | --soft tissue undergoes pressure | | | in combination | | | | | | with shear and/or friction | | | | | | Effects: discomfort, | | | disfigurement, decreased quality | | | of life, health care expenditures | | | | | | --at risk populations: older | | | adults and patients with spinal | | | cord injuries, traumatic brain | | | injuries, or neuromuscular | | | disorders | +-----------------------------------+-----------------------------------+ 8\. Describe the method of staging pressure injuries/ulcers. (CO4) +-----------------------------------+-----------------------------------+ | Method of staging pressure | Blanching (pale and white) of | | injuries/ulcers | skin area under pressure -- early | | | warning sign of potential injury | | | development | | | | | | --ischemia makes skin appear | | | paler than areas with adequate | | | circulation | | | | | | --pressure relieved: ischemia | | | rapidly followed by hyperemia | | | | | | Pressure injury develops if | | | pressure continues after ischemia | | | occurs | | | | | | --interventions depend on early | | | recognition of stage of | | | development of pressure injury | | | | | | Classification of Pressure | | | Injuries | | | | | | \- partial thickness: all or | | | portion of dermis intact - full | | | thickness: entire dermis, sweat | | | glands, and hair follicles | | | severed (can expose bone, tendon, | | | or muscle) | | | | | | \- unstageable: full-thickness | | | loss where true depth cannot be | | | determined | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | Stage 1 | Stage 2 | | | | | \- intact skin with localized | \- partial-thickness skin loss | | area of nonblanchable erythema | with exposed dermis - presents as | | | shallow, open ulcer OR | | \- may appear differently in | ruptured/intact serum-filled | | darkly pigmented skin - area: | blister | | painful, firm/soft, warm/cool | | | | \- granulation tissue, slough, or | | | eschar not present | +===================================+===================================+ | Stage 3 | Stage 4 | | | | | \- full-thickness skin loss | \- full-thickness skin and tissue | | | loss | | \- presents as shallow or deep, | | | open ulcer with adipose and | \- presents as shallow or deep, | | granulation tissue often present | open ulcer with exposed/palpable | | and visible | fascia, muscle, tendon, ligament, | | | cartilage, or bone | | \- slough/eschar (non-obscuring), | | | undermining, tunneling, epibole | \- slough/eschar (non-obscuring), | | | undermining, tunneling, epibole | +-----------------------------------+-----------------------------------+ | Unstageable Pressure Injury | Deep Tissue Pressure Injury | | | | | \- obscured full-thickness skin | -results from intense and/or | | and tissue loss | prolonged pressure and shearing | | | where bone and muscle interface | | \- extent of tissue damage within | | | ulcer cannot be confirmed because | -presents as persistent, | | it is obscured by slough and/or | nonblanchable deep red, maroon, | | eschar | or purple discoloration of intact | | | or nonintact skin, epidermal | | \- true depth and stage cannot be | separation revealing dark wound | | determined until enough slough | bed, or blood-filled blister | | and/or eschar removed | | | | -area: painful, firm, mushy, | | | boggy, warm/cool | +-----------------------------------+-----------------------------------+ 9\. Identify strategies to prevent pressure ulcers. (CO4, CO5) +-----------------------------------+-----------------------------------+ | Strategies to prevent pressure | Tissue load management | | ulcers | | | | --therapeutic means to manage | | | pressure, friction, and shear | | | | | | -turning and positioning | | | schedules (bed-bound: every two | | | hours, chair-bound: every hour) | | | -positioning devices (pillows, | | | foam wedges, pressure-reducing | | | boots) | | | | | | -support surfaces: pressure | | | redistribution devices (cushions, | | | mattresses, beds) | | | | | | -friction-reducing sheets and | | | lifting devices | +-----------------------------------+-----------------------------------+ Wound Care and Management 1\. Describe the use of drainage systems to promote wound healing. (CO4, CO5) +-----------------------------------+-----------------------------------+ | Use of drainage systems to | Open Drainage Systems Drain | | promote wound healing | into dressings Penrose | | | drain--soft and flexible, no | | | collection device, not sutured in | | | place --empties into absorptive | | | dressing material to promote | | | drainage passively --sterile | | | safety pin attached to outer | | | portion --medical orders may | | | indicate shortening of drain | | | | | | Closed Drainage Systems | | | Drainage tube connected to device | | | to maintain constant low suction | | | --prevent microorganisms from | | | entering wound, usually sutured | | | to skin --allow accurate | | | measurement of drainage --systems | | | emptied and suction reestablished | | | Types --Jackson-Pratt (JP) | | | drains --Hemovac drains | | | | | | Additional Techniques to Promote | | | Wound Healing | | | | | | Negative pressure wound therapy | | | --application of uniform negative | | | pressure on wound bed --promotes | | | healing and closure, reduces | | | bacteria, and removes excess | | | fluid | | | | | | Hyperbaric oxygen therapy | | | --tissues exposed to | | | high-concentration oxygen | | | environment --promotes cell | | | proliferation, blood flow, and | | | enhanced leukocyte action | +-----------------------------------+-----------------------------------+ 2\. Identify the role of proper nutrition in wound healing. (CO1, CO4) +-----------------------------------+-----------------------------------+ | Role of proper nutrition in wound | Proper nutrition plays a crucial | | healing | role in wound healing by | | | providing the essential nutrients | | | required for tissue repair, | | | immune function, and overall | | | recovery. | | | | | | **Protein**: Adequate protein | | | intake is essential for the | | | formation of new tissue and | | | collagen, the protein that | | | provides strength and structure | | | to healing wounds. Protein | | | deficiency can delay wound | | | healing and increase the risk of | | | infection. | | | | | | **Carbohydrates**: Provide the | | | necessary energy for cellular | | | activities during the repair | | | process, including collagen | | | synthesis and immune responses. | | | | | | **Fats**: Healthy fats, | | | particularly omega-3 fatty acids, | | | help modulate inflammation and | | | promote wound healing by | | | supporting cell membranes and | | | energy supply. | | | | | | **Hydration**: Proper hydration | | | is essential for maintaining skin | | | elasticity, delivering nutrients | | | to the wound site, and supporting | | | overall metabolic processes | | | required for healing. | +-----------------------------------+-----------------------------------+ 3\. Describe the importance of serum albumin and protein for wound healing. (CO1, CO4) +-----------------------------------+-----------------------------------+ | Importance of serum albumin and | **Serum albumin** and **protein** | | protein for wound healing | play critical roles in wound | | | healing, particularly due to | | | their influence on tissue repair, | | | immune function, and maintaining | | | fluid balance | | | | | | ### **Serum Albumin:** | | | | | | 1. | | | | | | ### **Overall Protein:** | | | | | | 1. 2. | +-----------------------------------+-----------------------------------+ 4\. Identify common wound dressings, including gauze, sponges, hydrocolloid dressings, and hydrogel. (CO4) Common wound dressings ------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Gauze Woven gauze (sponges): Absorbs exudate from the wound Sponges **Sponge dressings** play a vital role in wound management by absorbing excess fluid, protecting the wound, and creating a moist environment that accelerates healing. The choice of sponge dressing depends on the wound type, level of exudate, and patient needs. Hydrocolloid dressings Hydrocolloid: An occlusive dressing that swells in thepresence of exudate; composed of gelatin and pectin, itforms a seal at the wound\'s surface to prevent evaporationof moisture from the skin.·Maintains a granulating wound bed· Can stay in place for 3 to 5 days Hydrogel Hydrogel: Composition is mostly water. Gels after contactwith exudate, promoting autolytic debridement andcooling. Rehydrates and fills dead space. Might require asecondary occlusive dressing.·For infected, deep wounds or necrotic tissue·Not for moderately to heavily draining woundsProvides a moist wound bedSoothing and can reduce wound painPrevents skin breakdown in high-pressure areas(the sacrum) Nonadherent material Nonadherent material: Does not stick to the wound bedDamp to damp 4-inch by 4-inch dressings:Used tomechanically debride a wound until granulation tissuestarts to form in the wound bed. Must keep moist at alltimes to prevent pain and disruption of wound healing Surgical/ abdominal pad Surgical or abdominal pads are essential dressings for managing large, heavily draining wounds, particularly after surgeries or for abdominal trauma. Their ability to absorb significant exudate while providing protection and comfort makes them invaluable in both hospital and home care settings. Alginate Alginates: Nonadherent dressings that conform to thewound\'s shape and absorb exudate·Provides a moist wound bed·Packs wounds·Supports debridement Transparent film Self-adhesive, transparent film:A temporary"secondskin" ideal for small, superficial wounds Collagen Collagen:Powders, pastes, granules, sheets, gels, andpastes·Helps stop bleeding·.Promotes healing 5\. Demonstrate proper technique in wound cleansing. (CO4, CO5) +-----------------------------------+-----------------------------------+ | Proper technique in wound | Approximated Edges | | cleansing | | | | Clean from the Center Outward: | | | | | | Start at the center of the wound | | | and clean outward toward the | | | edges, using a sterile gauze pad. | | | Clean in one direction, moving | | | from the least contaminated | | | (center) to the more contaminated | | | (outer) areas. Use a new gauze | | | pad for each outward stroke to | | | avoid contaminating the wound | | | | | | Unapproximated edges | | | | | | Clean in a Circular Motion: | | | | | | Start from the center of the | | | wound and move outward, using a | | | circular or spiral motion. | | | Cleanse gently to avoid | | | disturbing any healing tissue or | | | causing further damage. Use a | | | fresh gauze pad for each circular | | | motion or swipe | +-----------------------------------+-----------------------------------+ 6\. Develop teaching for patients and caregivers to care for pressure injuries/ulcers and wounds at home +-----------------------------------+-----------------------------------+ | Teaching for patients and | General guidelines Pressure | | caregivers to care for pressure | injury prevention and care | | injuries/ulcers | terminology, risk factors, | | | pressure injury development, and | | Wounds at home | prevention strategies | | | instructions: hand hygiene, | | | appearance of skin, dressing | | | changes, signs/symptoms of | | | infection, follow-up | | | appointments, nutrition and | | | elimination habits, | | | activity/mobility, and pain | | | management | +-----------------------------------+-----------------------------------+ 7\. Identify strategies to practice and advocate for cost-effective care (CO2, CO6) ------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Strategies to practice and advocate for cost-effective care Promote preventative care oHealth screenings oHealth education Optimize resource utilization oReduce unnecessary interventions oEfficient use of supplies Implement evidence-based practice Coordinate care across disciplines Patient-centered care and shared decision-making Continuing education for nurses Advocate for access to care ------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 8\. Identify complications of wounds, including dehiscence, evisceration, hemorrhage, and infections. (CO4) +-----------------------------------+-----------------------------------+ | Complications of wounds | | +===================================+===================================+ | Dehiscence and Evisceration | Dehiscence and evisceration | | | | | | --dehiscence: partial or total | | | separation of wound layers | | | | | | --evisceration: complete | | | separation of wound with | | | protrusion of viscera through | | | incision | | | | | | --nursing interventions: place | | | patient in low - Fowler's | | | position, cover with sterile | | | nonadherent dressing moistened | | | with sterile 0.9% sodium chloride | | | solution, notify health care | | | provider immediately, do not | | | leave patient unattended | | | (abdominal wound -- medical | | | emergency) | +-----------------------------------+-----------------------------------+ | Hemorrhage | Hemorrhage | | | | | | --excessive bleeding (trauma, | | | slipped suture, dislodged clot, | | | infection, erosion of blood | | | vessel by foreign body) | | | | | | --internal hemorrhage: formation | | | of hematoma, pressure on | | | surrounding blood vessels (tissue | | | ischemia) | | | | | | --nursing interventions: apply | | | pressure or packing, clean wound | | | and apply/check dressing, | | | administer fluid replacement and | | | medications, prepare for surgical | | | intervention | +-----------------------------------+-----------------------------------+ | Infections | Infection | | | | | | --immune system fails to control | | | growth of microorganisms | | | | | | --symptoms: drainage and foul | | | odor, pain, redness, and swelling | | | increased body temperature and | | | WBC count, delayed healing, | | | discoloration of granulation | | | tissue | | | | | | nursing interventions: clean | | | wound and apply dressing, | | | administer antimicrobials and | | | other medications, manage | | | symptoms | +-----------------------------------+-----------------------------------+ 9\. Describe proper applications and associated benefits of heat (moist and dry) and cold therapy (moist and dry). (CO4) +-----------------------------------+-----------------------------------+ | Proper applications and | Dry Heat | | associated benefits of heat | | | (moist and dry) | \- types: hot water bags, hot | | | packs, electric heating pads, | | | aquathermia pads | | | | | | \- considerations: avoid lying or | | | leaning on equipment, cover with | | | protective cloth, set timer for | | | prescribed length of application | | | | | | \- disadvantages: burns, changes | | | in sensation, electric shock, | | | leaking, pain, redness | | | | | | Moist Heat | | | | | | \- types: warm compresses, sitz | | | baths, warm soaks - | | | considerations: maintain constant | | | temperature, set timer for | | | prescribed length of application | | | | | | \- disadvantages: dripping, | | | evaporation, rapid cooling | +===================================+===================================+ | Proper applications and | Dry Cold | | associated benefits of cold | | | therapy (moist and dry) | \- types: ice bags, cold packs, | | | hypothermia (cooling) blankets | | | | | | \- considerations: cover with | | | protective cloth, set timer for | | | prescribed length of application | | | | | | \- disadvantages: continuous | | | monitoring (hypothermia | | | blankets), leaking, numbness, | | | pain, skin irritation | | | | | | Moist Cold | | | | | | \- type: cold compresses | | | | | | \- considerations: maintain | | | constant temperature, set timer | | | for prescribed length of | | | application | | | | | | \- disadvantages: dripping, | | | evaporation, rapid warming | +-----------------------------------+-----------------------------------+ 10\. Identify risk factors associated with heat and cold therapy. (CO4) +-----------------------------------+-----------------------------------+ | Risk factors associated with heat | ### **Heat Therapy Risks** | | and cold therapy | | | | 1. 2. 3. 4. 5. | | | | | | ### **Cold Therapy Risks** | | | | | | 1. 2. 3. 4. 5. | +-----------------------------------+-----------------------------------+ Medical and Surgical Asepsis 1. +-----------------------------------+-----------------------------------+ | Medical asepsis (Clean Technique) | Purpose: To reduce the number | | | and spread of microorganisms. | | | | | | Application: Used in everyday | | | patient care, such as | | | administering oral medications, | | | cleaning wounds, and performing | | | non-invasive procedures. | | | | | | Practices: Hand hygiene | | | (washing hands before and after | | | patient contact). Wearing | | | gloves when handling body fluids. | | | Cleaning equipment and surfaces | | | with disinfectants. Proper | | | disposal of contaminated | | | materials (e.g., using biohazard | | | bags). | | | | | | Examples: Bathing patients, | | | changing bed linens, taking vital | | | signs. | +===================================+===================================+ | Surgical asepsis (Sterile | Purpose: To completely eliminate | | Technique) | all microorganisms from an area. | | | | | | Application: Used in invasive | | | procedures and surgeries, where | | | there is a high risk of | | | infection. Practices: | | | Sterilizing instruments and | | | materials. Wearing sterile | | | gloves, gowns, and masks. | | | Creating a sterile field and | | | ensuring nothing non-sterile | | | comes into contact with it. | | | Using antiseptic solutions to | | | clean the skin before invasive | | | procedures. | | | | | | Examples: Inserting catheters, | | | dressing wounds post- surgery, | | | performing surgeries | +-----------------------------------+-----------------------------------+ 2. +-----------------------------------+-----------------------------------+ | Proper set up of a sterile field | -Open the covering if the package | | | per the manufacturer's direction, | | | slipping the packages onto the | | | center of the workspace with the | | | top flap on the center of the | | | workspace with the top flap of | | | the wrapper opening | | | | | | -Grasp the tip of the top flap of | | | the package, and with the arm | | | positioned away from the sterile | | | field, unfold the top flap away | | | from the body | | | | | | -Next, open the side flaps, using | | | the right hand for the right flap | | | and the left hand for the left | | | flap | | | | | | -Grasp the last flap, and turn it | | | down toward the body | +===================================+===================================+ | The addition of sterile materials | -Open next to the field by | | to a sterile field | holding the bottom edge with one | | | hand and pulling back on the top | | | flap with the other hand. Place | | | the packages that will be used | | | last furthest from the sterile | | | field; open these first | | | | | | -Add them directly to the sterile | | | field. Lift the package from the | | | dry surface, holding it 15 | | | cm(6in) above the sterile field, | | | pulling the two surface apart, | | | and dropping it onto the sterile | | | field | +-----------------------------------+-----------------------------------+ | Pouring sterile solution | -Remove the bottle cap | | | | | | -Place the bottle cap face up on | | | a clean (non-sterile) surface | | | | | | Hold the bottle with the label in | | | the palm of the hand so that the | | | solution does not run down the | | | labe | | | | | | -First pour a small amount(1 to 2 | | | ml) of the solution into an | | | available receptacle | | | | | | -Pour the solution (without | | | splashing) onto the dressing or | | | site without touching the bottle | | | to the site (at least 4in) | | | | | | -Sterile solutions expire 24hr | | | after opening and recapping in | | | some facilities. Other facilities | | | policies state that once a | | | sterile solution container is | | | opened, it can be used only once | | | and then must be thrown away | +-----------------------------------+-----------------------------------+ Care for Patients with Alterations in Mobility 1. +-----------------------------------+-----------------------------------+ | Proper applications and | Dry Heat | | associated benefits of heat | | | (moist and dry) | \- types: hot water bags, hot | | | packs, electric heating pads, | | | aquathermia pads | | | | | | \- considerations: avoid lying or | | | leaning on equipment, cover with | | | protective cloth, set timer for | | | prescribed length of application | | | | | | \- disadvantages: burns, changes | | | in sensation, electric shock, | | | leaking, pain, redness | | | | | | Moist Heat | | | | | | \- types: warm compresses, sitz | | | baths, warm soaks - | | | considerations: maintain constant | | | temperature, set timer for | | | prescribed length of application | | | | | | \- disadvantages: dripping, | | | evaporation, rapid cooling | +===================================+===================================+ | Proper applications and | Dry Cold | | associated benefits of cold | | | therapy (moist and dry) | \- types: ice bags, cold packs, | | | hypothermia (cooling) blankets | | | | | | \- considerations: cover with | | | protective cloth, set timer for | | | prescribed length of application | | | | | | \- disadvantages: continuous | | | monitoring (hypothermia | | | blankets), leaking, numbness, | | | pain, skin irritation | | | | | | Moist Cold | | | | | | \- type: cold compresses | | | | | | \- considerations: maintain | | | constant temperature, set timer | | | for prescribed length of | | | application | | | | | | \- disadvantages: dripping, | | | evaporation, rapid warming | +-----------------------------------+-----------------------------------+ 2. +-----------------------------------+-----------------------------------+ | Risk factors associated with heat | ### **Heat Therapy Risks** | | and cold therapy | | | | 6. 7. 8. 9. 10. | | | | | | ### **Cold Therapy Risks** | | | | | | 6. 7. 8. 9. 10. | +-----------------------------------+-----------------------------------+ Promoting Healthy Sleep Patterns 1\. Describe the sleep cycle and the amount of sleep needed by adults. (CO4) +-----------------------------------+-----------------------------------+ | Sleep cycle and the amount of | Sleep Cycle: NREM 4 stages 4-5 | | sleep needed by adults | cycles per night Cycle lasts | | | about 90-110 minutes Cycle lasts | | | longer as morning approaches | | | Deep sleep occurs in Stages III | | | and IV in the first half of the | | | night | | | | | | Requirements: Recommended: | | | Adults: 7+ hours/day Older | | | Adults: 7-9 hours/day | +-----------------------------------+-----------------------------------+ 2\. Identify common sleep disturbances, including insomnia, sleep apnea, and narcolepsy. (CO4) +-----------------------------------+-----------------------------------+ | Common sleep disturbances | | +===================================+===================================+ | Insomnia | Insomnia is a common sleep | | | disorder that makes it difficult | | | to fall asleep, stay asleep, or | | | get quality sleep. | | | | | | ### **1. Acute Insomnia** | | | | | | - - - | | | | | | ### **2. Chronic Insomnia** | | | | | | - - - | | | | | | ### **3. Intermittent Insomnia** | | | | | | - - - | +-----------------------------------+-----------------------------------+ | Sleep apnea | Sleep apnea is a sleep disorder | | | characterized by repeated | | | interruptions in breathing during | | | sleep. The two main types are: | | | | | | ### **1. Obstructive Sleep Apnea | | | (OSA)** | | | | | | - - - | | | | | | ### **2. Central Sleep Apnea (CSA | | | )** | | | | | | - - - | +-----------------------------------+-----------------------------------+ | Narcolepsy | Narcolepsy is a chronic | | | neurological disorder | | | characterized by excessive | | | daytime sleepiness and sudden | | | sleep attacks | | | | | | #### **1. Excessive Daytime Sleep | | | iness (EDS)** | | | | | | - - | | | | | | #### **2. Cataplexy** | | | | | | - - | | | | | | #### **3. Sleep Paralysis** | | | | | | - - | | | | | | #### **4. Hypnagogic Hallucinatio | | | ns** | | | | | | - - | | | | | | #### **5. Disrupted Nighttime Sle | | | ep** | | | | | | - | +-----------------------------------+-----------------------------------+ | Hypersomnolence | Hypersomnolence, or | | | hypersomnolence disorder, is | | | characterized by excessive | | | sleepiness during the day, | | | despite getting a full night\'s | | | sleep. | | | | | | #### **1. Excessive Daytime Sleep | | | iness (EDS)** | | | | | | - - | | | | | | #### **2. Napping** | | | | | | - - | | | | | | #### **3. Sleep Quality** | | | | | | - - | +-----------------------------------+-----------------------------------+ 3\. Identify factors that interfere with sleep. (CO4) ----------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Factors that interfere with sleep Developmental Considerations Motivation Culture Environmental Factors Illness Medications Lifestyle & habits Physical Activity & Exercise Dietary Habits Smoking ----------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 4\. Identify non-pharmacological interventions to promote sleep. (CO4)" ---------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Non-pharmacological interventions to promote sleep Limit alcohol, caffeine, & nicotine at least 4 hours before bedtime Limit fluids 2-4 hours before bedtime Complete physical activity 3 hours before bedtime Establish a bedtime routine & regular sleep pattern Personal hygiene routine Engage in muscle relaxation Relaxing activities Reading, listening to soft music, talking to a family member, praying, aromatherapy ---------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Shallow wounds are more painful due to nerves Packing the wound helps with removal of dead tissues With wound infections, only a doctor a assessed and treat