Fundamentals session 7:

Hey guys, here is session 7 of the fundamentals lecture. It is the beginning of the test four material and covers, skin therapy with wound assessment, and urinary elimination techniques. Nice and quick with out to much to trip up on.

Thanks for reading!

-Peter

Skin integrity and wound healing

beginning of test 4 material

Session 7

Skin is the largest organ in the body

  • epidermis
  • Dermis
    • where the hair anchors to
    • the sweat gland starts in the mid bottom of the dermis
    • vascularity though the dermis
    • beefy red and wet wound is superficial dermal
    • pink red and less wet to dry wound is deep dermal
  • Subcutaneous

Assessment

  • color, vascularity, turgor, lesions

History

  • Age, diagnosis, DM, moisture(fecal or urinary incontinence), smoker(slow angiogenesis and vessel atrophy), nutrition(decent protein and water intake, zinc and vit C), perfusion assessment (ABI), mobility (bedridden), nasal cannula,

inspection of skin

  • jaundice will be seen in eyes first
  • erythema: palpate and inspect, temp, and blanch, erythema will blanch
  • assess on admission, when bathing, and moving

excoriation

  • abrasion or scration mark, uneven and red

Skin lesion

  • elevation- flat, raised, pedunculated
  • size in cm
  • exudate – drainage, from the white cells that were cleaning the wound
    • clean with NS or water, if infected the smell will not go away
  • chronology of appearance, and change in morphology
  • infected wounds hurt in a specific location
  • healing wounds hurt overall when exposed to air

Perfusion and O2 assessment

  • baseline VS
  • cap refill
  • color, temp

chronic wounds

  • not healed in 4 weeks
  • disorganized healing and chronic inflammation
    • inflammation over 96 hours, can be caused by DM or steroids
  • ex. DM ulcer, vessel ulcer

Acute wound

  • predictable healing less than 3 weeks
  • laceration, abrasion, incision
  • inflammation 96 hr

wound closure

  • First intention (primary union) – incision, sterile, early suture, small scar
  • second intention Granulation- gaping irregular wound, biggest scar
  • third intention (secondary suture)- wound, closure with wide scar
  • we want the least scarring for the pt’s well being and self image

phases

  • inflammation – reactive – macrophages
  • proliferation – reparative – Angiogenesis
  • maturation – collagen remodeling, in 6 months the wound skin is 90% as strong as uninjured skin.
  • extend the joint to avoid contracture
    • this can be painful

wound assessment

  • red yellow black
  • types of tissue
  • granulation tissue
    • red, moist, beefy, good sign of healing
  • slough
    • yellow, stringy substance on wound bed, use % for colors
  • eschar
    • described as “%covered in eschar
    • uncategorizable until eschar removed

tunneling – narrow channeling in wound

undermining – the skin is over the unhealed wound

Periwound – tissue around the wound

increase in drainage when the wound is getting infected.

Braden score assessing the skin 3-21, 18 is at risk for pressure ulcers higher is better

Deep tissue injury – acutely immobile, maroon/purple blood blister, if it breaks i can be a stage IV

  • off load the pressure!
  • stage if breaks

Stage 1-IV

  • I – skin unbroken
  • II – breaks epidermis into dermis
  • III – deep dermis
  • IV – into subcutaneous tissue  
  • unstageable – the wound is covered in eschar and level cannot be seen

MAAD – moisture associated dermatitis

IAD – incontinence associated dermatitis

psoriasis – skin growing too quickly and creates a silvery scaly patch

wound cleaning

  • Keep a moist wound covering over the wound
  • don’t scrub wounds anymore, just rub gently and tap water is ok for cleaning ie shower

Keloid scar – raised scar

Urinary Elimination: Altered Function Assessment

factors affecting the process – renal conditions

  • Prerenal
  • intrarenal
  • Postrenal

Healthy adequately hydrated patient will produce 30 ml of fluid an hour  

  • > 30ml for more than 2 hr is important and action needs to be taken

UTI – bacteria entered the urinary tract

  • cloudy(turbid) urine

Altered urinary elimination define:

  • Dysuria, polyuria, oliguria, urgency, frequency, nocturia(urination at night), hematuria(blood in urine) pyuria(pus in urine)
  • find the pt’s normal range

5 types of incontinence – Urge, stress, functional,

Urinary samples that are less self explanatory

  • Clean catch – sterile.
  • 24 hour specimen – collect urine over 24 hours.

catheter types

  • intermittent
    • spinal injury pt’s use this as opposed to a sterile foley.
  • Indwelling:
  • Foley
    • insert to the Y tubing before inflating the balloon to avoid inflating in the urethra.
    • keep bag lower than the bladder. (no back flow)
    • 50% infection rate after 7 days
    • Can be delegated
      • still responsible!
    • secured to leg
    • document time of removal

CAUTI – catheter Associated UTI

  • risk factor is duration of foley insertion

when is it ok for indwelling cath

  • accurately measure output (kidney injury)
  • bladder outlet obstruction
  • immobile
  • end of life care

Meatal care – skin around the foley needs to be clean

Non invasive therapies

  • Bladder Ultrasound measures volume
  • Bed pan

Stoma is an internal organ to the abdominal wall, in this case to transport urine from the ureters to the outside of the body. this would happen if a bladder was removed.

Neobladder – new bladder from intestinal tissue

Ureterostomy – brings ureters to the abdominal wall to drain,
supra pubic catheter is surgically placed and is long dwelling, the tube is directly inserted into the bladder.

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