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Factors Affecting Wound Healing

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Increased Age Overall client wellness Immune Function Medications Nutrition Tissue perfusion Obesity Chronic Diseases Chronic Stress Smoking Wound Stress

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General Principles of Wound Management

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1. A wound is a disruption of the skin. 2. Inflammation is a localized protective response brought on by injury or destruction of tissue. 3. Wounds heal by various processes and in stages. 4. Wounds may become infected by the invasion of a pathogenic microorganism. 5. Principles of would care include assessment, cleansing, and protection. 6. Wound care is a nursing responsibility that has a high impact on wound healing

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Appearance Open wounds vs Closed Wounds

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Open wounds, note color Red - Healthy regeneration of tissue Yellow - Presence of purulent drainage and slough (dead skin) Black - presence of eschar (thick, necrotic material) that hinders healing and must be removed. Closed wounds - skin edges should be well-approximated.

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Drainage (wound healing) What to note

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Amount surrounding skin conditions Characteristics of drainage by consistency, color, and odor.

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NANDA Nursing Diagnosis (wound healing)

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Pain Risk for infection Impaired skin integrity Impaired tissue integrity Disturbed body image Imbalanced nutrution

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Nursing Interventions (wound healing)

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--Provide adequate hydration and meet protein and calorie needs. --Perform wound cleansing --Perform wound dressing --Perform debridement --Use negative pressure wound vacuum-assisted closure if ordered. --Remove sutures/staples as needed --Administer analgesics as needed --Administer antimicrobials as ordered. --Document

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What do you document regarding a wound

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Location type of wound/incision status of wound type of drainage type of dressing & materials used client teaching provided How client tolerated procedure.

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Causes of Dehiscence or Evisceration

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Usually caused by increased flow of serosanguineous fluid occurring approximately 3-11 days post op.

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Evisceration requires immediate emergency treatment, the nurse should:

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1. Call for help. 2. Stay with the client. 3. Cover the wound and any protruding organs with sterile towels or dressing that have been soaked in saline solution. Do not attempt to reinsert organs. 4. Position the client supine with hips and knees bent. 5. Observe the client for signs of shock 6. Maintain a calm environment.

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S/S of dehiscence

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~Appreciable increase in the flow of serosanguineous fluid on the wound dressings. ~Immediate hx of sudden strain(coughing, sneezing, vomiting) ~Client states, "something just happened to my stomach. ~Visualization of visceral organs.

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Risk Factors of dehiscence

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~Chronic Disease ~Advanced Age ~Obesity ~Invasive abdominal cancer ~Vomiting ~Dehydration/malnutrition ~Ineffective suturing ~Abdominal surgery

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Infection - Risk Factors are:

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~Extremes in Age ~Impaired Circulatory and Oxygentation (COPD, peripheral vascular disease) ~Wound condition/nature(gunshot v surgical incision) ~Impaired/Suppressed immune system ~Malnutrition such as with alcoholism ~Chronic Disease ~Poor wound care (breaches in sterility)

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S/S of infection

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~usually appear 2 - 7 days after injury/surgery ~Purulent drainage ~Pain ~Redness & Edema (in or around wound) ~Fever ~Chills ~Increased pulse and respiration rate ~Increased WBC count

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Nursing Interventions for infection

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~Prevent infection from occurring by using proper aseptic technique ~Provide good nutrition to promote the immune response. ~ Provide for adequate rest to promote healing ~Administer antibiotic therapy per PCP orders

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Pressure Ulcer

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A Specific Tissue injury caused by external forces that result in unrelieved pressure that results in ischemia and damage to the underlying tissues

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Primary focus of prevention & treatment of pressure ulcers is

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to relieve the pressure and provide for good nutrition and hydration

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Pressure Ulcers - Risk Factors

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-Skin changes related to aging -immobility-incontinence or excessive moisture -skin friction and shearing -Vascular disorders -obesity -inadequate nutrition and/or hydration

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3 Things influenced by culture are

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1. Communication 2. Dietary Preferences 3. Dress

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Being a multicultural society in the US requires:

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transcultural nursing care that is culturally competent.

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Effectiveness of culturally competent care depends on

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The nurse's understanding of both her/his personal culture, as well as that of the clients.

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Nurses should accommodate the clients cultural beliefs and values whenever possible unless

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They are in direct conflict with known health practices

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In order to meet the client's cultural needs, a nurse must first

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Perform a cultural assessment to identify those needs

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When a culturally motivated behavior is in conflict with good client care:

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The behavior will need to be repatterned

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What is involved in the description of a culture

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Knowledge Value Beliefs Art Morals and Law Customs and habits

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Values

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~A set of rules by which individuals in a culture live. ~Guide decision making and behavior. ~are unconsciously developed during childhood.

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How does culture evolve

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over time and is shared by a group who has similar needs and life experiences

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Subcultures are

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diversity within a culture based upon: ~Age ~Sex ~Marital Status ~Family Structure ~Income ~Educational Level ~Religious Views ~Life experiences

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Transcultural Nursing is achieved through cultural

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Awareness Knowledge Skills Encounters Desires

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Perform the cultural assessment in a language that is common to both the nurse and the client, or employe an interpreter. Assess gestures, vocal tones, and inflections Data to be collected:

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~Cultural background and the amount of acculturation that has occured. ~Health & Wellness beliefs/practices ~Family patterns ~Verbal and nonverbal communication ~Space and time orientation ~Nutritional patterns ~Meaning of Pain ~Death Rituals

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Methods of Assessing Culture Include:

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Observation Interview Participation

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Culture - Interview

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1. Establish a therapeutic relationship with the client when possible/appropriate. This may be hindered by misinterpretations of communication. ~Verbal (language) ~Behavior (nonverbal) 2. Use focused, open-ended, and nonjudgmental questions.

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Culture - Participation - Examples

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1. Involvement in culturally related activities outside the health care setting. 2. Awareness of population demographics include: ~ number of members in a practice area ~ avg educational & economic levels ~ Typical occupations ~ Commonly practiced Religion(s)/spiritual beliefs. ~ Incidence of most common illnesses/health issues ~ most commonly held health, wellness and death beliefs. ~social organization

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NANDA Nursing Diagnoses after Cultural assessment

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1. Impaired verbal communication 2. Relocation stress syndrom 3. Risk of relocation stress syndrom 4. Social isolation 5. Spiritual Distress

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Nursing Interventions for Religion/Spirituality/Death Rituals

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~ Respect the religious spiritual practices of the client. ~ Death rituals vary among cultures, be prepared to facilitate rituals whenever possible.

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Critical Thinking RE: Culture/Spirituality

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~Taking a faith history reveals clients' beliefs about life, health, and a supreme being. ~Personal experience in caring for clients in spiritual distress is valuable. ~Each personality has a unique spirituality. ~The Joint Commission requires health organizations to provide for pastoral care.

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Nursing interventions for Pain (culture)

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~The way pain is reacted to & displayed varies by culture. ~Use an alternative to the pain scale 1 to 10 as it may not appropriately reflect pain evaluation of all cultures. ~Explore religious beliefs that may influence the meaning of pain.

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Nursing Interventions for Nutrition (culture)

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~Provide food choices and preparation that are consistent with cultural beliefs. ~As possible, allow the client to consume foods that may be viewed as a treatment for illness. ~Communicate food intolerances/allergies to dietary staff that are related to ethnicity.

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Nursing Interventions for Communication (culture)

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~Improve the nurse/client communication when cultural variations exist. ~Use interpreters when the communication barrier is great enough to impact the exchange of information between the nurse and client. ~Cautiously use nonverbal communication, as it may have different meanings for the client and the nurse.

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Nursing Interventions - Family patters & gender roles (culture)

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Communication with and including the person who has the authority to make decisions in the family.

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Nursing interventions - Culture and life transitions.

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~ Assist families as they mark rituals (rites of passage) that symbolize cultural values. ~Common events that are often expressed with cultural rituals include: Puberty Pregnancy Childbirth Dying & Death

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Nursing intervention - repatterning - culture

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~ Accomodate the client's cultural beliefs and values as much as in the client's best interest. ~ When a cultural value/behavior is a direct hindrance to the client's health/wellness, the nurse should attempt to repattern that belief to one that is compatible with health promotion.

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Nursing Process

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Assessment Nursing diagnosis Planning Implementation Evaluation

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Western Culture's Space Orientation Intimate Personal Social/public

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intimate zone 0-18 in. personal zone 18 in-36 in. social or public zone 3-6 ft.

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Current Cultural Baseline of Health Care Practice is based on

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~biological baselines of Caucasians ~research desperately needed in other groups to provide baseline data

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Cultural Barriers in Nursing Care

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Lack of knowledge about a culture Stereotypes Ethnocentrism Prejudice and discrimination

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To become Culturally competent you must

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~Identify your own cultural beliefs and recognize diversity ~Respect other cultures ~Recognize that some culture groups have definitions of health and illness that are different from yours ~Recognize that some cultural groups health maintenance and healing practices may differ from your own ~Be willing to deliver care congruent with client's cultural background

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Cultural Characteristics of Hispanics

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~High incidence of poverty and unemployment ~55.1% uninsured ~Uninsured often use public clinics and ED for care ~Issues related to lack of citizenship ~Increased incidence of DM and diabetes related complications ~Increased incidence of HTN ~Less likely to engage in risk reducing behaviors for MI ~85% health problems: communicable diseases ~HIV infection rate 3x nonHispanic ~Language barriers ~Group togetherness ~Nuclear family a priority ~Outcomes controlled by external circumstances ~Health is due to luck or a reward ~Folk medicine

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Cultural Characteristics of African American

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~High percentage is uninsured because of unemployment or fall between gaps for coverage. ~Large majority are single women, with female head of household. ~PCP tend to be free clinics and ER. ~Lower life expectancy than Caucasian American (71 vs. 76.4 yrs) ~Higher incidence of LBW infants and high infant mortality. ~Prominent disease are going to be Cardio vascular, HTN ~Higher HIV death rate. ~Sickle Cell Anemia ~Alcoholism and higher incidence of alcohol related diseases. ~Close personal space ~Matrifocal family structure ~Folk practitioners in rural south ~Illness perceived as natural or unnatural ~Good health due to grace of God.

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Cultural Characteristics of Asian Americans

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~Husbands and elders have authority ~Personal space boundaries, self control, respect ~Supernatural or metaphysical explanation (yin, yang) of illness ~Visit physicians less frequently than other Americans ~Longer life expectancy than white Americans ~Lowest infant mortality ~Increased incidence of liver, stomach and esophageal cancer ~Pockets of diabetes and obesity in Hawaii

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Cultural Characteristics of Caucasian

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~Lower poverty levels and unemployment rates ~25.8% uninsured ~Longer life expectancy than other groups except Asian Americans ~Infant mortality lower than other groups except Asian Americans ~Heart disease, hypertension, smoking, obesity Health Beliefs ~Cause-effect relationship to illness (lifestyle, microbes, injury) ~Health maintenance through healthy diet, exercise, and stress reduction ~Some religions teach illness as punishment Health Practices ~Health care is a right

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Spirituality

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~Derived from Latin spiritus which means breath or wind ~Spirit gives life to or animates a person ~Remember that health depends on a balance of many factors, including spiritual

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Spiritual Distress

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~Arises when catastrophic events interrupt the individual's sense of being. ~Clients who begin to question their belief system, and are unable to find support from those belief system may be experiencing spiritual distress.

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Nursing Interventions are directed at

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~Identification, ~Restoration, and/or ~Reconnection of a client and/or family to spiritual strength.

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Congruence

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The balance of life's patterns and rhythms, is a state that cannot be achieved but is continuously being sought

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Control in the spiritual realm

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Humans attempt to intervene in crises and incongruence through exertion of_____________

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Spirituality

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IMPLIES CONNECTEDNESS ~Intrapersonal - within ~Interpersonal - with other ~Transpersonal - higher power

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Faith

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-Can be defined by a culture or a religion -Can be defined as a relationship with a higher power

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Hope

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a concept that includes anticipation and optimism and provides comfort during times of crisis.

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Assessment/Data Collection Spirituality

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Primary - self reflection Initial - identify client's religion Focused - ongoing, identifies clients at risk for spiritual distress.

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Salicylism

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~ ~Tinnitus, Vertigo, and decreased hearing acuity

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Edema 1+

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Edema that is 2 mm - trace Rapid response after compressing the skin

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Edema 2+

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4 mm - mild rebounds 10 - 15 seconds after compressing the skin

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Edema 3+

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4 mm - 6 mm rebounds 1 - 2 minutes after compressing the skin

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Edema 4+

answer

6 mm - 8 mm rebounds 2 - 5 minutes after compressing the skin

Fundamentals of Nursing I – Test 2 – Flashcards

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