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Wound

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Any injury to the body's tissues involving a break in the skin. Either an open or closed wound.

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Incision

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Cut produced surgically by a sharp instrument creating an opening into an organ or space in the body.

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Puncture

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Stab wound for a drainage system.

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Factors of Wound Healing

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Age, nutritional status, physical condition, pre-existing health problems (diabetes), and medication habits. Also preoperative skin preparation, type of surgical procedure, environment within the surgical suite, and postoperative wound care.

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Classifications

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Derive from their cause, the severity of injury, the amount of contamination, or the skin's integrity.

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CDC Classifications

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Clean, clean-contaminated, contaminated, and dirty or infected.

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Clean

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Uninfected surgical wound; the chance of an infection occurring postoperatively is less than 5%.

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Clean-Contaminated

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Surgical incision made into the respiratory, the GI, or the genitourinary tract after special pre-surgical preparation. Likelihood that an infection will occur postoperatively is between 3% and 11%.

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Contaminated

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Presence of GI products (e.g., feces with E. coli in the colon); from an acute, non purulent inflammation; or when aseptic technique is broken during surfer. Wound infection occurs 10% to 17% of the time.

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Dirty or Infected

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27% chance of causing a wound infection. Wounds in this category (e.g., gangrenous toe) are infected before surgery.

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4 Phases of Wound Healing

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Hemostasis, inflammatory phase, reconstruction, and maturation.

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Wound Healing

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Begins immediately after an injury and sometimes continues for a year or longer. Although the process follows the same pattern, the type and tissue, severity, and overall condition of the patient influence the overall process.

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Hemostasis

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Termination of bleeding that begins as soon as the injury occurs. Blood platelets adhere to the walls of the injured vessel, a clot begins to form. Fibrin in the clot begins to hold the wound together, and bleeding subsides.

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Inflammatory

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Initial increase in the flow of blood elements (antibodies, electrolytes, plasma proteins) and water out of the blood vessel into the vascular space. This process causes the cardinal signs and symptoms; erythema (redness), heat, edema (swelling), pain and tissue dysfunction. Leukocytes appear and begin to engulf bacteria, fungi viruses, and toxic proteins. Cells in the injured tissue migrate, divide, and form new cells. Slowly, blood clots dissolve and the wound fill; the sides of the wound usually meet in 24 to 48 hours. As phase ends, new cells and capillaries fill in the wound from the underlying tissue to the skin surface. This process seals the wound and protects it from contamination.

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Reconstruction

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Collagen formation occurs. Begins on the third or fourth day after injury and lasts for 2 to 3 weeks. Fibroblasts produce collagen a gluelike protein substance that adds tensile strength to the wound and the tissue. Collagen formation increases rapidly between postoperative days 5 and 25. During this phase, wound take on the appearance of an irregular, raised, purplish, immature scar. During this time encourage the patient to consume foods rich in protein and vitamins A and C, which assist in wound repair. Wound dehiscence most frequently occurs during this phase.

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Maturation

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Approximately 3 weeks after surgery, fibroblasts begin to exit the wound. Wound continues to gain strength, although healed wounds rarely return to the strength the tissue had before surgery. Tissue heals at varying speeds, internal wound regain strength faster than skin wounds. Occasionally a keloid, which is an overgrowth of collagenous scar tissue at the site of a wound will form during this phase. Keloid's color ranges from red to pink to white. This new tissue is elevated, rounded and firm. African-Americans, dark-complexioned whites, and young women have the highest incidence of keloid formation. Therapy sometimes worsens the condition; only skilled professionals are qualified to perform it.

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Process of Acute Wound Healing

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Occurs by primary intention, secondary intention, or tertiary intention. Although progressive, do not necessarily occur in a linear fashion. Some normally healing wounds are in all three stages of wound healing simultaneously.

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Primary Intention

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Wounds in which skin edges are close together and little tissue is lost, such as those made surgically. Minimal scarring results. Begins during the inflammatory phase of healing; in surgery this is usually during closure of the wound.

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Secondary Intention

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Wound must granulate during healing, occurs when skin edges are not close together or when pus has formed. Some wounds develop purulent exudate when injured or diseased tissue dies. In this case, the surgeon provides a means for its release through a drainage system or by packing the wound with gauze. Slowly the necrotized tissue decomposes and escapes, and the cavity begins to fill with granulation tissue. Amount of granulation tissue required to fill the wound depends on the wound's size, scarring is greater in a large wound.

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Purulent

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Producing or containing pus.

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Exudate

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Fluid, cells, or other substances that have been slowly exuded, or discharged from cells or blood through small pores or breaks in cell membranes.

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Granulation Tissue

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Soft, pink, fleshy projections consisting of capillaries surrounded by fibrous collagen.

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Tertiary Intention

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Delayed primary intention. The practitioner leaves a contaminated wound open and closes it later, after the infection is controlled, by suturing two layers of granulation tissue together in the wound. Also occurs when a primary wound becomes infected, is opened, is allowed to granulate, and is then sutured. Results in a larger and deeper scar than healing by primary or secondary intention.

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Nutritional Status

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To promote healing, closely monitor fluid and nutritional needs. Provision of total parenteral nutrition or nasogastric feedings is a possibility. Often unable to tolerate large meals or solid foods, small frequent feedings provided. Offer fluids, when tolerated on an hourly basis. Unless there are contraindications, encourage an intake of 2000 to 2400 mL in 24 hours. Until hydration level is stable (usually 24 to 72 hours), monitor intake and output.

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Rest vs Activity

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Achieve a balance as a means to facilitate healing and to decrease venous stasis. When confined to bed, encourage him or her to move one body section at a time-head, chest, hips, legs. To sit up, the patient should roll to the side and, using the elbow as a lever, push to a sitting position; this reduces the stress placed on the incision. If coughing occurs, apply a pillow, rolled bath blanket, or the palms of the hands to the incisional area to lessen intraabdominal pressure; this is called splinting.

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Impairing Factors of Wound Healing

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Age, malnutrition, obesity, impaired oxygenation, smoking, drugs, diabetes mellitus, radiation, and wound stress.

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Age

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Alters all phases of wound healing. Vascular changes impair circulation to wound site. Reduced liver function alters syntheses of clotting factors. Inflammatory response is slowed. Formation of antibodies and lymphocytes is reduced. Scar tissue is less elastic. Intervention: Instruct patient on safety precautions to prevent injuries. Be prepared to provide wound care for longer period. Teach home caregivers wound care techniques.

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Malnutrition

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All phases of wound healing are impaired. Stress from burns or severe trauma increases nutritional requirements. Intervention: Provide balanced diet rich in protein, carbohydrates, lipids, vitamins A and C, minerals (zinc, copper), and B vitamins. Provide adequate amounts of calories and fluids.

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Obesity

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Fatty tissue lacks adequate blood supply to resist bacterial infection and deliver nutrients and cellular elements. Intervention: Observe patient for signs of wound infection, dehiscence, and evisceration.

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Impaired Oxygenation

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Low arterial oxygen tension alters synthesis of collagen and formation of epithelial cells. If local circulating blood flow is poor, tissues fail to receive needed oxygen. Decreased hemoglobin (anemia) reduces arterial oxygen levels in capillaries and interferes with tissue repair. Intervention: Provide diet adequate in iron, vitamin B, and folic acid. Monitor hematocrit and hemoglobin levels of patients with wounds.

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Smoking

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Reduces amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Sometimes increases platelet aggregation and causes hyper coagulability. Interferes with normal cellular mechanisms that promote release of oxygen to tissues. Intervention: Discourage patient by explaining its effects on wound healing.

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Drugs

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Steroids reduce inflammatory response. Antiinflammatory drugs suppress protein synths, wound contraction, epithelialization, and inflammation. Prolonged antibiotic use increases risk of superinfection. Chemotherapeutic drugs often depress bone marrow function, number of leukocytes, and inflammatory response. Intervention: Carefully observe patient; signs of inflammation are not always obvious. Vitamin A has the capacity to counteract effects of steroids.

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Diabetes Mellitus

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Chronic disease causes small blood vessel disease that impairs tissue perfusion. Causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues. Hyperglycemia alters ability of leukocytes to perform phagocytosis and also supports overgrowth of fungal and yeast infections. Intervention: Instruct patient to take preventive measures to avoid cuts or breaks in skin. Provide preventive foot care. Control blood sugar to reduce the physiologic changes associated with diabetes.

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Radiation

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Fibrosis and vascular scarring eventually develop in irradiated skin layers. Tissues become fragile and poorly oxygenated. Intervention: Closely observe patients who have had surgery for wound complications.

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Wound Stress

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Vomiting, abdominal distention, and respiratory effort sometimes stress suture line and potentially disrupt wound layer. Sudden, unexpected tension on incision inhibits formation of endothelial cell and collagen networks. Intervention: Control nausea with ordered anitemetics. Keep nasogastric tubes patent and draining to prevent accumulation of secretions. Instruct patient to splint abdominal wound during coughing.

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Sanguineous

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Composed of or pertaining to blood.

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Serosanguineous

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Thin and red, composed of serum and blood. Usually described as pink.

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Serous

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Clear, thin and watery, composed of the serum portion of blood.

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Inflammatory Response

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Tissue reaction to injury.

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Infectious Process

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Condition caused by the invasion of the body by pathogenic microorganisms.

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Purulent

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Thick, yellow, green, tan, or brown. Has an odor.

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Dressings

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Gauze, semiocclusive or occlusive. Semiocclusive and occlusive are thought to promote healing by keeping wounds moist (yet sterile) so epithelial cells are able to slide more easily over the surface of the wound during epithelialization.

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Gauze

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Permit air to reach the wound.

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Semiocclusive

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Permit oxygen but not air impurities to pass. place tape strips several inches apart to make the wound accessible to atmospheric oxygen.

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Occlusive

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Permit neither air not oxygen to pass. Place tape strips on all sides of the dressing.

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Dry Dressing

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Choice for management of a wound with little exudate or drainage such as abrasions and nondraining postoperative incisions. Keeps initial bleeding to a minimum, protects the wound from injury, prevents introduction of bacteria, reduces discomfort, and speeds healing. Prevents deeper tissue from drying out. Does not debride.

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Removal

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Can be painful, it frequently helps to give an analgesic at least 30 minutes before exposing a wound.

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Sterile Technique

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Whenever handling the wound or dressing. Protects you from drainage, but also lessens the chance of acquiring a health care-associated infection. Wear a gown, mask and protective goggles if you anticipate soiling or splashing of wound exudate.

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Wet-To-Dry Dressing

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Primary purpose to mechanically debride a wound. Moistened contact layer of dressing increases the absorptive ability of dressing to collect exudate and wound debris. As dressing dries, it adheres to the wound and, when removed, debrides it. Most appropriate for wounds that do not have significant amounts of ischemic or necrotic tissue or large amounts of drainage or exudate.

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Too-Wet Dressing

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Potential to cause tissue maceration and bacterial growth.

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Wetting Agents

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Saline, lactated Ringer's solution, isotonic solutions, acetic acid, sodium hypochlorite (Dakin's), and Povidone-iodine. Should be discarded 24 hours after opening and replaced with fresh solution because they can harbor microorganism growth.

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Transparent Dressing

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Self-adhesive transparent film that is semiocclusive or occlusive. Synthetic permeable membrane, it acts as a temporary second skin. Adheres to undamaged skin to contain exudate and minimize contamination. Serves as a barrier to external fluids and bacteria yet still allows wound to breathe. Promotes a moist environment that speeds epithelial cell growth. Can assess the wound without removing the film. Can be removed without damaging underlying tissue. Acceptable for them to stay in place up to 7 days, if complete occlusion is maintained.

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Irrigation

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Gentle washing of an area with a stream of solution delivered through an irrigating syringe. 1. Cleanse from least contaminated to most. 2. Make sure all solution flows from least contaminated to most contaminated area. Promote wound healing by removing debris from wound surface, decreasing bacterial counts, and loosening and removing eschar. Solutions include warm water, saline, and mild detergents. Introduce solution directly with a syringe, syringe and catheter, shower, or whirlpool. Prevent fluid retention in wound, position pt on their side to encourage irrigant to flow away from wound.

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Eschar

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Black, leathery crust.

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Abscess

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Cavity containing pus and surrounded by inflamed tissue, formed as a result of suppuration in a localized infection.

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Adhesion

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Band of scar tissue that binds together two anatomical surfaces normally separated; most commonly found in the abdomen.

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Cellulitis

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Infection of the skin characterized by heat, pain, erythema, and edema.

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Dehiscence

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Separation of a surgical incision or rupture of a wound closure. Patients will tell you that something has given way. Sometimes brought on by periods of sneezing, coughing, or vomiting. Sometimes preceded by serosanguineous drainage. If wound is not covered, have the patient remain in bed and NPO; tell patient not to cough, place warm, moist sterile dressing over area until physician evaluates.

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Evisceration

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Protrusion of an internal organ through a wound or surgical incision. Patient is to remain in bed in a low Fowler's position, with knees flexed to reduce pressure on wound. NPO, cover wound and contents with warm, sterile saline dressing, notify surgeon immediately.

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Extravasation

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Passage or escape into the tissues; usually of blood, serum, or lymph.

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Hematoma

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Collection of extravasated blood trapped in the tissues or in an organ resulting from incomplete hemostasis after surgery or injury.

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Wound Bleeding

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Potentially indicates a slipped suture, dislodged clot, coagulation problem, or trauma to blood vessels or tissue. If hemorrhage results internally, the dressing will sometimes remain dry while the abdominal cavity collects blood. Signs and symptoms of hemorrhage are increased thirst; restlessness; rapid, thready pulse; decreased blood pressure; decreased urinary output; and cool, clammy skin.

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Infected

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CDC label wound when it contains purulent drainage. Displays fever, tenderness and pain at site, edema and an elevated WBC count.

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Staple and Suture Removal

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Need physician's written order. Generally in 7 to 10 days after surgery, or sooner, if healing is adequate. Sometimes one suture or staple comes out at a time and sometimes in two phases: First, every other is removed and replaced with a Steri-Strip, and same sequence occurs with the remainder in the second phase.

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Sutures

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Threads of wire or other material (silk, steel, cotton, linen, nylon, or Dacron) used to sew body tissues together. Placed within tissue layers in deep wounds and superficially as the final means for wound closure.

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Staples

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Made of stainless steel wire, are quick to use, and provide ample strength. Popular for skin closure of abdominal incisions and orthopedic surgery when appearance of the incision is not critical. Removal requires a sterile staple extractor and aseptic technique.

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Retention Sutures

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Left in place longer (14 days or more). Covered with rubber tubing to provide greater strength. Leaving in too long makes removal more difficult and increases risk of infection.

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Drainage

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Removal of fluids from a body cavity, wound, or other source of discharge by one or more methods; it may occur passively on its own or with mechanical assistance.

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300mL

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Exudate or drainage greater than this in the first 24 hours treat as abnormal and report it immediately.

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Exudate and Drainage Assessment

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Color, amount constancy, and odor.

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Closed Drainage

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System of tubing and other apparatus attached to body to remove fluid in an airtight circuit that prevents environmental contaminants from entering the wound or cavity.

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Open Drainage

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Passes through an open-ended tube into a receptacle or out onto the dressing.

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Suction Drainage

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Uses a pump or other mechanical device to help extract a fluid.

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Jackson-Pratt

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Type of closed drainage system that uses a bulb to provide the needed vacuum.

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T-Tube

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Tube used after surgical removal of the gallbladder, the bile duct is often inflamed and edematous. Physician will insert drainage tube into duct to maintain free flow of bile until edema subsides. Long end exits through abdominal incision or through a separate surgical wound. Drains by gravity into a closed drainage system. Collection bag is emptied and measured every shift or as necessary.

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Wound VAC

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Wound vacuum-assisted closure is a device that assists in wound closure by applying localized negative pressure to draw edges together. Accelerates healing by promoting formation of granulation tissue, collagen, fibroblasts, and inflammatory cells in order to close or improve condition of wound in preparation for a skin graft. Negative pressure removes fluid from area, thus reducing local or peripheral edema and improving circulation. After 3 or 4 days, bacterial counts drop.

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Bandage

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Strip or roll of cloth or other material that can be wound around a part of the body in a variety of ways for multiple purposes. Gauze, elasticized knit, elastic webbing, flannel, and muslin are examples.

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Binder

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Bandage made of large pieces of material to fit a specific body part. Abdominal or breast are examples.

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Correctly Applied

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Bandages and binders do not cause injury to underlying and nearby body parts or create discomfort for the patient.

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Before Applying

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Inspect skin for abrasions, edema, discoloration, or exposed wound edges. Cover exposed wounds or open abrasions with sterile dressings. Assessing condition of underlying dressings and changing them if soiled. Assessing the skin of underlying body parts and parts that will be distal to bandage for signs of circulatory impairment.

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After Applying

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Assess, document, and immediately report changes in circulation, skin integrity, comfort level, and body function, such as ventilation or movement. Loosen or readjust it as necessary. Obtain a physician's order before removal or adjustment if physician applied it. Should feel firm or tight. Assess to be sure it is properly applied and is providing therapeutic benefit and replaced soiled bandages.

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Basic Bandage Turns

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Circular, Spiral, Spiral-Reverse, Figure-Of-8, and Recurrent.

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Teaching for Wound Care

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Accept, Ambulation (early), Nutrition, Dressings (supplies), Assistance (might be needed), Demonstrating (have them demonstrate back), Dry and Clean, Wash Hands, Infection (signs and symptoms), Physician (notify of infection, follow directions), Written (instructions), Questions (allow time), Drainage (if present), Binder, Loose (report), Breathing (report is restricted).

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Importance of Pain

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Promoting physical and psychological comfort is a vital aspect of your role as a nurse. Serves as a warning to the body because it often occurs where there is actual or potential tissue damage.

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Breakthrough Pain

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Pain felt between regular doses.

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Referred Pain

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Felt at a site other than the injured or diseased organ or part of the body.

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Acute Pain

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Intense and short duration, usually lasting less than 6 month.

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Chronic Pain

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Generally characterized as pain lasting longer than 6 months.

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Synergistic

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Action of two or more substances or organs to achieve an effect of which each is individually incapable.

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Gate Control Theory

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Proposed by Melzack, suggests that pain impulses are regulated and even blocked by gating mechanisms located along the CNS. When gates are open, pain impulses flow freely. When gates are closed, pain impulses become blocked.

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Endorphins

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Morphinelike substances. Potent polypeptides composed of many amino acids found in the pituitary gland and other areas of the CNS.

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Analgesia

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Attach to opioid receptor sites in the brain and prevent the release of neurotransmitters, thereby inhibiting the transmission of pain impulses. Often provide patients effective pain relief.

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TJC

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Create standards for pain assessment and treatment. "The management of pain is appropriate for all patients not just dying patients." Patients have the right to appropriate assessment. routine and prn analgesics are to be administered as ordered. Discharge planning and teaching will include continuing care based on the patient's needs at the time of discharge, including the need for pain management.

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THILDA

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Pain assessment guide. Type. How does your pain feel? Intensity 0 -10. Location. Duration. Aggravating and Alleviating Factors.

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TENS

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Transcutaneous Electric Nerve Stimulation. Noninvasive battery-operated device that provides a continuous, mild electric current to the skin. Simulating large nerve fibers to "close the gate" in the spinal cord. Hypothesized to stimulate endorphin production.

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Invasive

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Anything that enters the body.

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Nonopioids

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Acetaminophen and nonsteroidal intiinflammatory drugs (NSAIDs) are the most widely available and frequently used analgesic group. Primarily for mild to moderate pain but are sometimes also used to relieve certain types of severe pain. OTC are aspirin, ibuprofen (Advil, Nuprin, Motrin), and naproxen sodium (Aleve). Aspirin blocks pain impulses in the CNS and reduces inflammation. Pose the risk of GI bleeding.

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Acetaminophen

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Maximum recommended dosage is 4,000mb (4g) in 24 hours. Toxic side effect is hepatotoxicity.

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Opioids

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Morphine, meperidine (Demerol), hydromorphone (Dilauded), levorphanol, oxycodone, and fentanyl (Actiq, Duragesic) act on higher centers of the brain to modify perception and reaction to pain. Decrease perception of pain y binding to pain receptor sites in the CNS. Cornerstone for managing moderate to severe acute pain. Danger is their potential to cause depression of vital nervous system functions. Respiratory depression. Risk for constipation is the most common side effect. Proper diet, fluids and exercise.

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Demerol

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Meperidine no longer the drug of choice for pain management. Potential for inducing seizures. Main stimulant and sometimes produces irritability, tremors, muscle twitching, jerking, agitation, and seizures. Do not used in patients with renal function.

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Addiction

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Opioid tolerance and physiologic dependence are unusual with short-term postoperative use, and psychological dependence are extremely unlikely after taking opiates for acute pain. Studies have shown that likelihood occurring as a result of taking opioids for pain relief, even over a long period, is rare-probably less than 1%.

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Adjuvant Analgesics

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Diverse class of drugs the relieve pain by a variety of mechanisms. Antidepressants relieve pain by blocking the reuptake of serotonin, resulting in the presence of greater amounts of serotonin. Local anesthetics such as mexiletine (Mexitil) and certain anticonvulsants such as carbamazepine (Tegretol) are sodium channel blocking agents, and this is perhaps part of the mechanism to relieve pain. Neuropathic pain is difficult to treat. Gabapentin (Neurontin), anticonvulsant, binds to neoneuropathic pain. Duloxetine (Cymbalta), antidepressant, control pain associated with diabetic neuropathy, as is pregabaline (Lyrica), anticonvulsant.

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IM

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Intramuscular. In general, avoid the IM route for opiods, especially repeated IM administration. Wide fluctuations in absorption, including delayed absorption in postoperative patients, making it an ineffective and potentially dangerous method of managing pain.

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IV

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Intravenous. Best for administration of opioid analgesics after major surgery. Quick onset.

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Oral Route

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Often optimal route, especially for chronic pain treatment, because of convenience, flexibility, and relatively steady blood levels produced. Mainstay of pain management for ambulatory surgical patients.

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PCA

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Patient-controlled analgesia allows patients to self-administer whenever needed. Time prevents system from delivering more than a specified number of doses every hour, to prevent overdose. Based on idea that only patient can feel pain and only patient knows how much analgesic will relieve it. Someone other than patient pushes button, even at patient's request, it is termed by proxy. Patient use only. Invasive.

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Epidural

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Infusion of opiates into epidural space. Medication diffuses slowly into cerebrospinal fluid. Brings drug close to the action site, therefore relatively small doses are effective. Absorbed systemically. Moderate to severe acute pain expected to last for at least 24 hours. Invasive. Urinary retention, postural hypotension, pruritus, nausea, vomiting, and respiratory depression. Monitor every 15 minutes during infusion.

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Visual Analog Scale

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Patient marks a spot on a horizontal line to indicate pain intensity. 0 to 10 most common scale. Visual scale with numerical ratings combines both, providing a description and facial expressions with assigned numbers.

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Pain Assessment

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THILDA. Always use same scale with same patient. Look for objective signs and nonverbal signs of pain. Be unbiased and nonjudgmental.

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Pain Scale

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Should be easy to use and not time consuming. If patient is able to read and understand scale easily, description of pain will be more accurate.

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Objective Signs of Pain

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Physiologic: Increased pulse. Increased respirations, depth and rate. Increased systolic and diastolic blood pressure. Continuous severe pain, body will return to equilibrium, rarely remain elevated. Diaphoresis, pallor. Dilated pupils. Muscle tension. Nausea and vomiting if severe. Behavioral: Rigid body position. Restlessness. Frowning. Grimacing. Clenched teeth. Clenched fists. Crying. Moaning.

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Sleep

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State of rest that occurs for a sustained period. Reduced consciousness provides time for repair and recovery of body systems for the next period of wakefulness. Theory is it associated with healing. Restores energy and feeling of well-being.

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Sleep-Wake Cycle

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Influences and regulates body functions and behavioral responses. Affected by light and temperature and external factors such as social activities and environmental stressors.

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Sleep Factors

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Physical Illness. Anxiety and Depression. Drugs and Substances. Lifestyle. Sleep Patterns. Stress. Environment. Exercise and Fatigue. Nutrition.

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Environment

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Ventilation, lighting, type of bed, sound level, and the presence or absence of a bed partner. Unfamiliar noises and higher noise levels have the capacity to cause sleep deprivation.

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REM

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Rapid eye movement. One of the two phases of sleep. Important for brain and cognitive restoration. Changes in cerebral flow and increases in cortical activity, oxygen consumption, and epinephrine release, which are beneficial to memory storage and learning. Vivid, full-color dreaming. Occurs 90 minutes after sleep has begun and after each NREM cycle. Autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, increased or fluctuating BP. Loss of skeletal muscle tone. Most difficult to arouse. Duration increases with each cycle and averages 20 minutes.

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NREM

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Non-rapid eye movement. Second phase of sleep that is further divided into 4 stages. Necessary for body tissue restoration and healthy cardiac function. Biologic functions slow.

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Presleep

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Aware only of gradually developing drowsiness. Normally lasts 10 to 30 minutes.

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Sleep Cycle

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Presleep, progress through 4 stages of NREM. Come out of deep sleep back to stage 2 then enter REM. REM is reached in about 90 minutes. Typical night's sleep consists of four to six such cycles.

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Stage 1

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Lightest level. Lasts a few minutes. Decreased physiologic activity. Easily aroused by sensory stimuli. If awakened feel as though daydreaming. Reduction in autonomic activities.

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Stage 2

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Period of sound sleep. Relaxation progresses. Arousal still easy. Lasts 10 to 20 minutes. Body functions slowing.

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Stage 3

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Initial stages of deep sleep. Difficult to arouse and rarely moves. Muscles completely relaxed. Vital signs decline but remain regular. Lasts 15 to 30 minutes. Hormonal response includes secretion of growth hormone.

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Stage 4

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Deepest stage. Very difficult to arouse. If sleep loss occurred sleeper will spend most of night in this stage. Restores and rests body. Vital signs significantly lower than waking hours. Lasts approximately 15 to 30 minutes. Possible sleepwalking and enuresis. Hormonal response continues.

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Sleep Deprivation

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Decreases in amount, quality, and consistency of sleep. When sleep is interrupted of fragmented, changes in normal sequence of sleep stages occur, and cycles are not completed. Gradually cumulative deprivation develops. Signs and symptoms: Physiologic; Hand tremors, decreased reflexes, slowed response time, reduction in word memory, decreased reasoning and judgement, and cardiac dysrhythmias. Psychological; Mood swings, disorientation, irritability, decreased motivation, fatigue, sleepiness, and hyperexcitability.

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30 to 40 minutes

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Time you should give medication before a procedure.

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Neuropathic Pain

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Arises from the nerves and the nervous system. tingling, burning, or shooting pains are often due to neuropathic causes.

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Cutaneous Stimulation

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If other cuatneous stimuli besides pain are transmitted, the "gate" through which the pain are transmitted, the "gate is temporarily blocked by the stimuli. brain does not acknowledge pain while interpreting other stimuli.

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Cutaneous Pain

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Pain felt on the surface layer, skin.

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Phantom Limb Pain

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Pain felt in missing/amputated limb. Acknowledge pain, but do not medicate. Reaffirm that the limb is missing. Felt because nerves are still present even though limb is not.

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ADPIE

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Assessment, Diagnosis, Planning, Implementation, Evaluation.

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Subjective Data

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Data that only the patient can experience. Pain and nausea are examples.

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Objective Data

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Data that can be measured and observed by someone other than the patient.

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Sterile Technique

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Surgical asepsis. Absence of bacteria and their spores.

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Complimentary Therapy

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Therapies used in addition to conventional treatment recommended by a health care provider.

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Alternative Therapy

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Therapies that become the primary treatment modality that replaces conventional treatment.

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Allopathic Medicine

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Traditional or conventional Western medicine.

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Holistic Nursing

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Addresses and treats the mind-body-spirit.

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Herbal Therapy

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Use of herbs in treatment. Goal is to restore balance within individual by facilitating self-healing capacity. Goes back thousands of years. Many drugs and medications have their origins in herbs. Usually uses of an unpurified extract of the whole plant. Sold as foods or food supplements because they have not undergone rigorous research and have not received approval as drugs.

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Pharmaceuticals

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Drugs

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Asian Ginseng

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Improves overall health and well-being. Atherosclerosis, bleeding disorders, colitis, diabetes, depressant cancer. Do not use: Pregnant, breastfeeding, CV disease, hypertension, diabetes, Anticoagulants, CNS stimulants, estrogen, furosemide, ibuprofen, caffeine.

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Aloe Vera

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Burns, skin irritation. Laxative properties. Do not use: Cramps, electrolyte imbalance, hemorrhagic diarrhea, and kidney damage. Antidysrhytmics, cardiac glycosides, antidiabetics, beta blockers, steroids, diuretics, and disulfiram.

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Cayenne

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General CV health, reduces cholesterol level, topically analgesia, controls bleeding. Do not use: Burning and pruritus. ACE inhibitors, heparin, ASA, disulfiram, theophyline.

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Comfrey

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Cell proliferent, stimulates quick healing of strains and slow-healing wounds. Use externally only. Do not use: Liver toxicity, abdominal distention, nausea, abdominal pain, and elevated liver function, toxic alkaloids.

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Echinacea

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Stimulates immune function, blood cleanser, upper respiratory infections, wound healing. Do not use: Fever, taste disturbance, GI disturbances nausea, vomiting, diuresis, photosensitivity, ragweed allergy, immune suppression. Amprenavir, protease inhibitors, disufiram, metronidazole, immunosuppressants, cyclosporine, methotrexate, prednisone, alcohol, warfarin, digoxin, contraceptives, SSRIs, MAOIs.

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Evening Primrose

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Premenstrual syndrom, ADHD, CV problems, hot flashes, mastalgia. Do not use: Undiagnosed epilepsy, GI reactions, pregnant, breastfeeding, allergy, tricyclic antidepressant, phenothiazine, lowered seizure threshold.

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Ginger

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Nausea, vomiting, motion sickness, appetite improvement, impotence, liver toxicity, burns. Do not use: CNS depression, dysrhythmias, anticoagulants, pregnant, no consensus on dosage, antacids, histamine H2 receptor blockers, proton pump inhibitors, barbiturates, disulfiram, metronidazole.

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Ginkgo

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Improves memory, increases circulation to extremities and brain. Do not use: Arterial and venous vasoactive changes, dizziness, headache, subarachnoid and subdural hemorrhage, cardiac insufficiency, seizures, bleeding complications, antiplatelet therapy, anticoagulants, anticonvulsants, buproprion, tricyclic antidepressants, disufiram, metronidazole, MAOIs, SSRIs, trazodone.

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Chiropractic Therapy

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Manipulation of musculoskeletal system.

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Acupuncture and Acupressure

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Based on belief that there is a form of energy or Qi (life force) that flows through the body along meridians (channels of energy).

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Acupuncture

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Method of stimulating certain points on the body by the insertion of special needles to modify the perception of pain, normalize physiologic functions or treat or prevent disease.

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Acupressure

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Uses gentle pressure at similar points on the body.

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Therapeutic Massage

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Massage performed by trained professionals to manipulate the soft tissues of the body and assist with healing.

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Aromatherapy

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Pure essential oils, produced from plants, to provide health benefits.

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Reflexology

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Thought that it is possible to exert an effect on the entire body by applying pressure to specific areas on the feet.

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Imagery

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Visualization techniques use the conscious mind to create mental images to evoke physical changes in the body, create a sense of improved well-being, and enhance self-awareness.

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Relaxation

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State of a generalized decrease in cognitive, physiologic, or behavioral arousal. Also defined as the act or process of arousal reduction.

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Yoga

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Combination of breathing exercises, physical postures, and meditation that has been practiced for over 5000 years.

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T'ai chi or Taiji

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Originally developed as a martial art in seventeenth century China, yin and yang. Relaxing the body and calming and focusing the mind.

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Biofeedback

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Noninvasive method of determining a patient's neuromuscular and autonomic nervous system response by measuring body functions such as blood pressure, pulse, muscle tension, and skin temperature with the use of electronic or electromechanical equipment.

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Heat Application

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Vasodilation causes the lumen of blood vessels to dilate, increasing blood flow to that area of the body. More than 1 hour: Vessels constrict, damage to epithelial cells, erythema, tenderness, and blistering.

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Cold Application

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Vasoconstriction, tissue ischemia (decreased blood supply to a body part of organ; often accompanied by pain and organ dysfunction) refers to tissue cells that are lacking in sufficient blood flow and nutrients. Exposed to cold, initially becomes erythematous or reddened, followed by mottled appearance, as well as a burning pain. Prolonged exposure for extensive period: Skin will freeze.

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Compress

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Consists of gauze that is moistened with a prescribed warm solution.

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Hot, Moist Compress

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Increases circulation, decrease edema, consolidate any purulent exudates. Lower temp for moist than dry, because most is a better conductor.

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Very Hot

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105 to 115

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Hot

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98 to 105

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Warm

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93 to 98

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Tepid

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80 to 93

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Cool

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65 to 80

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Cold

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50 to 65

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Warm Soaks

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Increase circulation, reduce edema, wound debridement, muscle relaxation, ability to apply to large areas. Immerse body part in warm solution or wrapping a body part in dressing that have been saturated with a warm solution. Also whirlpool.

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Paraffin Bath

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Mixture of heated paraffin was and mineral oil. Helps with painful arthritis or other joint discomforts of the hands.

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Aquathermia

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Source of moist or dry heat application in lieu of conventional heating pads. Safer than heating pads since a precise temperature is set. Recommended temp is between 105 and 110.

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Commercial Hot Packs

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Warm, dry heat applications from chemicals are mixed within package.

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Electric Heating Pads

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Electrical coil surrounded by a water-proof pad covered by cotton or flannel fabric.

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Cold Compress

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Clean or sterile. Apply fro 20 minutes at 59F. Treat inflammation and prevent edema.

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Ice Bags of Collars

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Reduce edema formation and bleeding and provide an anesthetic effect to areas. Ideal for localized hemorrhage and hematoma formations.

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Diuretics

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Best to take in the morning. Take 6 to 8 hours to take effect.

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Pain Management

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Patients right to assessment and treatment of pain. Treatments thats goal is to provide comfort and reduce pain for a patient.

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Packing Wound

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Gently pack gauze into wound with forceps until all wound surfaces are in contact with moist gauze.

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Wound Charting

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Appearance of wound color, characteristics of any drainage. Size, Color, Location. Response

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Sterile Gloving

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Pinch bottom of glove. Cup other glove and put on. Flip inside out, then other glove.

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