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Nursing Care for Patients with Acute and Chronic Wounds, Study notes of Nursing

Johns Hopkins University (JHU)Nursing

Comprehensive guidelines for the nursing care of patients with acute and chronic wounds. It covers key aspects such as wound assessment, pain management, nutritional support, and infection prevention. The document emphasizes the importance of a multidisciplinary approach, involving nurses, physicians, dietitians, and other healthcare professionals, to ensure optimal patient outcomes. It also highlights the significance of patient education and the role of technology in wound management. The information presented can be valuable for nurses, nursing students, and healthcare providers involved in the care of patients with various types of wounds, from traumatic injuries to chronic conditions like pressure ulcers and diabetic foot ulcers.

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Nursing 204 - Complete Study Guide

Final Exam Quizzes and Verified

Answers 2024 2025

1. Standard Precautions

2. Precautions designed for the care of patients who are known or suspected to be infected or colonized

with microorganisms transmitted by droplet, airborne, or contact routes (Airborne, Droplet, Contact,

and Protective Equipment Precautions) - What are the two recommendation tiers from CDC about

precaution?

12 Cranial Nerves - 1. *Olfactory*: Sense of smell

2. *Optic*: Visual Acuity

3. *Oculomotor*: EOM, inward, up, and outward, down and outward, and opening of the eyes, and

pupil constriction

4. *Trochlear*: Downward, inward eye movements

5. *Trigeminal*: Sensory nerve to skin of face and chewing

6. *Abducens*: Lateral movement of eyeballs

7. *Facial*: Facial expressions and taste

8. *Vestibulocochlear/Auditory*: Balance and Hearing

9. *Glossopharyngeal*: Taste

10. *Vagus*: Sensation of pharynx, movement of vocal cords, and parasympathetic innervation to

glands of mucous membranes

11. *Spinal accessory*: Movement of head and shoulders

12. *Hypoglossal*: Position of tongue

6am; 4pm - The time of day also affects body temperature with the lowest temperature at ___ and the

highest temperature at ___ for healthy adults.

AAOx3 - Alert, Awake and Oriented to Person, Place and Time

Discover Study notes of Nursing Johns Hopkins University (JHU)

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Nursing 204 - Complete Study Guide

Final Exam Quizzes and Verified

Answers 2024 2025

Standard Precautions
Precautions designed for the care of patients who are known or suspected to be infected or colonized with microorganisms transmitted by droplet, airborne, or contact routes (Airborne, Droplet, Contact, and Protective Equipment Precautions) - What are the two recommendation tiers from CDC about precaution? 12 Cranial Nerves - 1. Olfactory: Sense of smell
Optic: Visual Acuity
Oculomotor: EOM, inward, up, and outward, down and outward, and opening of the eyes, and pupil constriction
Trochlear: Downward, inward eye movements
Trigeminal: Sensory nerve to skin of face and chewing
Abducens: Lateral movement of eyeballs
Facial: Facial expressions and taste
Vestibulocochlear/Auditory: Balance and Hearing
Glossopharyngeal: Taste
Vagus: Sensation of pharynx, movement of vocal cords, and parasympathetic innervation to glands of mucous membranes
Spinal accessory: Movement of head and shoulders
Hypoglossal: Position of tongue 6am; 4pm - The time of day also affects body temperature with the lowest temperature at ___ and the highest temperature at ___ for healthy adults. AAOx3 - Alert, Awake and Oriented to Person, Place and Time

ABCDE Pain Assessment - - A = Ask about pain regularly & assess for it systematically

B = Believe reports of pain and what relieves it
C = Choose pain control individualized to the pt and setting
D = Deliver interventions in a timely, logical and coordinated fashion
E = Empower pts & enable them to control as much as possible Abnormal Stool Finding - - Color: white or clay (biliary issue), black or tarry (melena), red, pale with fat, translucent mucus, bloody mucus (infection, inflammation, or cancer)
Odor: noxious change (absorption issue)
Consistency: liquid, hard
Shape: narrow, pencil shaped
Constituents: blood, pus, foreign bodies, mucus, worms, excess fat Absorption - Occurs when medication molecules pass into the blood from the site of medication administration.
- Route of Administration: Each route has a different rate of absorption. Intradermal < Oral < Mucous = Respiratory < IV (absorption from slowest to fastest)
- Ability of a Medication to Dissolve: The ability of an oral medication to dissolve depends largely on its form or preparation.
- Blood Flow to the Site of Administration: The blood supply to the site of administration will determine how quickly the body can absorb a medication
- Body Surface Area: When a medication comes in contact with a large surface area, it is absorbed at a faster rate.
- Lipid Solubility: Because the cell membrane has a lipid layer, highly lipid-soluble medications cross cell membranes easily and are absorbed quickly. Acceptable Ranges for Adults for Vital signs - Temperature:
- Oral/Tympanic Range: 37 C (98.6 F)
- Rectal Range: 37.5 C (98.6 F)
- Axillary Range: 36.5 C (97.7 F) Pulse:

Activity and Exercise - Physical activity (PA) is any movement produced by skeletal muscles that results in energy expenditure.

Physical exercise is a subset of PA that is planned, structured, and repetitive and has a final or an intermediate objective, such as the improvement or maintenance of physical fitness. Acuity Rating Systems - Nurses use acuity ratings to determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours. Based on type and number of nursing interventions required by a patient over a 24-hour period. The acuity level is a classification used to compare one or more patients to another group of patients. Acute and Restorative care: Fires - - All patients are to be moved away from a fire
If they are on life support, ventilate them manually till they can be placed back on a machine in a safe environment PASS Acronym
Pull the pin
Aim low at base of the fire
Squeeze the handle
Sweep the unit from side to side Acute and Restorative care: Seizures - - A patient with a metabolic and neurological disturbance/injury are at risk
They are at risk for injuring themselves due to tonicity (rigidity of muscles), clonicity (jerking of muscles), and loss of consciousness
They usually last 3 to 5 minutes

Acute Care - Patients with acute pulmonary illnesses require nursing interventions directed toward halting the pathological process, shortening the duration and severity of the illness, hospitalization, and preventing complications. Dyspnea Management

Dyspnea is difficult to treat. Pharmacological agents include bronchodilators, inhaled steroids, mucolytics, and low-dose antianxiety medications. Airway Maintenance
Airway maintenance requires adequate hydration to prevent, thick, tenacious secretions. Interventions such as suctioning, chest physiotherapy, and nebulizer therapy assist patients in managing alterations in airway. Mobilization of Pulmonary Secretions
Nursing interventions promoting removal of pulmonary secretions such as repositioning and suctioning assist in achieving and maintaining a clear airway and help to promote lung expansion/gas exchange. Hydration
The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2500 ml/day unless contraindicated by cardiac or renal status. Humidification
The process of adding water to gas to keep airways moist. Oxygen humidification via nasal cannula or face mask is achieved by bubbling oxygen through sterile water. Nebulization
Nebulization adds moisture to inspired air by mixing particles of varying sizes with the air. Coughing and Deep Breathing Techniques
Coughing is an effective technique for maintaining a patent airway. Chest Physiotherapy
Chest physiotherapy is external chest wall manipulation using percussion, vibration, or high-frequency chest wall compressions. Postural drainage: a component of pulmonary hygiene; it consists of drainage, positioning, and turning and is sometimes accompanied by chest percussion and vibration. Positive Expiratory Pressure
PEP is an airway clearance technique that can be u Acute Care for Pressure Injury - • Definition: emergency first aid for traumatic wounds and also aggressive management of stable, acute, and chronic wounds

Adjuvants - Co-analgesics or adjuvants are drugs originally developed to treat conditions other that pain but that also have analgesic properties. Administering Injections: Subcutaneous Injections - Subcutaneous injections involve placing medication into the loose connective tissue under the dermis. Because the skin is not rich which blood vessels, it takes a longer time for absorption to occur.

Sites for SUBQ: Outer posterior aspect of the upper arm, the abdomen from below the costal margins to the iliac crest, and the anterior aspects of the thighs.
Heparin is given in the abdomen.
Angle of insertion
45-degrees
90-degrees Administering Medications by Inhalation - Pressurized metered-dose inhalers (pMDIs): delivers medication that produce local effects. -Need sufficient hand strength for use -May be used with a spacer Breath-actuated metered-dose inhalers (BAIs) -Release depends on strength of patient's breath Dry powder inhalers (DPIs) -Activated by patient's breath and delivers more medication to the lung Administering Medications by Irrigation - - Irrigations most commonly use sterile water, saline, or antiseptic solutions on the eye, ear, throat, vagina, or urinary tract.
Use aseptic technique if there is a break in the skin or mucosa.
Use clean technique when the cavity to be irrigated is not sterile, as in the case of the ear canal or vagina.
Irrigations cleanse an area, instill a medication, or apply hot or cold to injured tissue.

Admission Nursing History Form - Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems when a patient is admitted to a nursing unit. Adult Respiratory Distress Syndrome (ARDS) - acute respiratory failure in adults characterized by tachypnea, dyspnea, cyanosis, tachycardia, and hypoxia. Fluid in the alveoli sacs Afterload - The force or resistance against which the heart pumps. Airborne Precautions - Focuses on diseases that are transmitted by smaller droplets, which remain in the air for longer periods of time. Airborne Precautions require a specially equipped room with a negative airflow referred to as an airborne infection isolation room.

High-efficiency Particulate Air (HEPA) filters the air directly outside. Alignment and Balance - The terms body alignment and posture are similar and refer to the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying.
- Disease, injury, pain, physical development, and life changes compromise the ability to remain balanced. Impaired balance is a major threat to mobility and physical safety and contributes to a fear of falling and self-imposed activity restrictions. All health record contains the following information: - Patient identification Existence of "living will" or "durable power of attorney for health care" documents Informed consent for treatment and procedures Admission data Nursing diagnoses or problems and the nursing or interprofessional data Record of nursing care treatment and evaluation Medical history Medical diagnoses Therapeutic orders Medical and interprofessional progress notes Physical assessment findings Diagnostic study results

Risk for Infection
Impaired Nutritional Status: Deficient Food Intake
Impaired Oral Mucous Membrane
Social Isolation
Impaired Tissue Integrity Analysis and Nursing Diagnosis (Pulse) - Pulse assessment determines the general state of cardiovascular health and the response of the body to other system imbalances. Tachycardia/Bradycardia/Dysrhythmias are important assessment data that support many nursing diagnoses, including the following examples:
- Activity Intolerance
- Dehydration
- Hypervolemia
- Impaired Cardiac Function
- Impaired Peripheral Tissue Perfusion Analysis and Nursing Diagnosis (Temperature) - After concluding your assessment, identify patterns or clusters of assessment data to form a nursing diagnosis. Examples of additional nursing diagnoses for patients with body temperature alterations: Impaired thermoregulation
- Risk for impaired thermoregulation
- Hyperthermia
- Fever
- Chronic fever Anatomy and Physiology of the Digestive System - - Digestion: The mechanical breakdown that results from chewing, churning, and mixing with fluid and chemical reaction in which food is reduced to its simplest form.
Absorption: The small intestine, lined with fingerlike projections called villi, is the primary absorption site for nutrients.

Metabolism and storage of nutrients: Metabolism refers to all the biochemical reactions within the cells of the body. Through the chemical changes of metabolism, the body converts nutrients into several required substances.
Elimination: Chyme moves by peristaltic action through the ileocecal valve into the large intestine, where it becomes feces. Water is absorbed (the longer feces remains in the tract the more water is absorbed). Feces is then released outside the body through the rectum. Anterior Thorax - - Observe accessory muscles.
Palpate muscles and skeleton.
Assess tactile fremitus.
Compare right and left sides.
Auscultate for bronchial sounds. Anti-embolism Stockings: - - The provider order one or the other
Heel to end of butt Antipyretics - Medications that reduce fever. Acetaminophen (Tylenol) and nonsteroidal anti- inflammatory drugs as ibuprofen, salicylates, and indomethacin reduce fever by increasing heat loss. Artificial Airway - Any tube inserted into the respiratory tract for the purpose of maintaining an airway and facilitating ventilation Asepsis - The absence of pathogenic (disease-producing) microorganisms. Aseptic technique refers to the practice/procedures that help reduce the risk for infection. Assessing for Edema - - 1+ mild pitting, slight indentation, no perceptible swelling (2mm).
2+ moderate pitting, indentation subsides rapidly (4mm).
3+ deep pitting, leg looks swollen, indentation remains a short time (6mm)
4+ leg is grossly swollen, very deep pitting, indentation lasts a long time (8mm+) Assessing the Heart: Auscultation - Begin with the diaphragm and listen for rate, rhythm, identify S1 and S2 separately. Some sounds may flow together. Then try to identify any extra heart sounds or murmurs.

Assessment of Blood Pressure - Arterial BP measurements are obtained either directly (invasively) or indirectly (noninvasively). The direct method requires the insertion of a thin catheter into an artery. Common indirect requires either a sphygmomanometer and stethoscope with auscultation or an automated oscillometric device without auscultation. Assessment of Diffusion and Perfusion - Measurement of arterial oxygen saturation (SaO2), the percent of hgb that is bound with O2 in the arteries Usually 95%-100% Measure with pulse oximeter on digit, earlobe, toe if needed Assessment of Pain - It is your job to accept the patient's level of pain not the patient's responsibility to prove it.

Subjective - The patient's description of discomfort (scale 1-10, faces scale for children and those who are unable to communicate)
Objective - Detectable signs of pain (restlessness, moaning, grimacing, diaphoresis, vital sign changes, pallor, guarding area of pain) Assessment of Pressure Injury - • Anatomic location
Size (length, width and depth in centimeters)
Tracts or tunneling
Necrotic tissue
Wound bed (granulation tissue present?)
Odor
Pressure injury edges and surrounding skin (redness, warmth, induration (hardness), swelling and signs of infection) Assessment of Pressure Injury Continued - - Environment: Be aware of environmental factors in the health care setting that have the potential to affect your ability to assess a patient's skin integrity.
Skin: Perform skin assessment of a patient when you initiate care and then at minimum of once a shift. Inspect the skin for signs of skin breakdown and/or injury. High risk patients need more frequent skin assessment, sometimes as often as every 4 hours.

Wounds and Pressure Injuries: When you identify the presence of a skin would or pressure injury, closer assessment is required. Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression of healing. Soft yellow or white tissue is characterized as slough. Black, brown, tan, or necrotic tissue is eschar, which needs to be removed before healing occurs as well as slough. Assessment of Pulse - Assessing a patient's peripheral pulse determines the integrity of the cardiovascular system. The radial and apical locations are the most common sites for pulse rate assessment. Assessment of Urine - - Intake and output: Assessment of I&O is a way to evaluate bladder emptying, renal function, and fluid and electrolyte balance. Urinary output is a key indicator of kidney and bladder function. Urinary output below 30ml/h might be a sign of blood loss
Characteristics of Urine:
- Color: Pale-straw to amber color
- Clarity: Transparent unless pathology is present
- Odor: Ammonia in nature
Urine Testing:
- Specimen collection Assessment of Ventilation - Easy to assess
Respiratory rate: breaths/minute
Ventilatory depth: deep, normal, shallow
Ventilatory rhythm: regular/irregular Assistive Devices for Walking - Walkers
- A walker is a lightweight, movable device that stands about waist high and consists of a metal frame with handgrips, four widely places sturdy legs, and one open side. Typically used for patients with lower extremity weakness or has problems with balance. Canes
- Canes provide less support than a walker and are less stable. The cane should be place on the patient's strong side. Quad cranes provide the most support and is used when there is partial or complete leg paralysis.

Around 50,000 people a year go to the ER due to CO poisoning
Nutrition:
Requires knowledge about healthy food and food safety
48 mil people a year get sick from a foodborne illness
Knowledge about food care prevents food infections and poisoning
Temperature:
Extremes poses safety risks to vulnerable populations
Those at risk for hypothermia:
Older adults
Children
People with cardiovascular conditions
People that consumed drugs and/or alcohol
People who are homeless Bath Guidelines - - Provide privacy
Maintain safety
Maintain warmth
Promote independence
Anticipate needs Bilevel Positive Airway Pressure (BiPAP) - Works by providing assistance during inspiration and preventing alveolar closure during expiration. Blanchable Hyperemia - Redness of the skin caused by dilation of the superficial capillaries. When pressure is applied to the skin, the area blanches, or turns a lighter color. Blanching - Occurs when the normal red tones of the light-skinned patient are absent. When checking for pressure injuries in patients with dark-pigmented skin, dark skin may not show the blanch response.

Blood Pressure - The force exerted on the walls of an artery by the pulsing blood under pressure from the heart. Blood Pressure Assessment in Children - Blood pressure measurement in the ambulatory setting begins at 3 years of age. Body System Defenses - A number of body organ systems have unique defenses against infection. Each organ system has defense mechanisms physiologically suited to its specific structure and function. Ex. Skin Respiratory Tract, GI tract have methods to reduce the likelihood of infection. Body Temperature - The difference between the amount of heat produced by body processes and the amount of heat lost to the external environment.

Heat Produced - Heat Lost = Body Temperature Bowel Diversions - Certain diseases or surgical alterations make the normal passage of intestinal contents throughout the small and large intestine difficult or inadvisable. When these conditions are present, a temporary or permanent opening (stoma) is created surgically by bringing the part of the intestine out through the abdominal wall. Either called an ileostomy or colostomy Bowel Diversions: Ileoanal Pouch Anastomosis - The ileoanal pouch anastomosis is a surgical procedure for patients who need to have a colectomy for treatment of ulcerative colitis or familial adenopolyposis Bowel Diversions: Ostomies - Location of an ostomy determines consistency.
Person with a sigmoid colostomy will have more formed stool.
The output from a transverse colostomy will be thick liquid to soft consistency.
With an ileostomy the fecal effluent leaved the body before it enters the colon, creating frequent, liquid stools.
Loop colostomies are reversible stomas that a surgeon constructs in the ileum or the colon. The surgeon pulls a loop of intestine onto the abdomen and often places a plastic rod, bridge, or rubber catheter temporarily under the bowel loop to keep it from slipping back/
The loop ostomy has two openings through the stoma. The proximal end drains fecal effluent, and the distal part drains mucus.

Cardiac Enzymes: Providers use cardiac enzymes, along with troponin to diagnose acute myocardial infarcts.
Cardiac Troponins: Troponin levels elevate as early as 3 hours after myocardial injury. Often remains elevated for 10-14 days.
PT/PTT: Tests how fast someone coagulates
Arterial Blood Gas: Test for oxygen, carbon dioxide, and the pH
Electrolyte: Tests the amount of electrolytes in the body (Note: Potassium is important for heart contractions) Cardiovascular Physiology - Cardiopulmonary physiology involves delivery of deoxygenated blood (blood high in carbon dioxide and low in oxygen) to the right side of the heart and then to the lungs, where it is oxygenated.
- Oxygenated blood (blood high in oxygen and low in carbon dioxide) then travels from the lungs to the left side of the heart and the tissues. Structure and Function
- The right ventricle pumps deoxygenated blood through the pulmonary circulation. The left ventricle pumps oxygenated blood through the systemic circulation. Myocardial Blood Flow
- The pumping action of the heart is essential to oxygen delivery. Myocardial Blood Flow
- To maintain adequate blood flow to the pulmonary and systemic circulation, myocardial blood flow must supply sufficient oxygen and nutrients to the myocardium itself. Care of the eyes, ears, and nose - Medical devices:
- Oxygen tube
- Feeding tube
- Nasotracheal tube
- You need to protect skin of those areas from getting MDRPI (medical device related pressure injury)
Basic eye care
- Unconscious patients require more frequent eye care
- Eyeglasses
- Take care to not break patient's glasses

Contact lenses
- Educate patient on removing contacts throughout the day to not have eye complications from leaving them in
- Figure out whether patient has them so you know to remove them
Ear care
- Instruct patients not to use q-tips
- You can clear out impacted cerumen by irrigating the ear
- Their provider needs to write an order for that to happen
Hearing aid care
- 4 types:
1. Completely in canal (CIC)
2. In the ear (ITE)
3. Behind the ear (BTE)
4. Digital hearing aid Care Plans - Written plans developed by the nurse that outline the steps taken by the staff to reach the goals or outcomes set Case Management Model - incorporates an interprofessional approach to delivery and documentation of patient care. Cerumen - A waxy substance secreted by glands located throughout the external canal Chain of Infection - •Infectious agent •Reservoir: source of pathogen growth •Portal of exit from the reservoir •Modes of transmission •Portal of entry •Susceptible host

Nursing Care for Patients with Acute and Chronic Wounds, Study notes of Nursing

Related documents

Partial preview of the text

Download Nursing Care for Patients with Acute and Chronic Wounds and more Study notes Nursing in PDF only on Docsity!

Nursing 204 - Complete Study Guide

Final Exam Quizzes and Verified

Answers 2024 2025