Trauma Wound Care and Infection Prevention in HIV Patients, Exams of Nursing

Download Trauma Wound Care and Infection Prevention in HIV Patients and more Exams Nursing in PDF only on Docsity! MULTIDIMENSIONAL CARE PREP EXAM Questions and Answers Latest Update 2024 GRADED A+ What are the 4 levels of wound contaminiation? - ANS-- Clean - Clean-contaminated - Contaminated - Infected Level of Contamination: Clean - ANS-minimal infection Level of Contamination: Clean - ANS-increased risk for infection (surgical incisions that enter the GI tract, respiratory, or genitourinary) Level of Contamination: Contaminated - ANS-high risk for infection (trauma). Open wounds through trauma or surgical incision that break asepsis Level of Contamination: Infected - ANS-Bacteria count is greater than 100k (any presence in beta-hemolytic streptococci is considered infected) What are the 4 wound depth descriptions? ANS-- superficial - Partial thickness - Full thickness - Penetration Wound depth: Superficial - ANS-damage to epidermis (shearing, friction) Wound depth: Partial thickness Signs of internal hemorrhage - ANS-- swelling - changes in vital signs - pain Complication of Wound healing: Infection - ANS-microorganisms are introduced to wound. Signs include swelling, redness, heat, pain, fever, foul smell, change in color of drainage Complication of wound healing: Dehiscence - ANS-Rupture or separation of one or more layers, occurs during inflammation stage of healing - occurs often in the abdomen - caused by obesity, poor nutrition status, wound infection, increased tension in suture line (coughing) - hear a pop or tear feelingN Nursing intervention for Dehiscence - ANS-- elevate bed at 20 degrees and have knees flexed - apply binder to prevent eviscerations - notify provider Complication of wound healing: Evisceration - ANS-total separation of layers medical emergency rare complication of surgical emergency Nursing interventions for evisceration - ANS-- cover wound with sterile towels - have patient stay in bed with knees bent - DO NOT put a binder - notify surgeon and prepare for surgery Complication of wound healing: Fistulas - ANS-abnormal passage connecting two body cavities and skin First thing you do when obtaining a wound culture? - ANS-Wash hands Diagnostic studies for wound infection: Cultures - ANS--Fungal infection -bacterial infections -viral infection Diagnostic studies for wound infection: skin biopsy - ANS-- punch biopsy: 2-6cm of plug tissue is removed - shave biopsy: removal of raised lesion - excisional biopsy: obtained with a scalpel After care for skin biopsy - ANS-o Keep dressing dry and intact for at least 8 hours o Clean site daily o Antibiotic cream may be prescribed to reduce risk of infection o Report any redness of drainage (signs of infection) o If sutures are used they are usually removed after 7-10 days. Wood's light examination - ANS-A type of dermatologic examination in which a physician inspects the patient's skin under an ultraviolet lamp in a darkened room Diascopy - ANS-examination of skin lesions by pressing a glass plate against the skin Risk factors for pressure ulcers - ANS-- impaired mobility - impaired sensation (Stroke, spinal injury) - impaired communication - Mechanical forces: shearing, friction (keep bed at 30 degrees or lower) - Moisture - impaired nutrition status (low protein) Braden scale - ANS-scale that evaluates risk for pressure injury. Higher the number the higher the risk Tests... - sensory perception - moisture - activity - mobility - nutrition - mechanical forces Norton Scale - ANS-similar to braden but less in depth (low score indicates higher risk for pressure ulcers) Evaluates... physical condition mental status activity mobility incontinence Analysis/diagnosis for pressure injury - ANS-- risk for impaired tissue integrity - risk for impaired skin integrity - risk for disturbed body image - risk for infection - risk for pain Interventions for pressure injury - ANS-Positioning: pad hard surfaces, do NOT elevate bed more then 30 degrees Nutrition: high protein diet, high calorie intake, fluid intake b/t 2000-3000 mL/day Skin care: daily skin inspection, moisturize dry skin, do not massage bony prominences, use moisture barriers, humidify room CMP Albumin Protein levels Blood culture x2 When does the wound healing phase start? - ANS-As soon as the injury happens how is trauma classified - ANS-§ Incisional (surgical or clean cut with a knife) § Laceration (skin tear) § Abrasion (road rash) § Puncture (stab) § Penetration (gun shot) § Contusion (fall, bruises) § Hematoma (forced injury) Interventions for trauma wound care - ANS-§ Wound irrigation (lavage) would be needed § Use a high-pressure irrigation of 35-70psi to remove debris Hydrophobic dressings - ANS-nonabsorbent, waterproof useful for when wound has little drainage Hydrophilic dressings - ANS-absorbent, useful for excessive drainage What is normal WBC count? - ANS-5-10k What studies are done to determine inadequate blood flow to a delayed healing wound? - ANS- arterial blood flow studies What is the chain of infection? - ANS-1. infectious agent 2. reservoir 3. portal of exit 4. mode of transmission 5. portal of entry 6. susceptible host Infectious agent - ANS-a pathogen, such as a bacterium or virus that can cause a disease o Factors that determine if a pathogen causes an infection § Virulence: power of the agent to cause a disease. § Ability of the pathogen to survive in the host environment § Number of the organisms § Ability of the host to prevent the infection Reservoir - ANS-the place where the organisms survive and multiply - human body - animals - insects - nonliving surfaces (soil, water, food) - environmental surfaces (temp of 95 degrees is ideal for pathogens) Mode of transmission - ANS-- Direct contact - indirect contact - droplet transmission - airborne transmission - vector: organism carrying a pathogen to a susceptible host by biting, stinging, and creating a portal of entry Portal of entry - ANS-- normal body openings - cutes, scrapes, surgical incisions - invasive devices like IV sites or urinary catheters Susceptible host - ANS-person at risk because of inadequate defenses against the pathogen - age - compromised immune system (cancer treatment) - conditions causing immune deficiency (HIV) If a patient states they are feeling pain 5/10 what is the priority nursing intervention? - ANS- Administer/ order pain medication How do you break the chain of infection? - ANS-hand washing Nursing activities planned to break the links in the chain of infection: Infectious agents - ANS-o Reduce exposure to pathogen by using aseptic technique o Maintain skin integrity and support natural defense systems of the body against infections o Reduce stress o Reduce the length of time clients require invasive devices (medical equipment) Nursing activities planned to break the links in the chain of infection: Reservoir - ANS-o Maintaining a clean environment § Avoid stocking with unnecessary supplies § Clean all reusable equipment before using it on another patient § Dispose of all supplies brought to the room when patient is discharged, they are contaminated. o Proper care of equipment Nursing activities planned to break the links in the chain of infection: Mode of transmission - ANS-- standard precautions for ... - contact precautions: gloves and gown - droplet precaution: mask - airborne precautions: N95 What is the key role of cell-mediated immunity? - ANS-prevention of the development of cancer and metastasis after exposure to carcinogens. If a patient with HIV develops pneumonia, what kind of infection is this called? - ANS-Opportunistic infection What is nursing priority for an immunocompromised patient? - ANS-WASH HANDS What happens with CD4 cells and Tcells with HIV? - ANS-reduce CD4 less then 200 = AIDS Opportunistic infections related to HIV - ANS-candida PCP C-diff TB Herpes cytomegalovirus histoplasmosis Assessment for HIV - ANS-§ General information: age, gender, occupation, living arrangement § Information about current illness § Information about diagnosis of HIV infection § Inquire about STI's and other infectious diseases such as TB, drug use, § Cognitive function and knowledge level regarding the treatment and management of the disease. § Understanding of safe sexual practices Integumentary assessment for HIV - ANS-· Dry skin · Poor wound healing · Skin lesions · Night sweats Respiratory assessment for HIV - ANS-· Cough · Shortness of breath GI assessment for HIV - ANS-· Diarrhea · Weight loss · Nausea and vomiting . Dehydration Renal assessment for HIV - ANS-. nephropathy CNS assessment for HIV - ANS-· Confusion · Dementia · Fever . Headache · Visual changes · Memory loss · Personality changes · Pain · Seizures Immune system assessment for HIV - ANS-Lymphadenopathy fatigue opportunistic infections endocrine assessment for HIV - ANS-· Changes in gonad function · Changes in body shape Psychosocial assessment for HIV - ANS-Social support system An HIV patient has PCP, what is the nursing priority? What do you check for first? - ANS-LUNG SOUNDS Laboratory Assessment for HIV - ANS-§ Lymphocytic Counts · CD4+ and CD8+ counts § Antibody-Antigen Tests § Viral load testing § CBC with differential § Antibodies for hepatitis A, B, And C § Lipid profile § TB testing § Toxoplasmosis antibody titer § Cervical and anal pap smear § Bone marrow aspiration § Stool for ova and parasites § Biopsy of the skin, lymph nodes, lungs, liver, GI tract, or brain § Chest x-ray § Gallium scans, bronchoscopy, endoscopy, or colonoscopy § Liver or spleen scans § CT scans § PFT § ABG Diagnosis for HIV - ANS-- risk for infection due to decrease WBC - Risk for impaired gas exchange related to impaired O2 carrying capacity -Risk for impaired tissue integrity related to diarrhea Interventions for HIV - ANS-- CART (combination antiviral drug therapy) - preventing infections - enhancing gas exchange - Managing pain - enhancing nutrition - Managing diarrhea · NSAIDS-arthralgia · Tricyclic antidepressants-neuropathy · Weak opioids: for mild pain to stronger opioids for more severe pain · Complementary therapy such as accupuncture, biofeedback, progressive relaxation Enhancing nutrition with HIV - ANS-§ Diagnostic procedures to determine the cause of malnutrition § If candidiasis is the issue for impaired swallowing for example then the patient will receive medication fluconazole to treat the infection to improve the discomfort of swallowing along with antiemetic drugs for nausea as needed. § Monitor · Weight · I and o · Calorie count § Provide food preferences § High calorie, high protein diet § Avoid high fat foods because of intolerance § Small frequent meals § Good oral care § Do not use alcohol based mouth washes Managing diarrhea with HIV - ANS-§ Medication: Diphenoxylate hydrochloride given on a regular schedule § Less fatty, spicy and sweet foods § No alcohol or caffeine § Assess perianal skin every 8 - 12 hours for integrity § Provide a bedside commode if client has difficulty reaching the bathroom Restoring skin integrity with HIV - ANS-- lesions caused by Kaposi sarcoma, herpes, varicella zoster - analgesic for pain - dress to disguise lesions Enhancing cognition with HIV - ANS-§ Reorient x3 § Provide short simple directions § Maintain safe environment-bed alarms side rails, etc § Some clients with AIDS have seizures so implement seizure precautions, padded side rails, padded tongue blade at head of bed, side rails up, oxygen and suctioning equipment readily available. Psychosocial distress with HIV - ANS-§ Acceptance of the client and a positive inter-professional relationship § Assess for indications of depression What is the most common arthritis in the US? - ANS-Osteoarthritis Osteoarthritis - ANS-inflammation of the bone and joint Obtaining history for OA - ANS-- How has pain affected ADL? - Is there any swelling? - Is there any pain? - Weight history - family history - occupational history - history of joint injury - Does it affect your mobility? Physical assessment of OA - ANS-- Chronic joint pain and stiffness is the common complaint - Crepitus of the joint - Atrophy of skeletal muscle from disuse - Limp Psychosocial Assessment of OA - ANS-§ Depression § Anxiety § Altered body image/self-esteem Lab assessment for OA - ANS-§ Erythrocyte sedimentation rate § C-reactive protein Imaging assessment for OA - ANS-§ MRI & CT imaging may be helpful for vertebral and knee involvement Diagnosis for OA - ANS-o Chronic pain related to joint inflammation as evidence by a pain rating of 5 on a scale of 0 - 10. o Risk for impaired physical mobility related to pain and muscle atrophy. Pharmacological Interventions for OA - ANS-Managing chronic pain - NSAIDS - Drug therapy such as acetaminophen, tropical drug applications (lidocaine, topical NSAIDS) - cortisone injection - hyaluronic acid into the joint space of hip or knee - muscle relaxants (cytobenzaprine hydrochloride) - weak opioids (tramadol) What is the goal with medication therapy for a patient with OA? - ANS-- Reduce pain and inflammation Non- Pharmacological Interventions for OA - ANS-§ Rest balanced with exercise § Joint positioning § Heat or cold application § Weight control § Complementary/integrative therapies · Topical capsaicin · Dietary supplements such as glucosamine and chondroitin Surgical interventions for OA - ANS-o Total joint arthroplasty or total joint replacement Physical assessment for RA: later signs and symptoms - ANS-· Progressive inflammation and increased pain · Morning stiffness · Joints feel soft and puffy because of swelling · Fingers appear spindle-like · Muscle atrophy · Tendon rupture · Weight loss · Fever · Extreme fatigue · Subcutaneous nodules on the ulnar surface of the arm, fingers or along the Achilles tendon · Vasculitis · Peripheral neuropathy associated with decreased circulation can lead to foot drop and paresthesias · Pleurisy · Pericarditis/myocarditis · Sjogren's syndrome Sjogren's syndrome - ANS-Dry eyes, dry mouth, dry vagina due to arthritis psychosocial assessment of RA - ANS-§ Altered body image § Uncertainty about the disease process § Depression laboratory assessment with RA - ANS-§ POSITIVE Rheumatoid factor § Erythrocyte sedimentation rate Diagnostic assessment of RA - ANS-§ Standard x-ray § CT scan Arthrocentesis Arthrocentesis - ANS-· Insertion of a large-bore needle into the joint to remove synovial fluid to remove the pressure. o Analyzed for inflammatory cells and immune complexes § Reveals increased WBC's, cloudiness and volume · Aftercare o Teach patient to use ice and rest the affected joint for 24 hours o Acetaminophen for discomfort o Notify PCP if increase pain or swelling occurs Diagnosis for RA - ANS-o Chronic pain related to ... o Risk for impaired mobility o Risk for impaired body image Interventions for RA: Pharmacological - ANS-§ Drug therapy · NSAIDs may be given with an H2- blocking agent · Biological response modifiers o Very expensive and may not be covered by insurance o High risk for developing impaired immunity and subsequent infection o Must have a TB test prior to beginning therapy · Disease-modifying antirheumatic drugs- o Methotrexate § Slow acting taking 4 - 6 weeks to control symptoms § Cause decreasing WBC's and platelets as a result if bone marrow depression § Elevation of liver enzymes and serum creatinine § Strict birth control o Leflunomide § Slow acting § 100 mg p.o. x 3 days then 20 mg after that § Causes hair loss, diarrhea, decrease WBC's and platelets or increased liver enzymes · Steroids o Given for their fast-acting anti-inflammatory and immunosuppressive effects. o Cause many complications § Diabetes mellitus § Osteoporosis § Decreased immunity § Glaucoma § Hypertension Interventions for RA: Non-Pharmacological - ANS-§ Adequate rest § Proper positioning § Ice and heat applications § Hypnosis § Imagery § Music therapy § Adequate nutrition o Promoting rest § Quiet environment § Warm drink at bedtime § Administering hypnotics discoid lupus erythematosus - ANS-affects only the skin, characterized by lesions that are covered with scales systemic lupus erythematosus - ANS-o progressive inflammatory connective tissue disorder that causes major body organs and systems to fail. § Remissions and exacerbations § Cause direct damage to the organ or cause vasculitis which deprives the organ of blood and oxygen § Most attracted to glomeruli of the kidneys leading to lupus nephritis the leading cause of death from the disease