Exam 2 – MEDSURG 2024
STAND Bundle - S- Score: Using the Braden Scale for predicting pressure injury risk
T- Turn: Reposition tubes and devices,
... [Show More] turning the patients
A- Apply: Bordered foam dressing or barrier cream
N: Nutrition: Attention given to nutrition status
D: Discuss: Involvement of specialists
Pressure Injury Assessment - 1. Assess the patient
2. Assess the regional area
3. Assess the local wound area
4. Assess the peri-wound area
5. Assess the current dressing regime
Skin Layers - 1. Epidermis
2. Dermis
3. Capillary Bed (which feeds, perfuses, and supplies dermis and epidermis)
4. Fatty SUBQ tissue
5. Muscle
6. Bone
Stage 1 Pressure Injury - - COMPLETELY INTACT
- Skin area will be red but non blanchable
- Color changes are NOT purple or maroon
- May be preceded by changes in sensation, temperature, or firmness
Stage 2 Pressure Injury - - NOT INTACT
- Partial thickness loss of skin with exposed dermis
- Wound bed is viable, pink or red, and moist
- May look ruptured serum filled blister
- NO SUBQ TISSUE IS VISIBLE
Stage 3 Pressure Injury - - Full thickness skin loss with adipose (fat) visible in the ulcer
- Granulation tissue and rolled wound edges are often present
- Slough and/or eschar may be present
- Undermining and tunneling may be present
- SUBQ tissue may be damaged or necrotic
- Bone, tendon, and muscle NOT visible
Stage 4 Pressure Injury - - Full thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone
- May have slough or eschar
- Rolled edges, undermining, or tunneling may be present
Unstageable - - Slough or eschar is covering a full thickness skin loss injury
- You can't assess the actual depth of the wound because of the slough or eschar covering the wound
Deep-Tissue Injury - - Presents as a purplish or blackish areas over skin that is intact
- The fatty tissue below is injured
- May look like a black blister area
- May feel heavy/spongy
Postoperative Phase - Phase I- Immediately after surgery: 1 hour to days
Phase II- Transition phase: 30 minutes to 2 hours; patients returning to presurgical LOC
Phase III- Extended care: Continuous monitoring of vital signs; typically MedSurg units
Emphysema - - A destructive problem of lung elastic tissue that reduces its ability to recoil after stretching, leading to hyperinflation of the lung
- Changes result in dyspnea with reduced gas exchange and the need for an increased respiratory rate
Chronic Bronchitis - An inflammation of the bronchi and bronchioles (bronchiolitis) caused by exposure to irritants, especially cigarette smoke
Low-Flow Oxygen Delivery Systems - - Easy to use
- Comfortable
- Amount of oxygen delivered varies
- Nasal Cannula (1 to 6L)
Facemask for low-flow oxygen delivery system - - Simple
- Partial Rebreather
- Nonrebreather
Nasal Cannula - - Flow rates of 1 to 6 L/min
- O2 concentration of 24% to 44% (1 to 6 L/min)
- Used for chronic lung disease or long term therapy
Simple Facemask - - Delivers O2 up to 40% to 60% for short term therapy
- Minimum of 5 L/min
- Ensure appropriate fit
Partial Rebreather Mask - - Provides 60% to 75% with flow rate of 6 to 11 L/min
- Patient rebreathes one third exhaled tidal volume
Non-Rebreather Mask - - Delivers highest O2 level (of the low-flow system)
- Can deliver FiO2 greater than 90%
- Used for unstable clients who may require intubation
- Ensure valves are patent and functional
High-Flow Nasal Cannula - - 30 L/min to 60 L/min
- Combination of heat and humidity minimizes damage to mucous membranes [Show Less]