Unit 5 1 2004

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Information about Unit 5 1 2004

Published on January 1, 2008

Author: Miguel

Source: authorstream.com

LEG 5 A:  LEG 5 A Surgical Asepsis:  Surgical Asepsis All objects used in a sterile field must be sterile. Sterile items out of vision or below the waistline are unsterile. Sterile items become unsterile by prolonged exposure to air. Moisture draws microorganisms from unsterile surfaces to sterile objects by capillary action. Edges of a sterile field are considered unsterile. Assessments & Interventions for Removal of Retention Catheter:  Assessments & Interventions for Removal of Retention Catheter Voiding pattern Frequency 1st void Discomfort Burning, urgency, dribbling Small amounts Bladder distention Urine Color Consistency http://www.pediatrics.wisc.edu/education/derm/tuta/nodule.html (will not open - type address):  http://www.pediatrics.wisc.edu/education/derm/tuta/nodule.html (will not open - type address) Williams, pg. 942 http://www.nlm.nih.gov/medlineplus/ency/article/003220.htm#visualContent Slide5:  http://www.nsc.gov.sg/cgi-bin/WB_GroupGen.pl?id=33 http://www.skinema.com/ Pressure Sores:  Pressure Sores Factors influencing Wound Healing:  Factors influencing Wound Healing Wound environment Oxygen Temperature Patient’s Age Skin/muscle tone Metabolism Circulation Healing time Wound Healing cont…:  Wound Healing cont… Weight Obesity Nutritional status Deficiencies: CHO, protein, zinc, vitamins A, B, C Dehydration Wound Healing cont…:  Wound Healing cont… Immune Response Chronic Diseases Lab tests Skin Care Guidelines:  Skin Care Guidelines Inspect skin at least once p/shift Document findings Clean skin No hot water/mild cleansing agent Elderly (require less frequent cleansing) Keep skin moist Dry, flaky skin (pressure sores) Exception: urines, feces, perspiration, wound drainage Skin Care cont.:  Skin Care cont. Avoid massage over bony prominences ↓blood flow/skin temperature Avoid friction/shearing forces Friction: skin moves over coarse surface (bed linen) Shearing: skin stays stationary/underlying tissue shifts (↓blood supply) Precancerous Lesions:  Precancerous Lesions Moles Majority are harmless, may change into melanoma Observe for changes in color, shape, size (yellow, brown, black – flat elevated) Leukoplakia (mouth lesions) Small, pearly patches on mucous membrane Keratosis (usually not malignant/squamous cell CA) Rough, scaly with redness (sun-exposed body areas) Skin Treatments:  Skin Treatments Medicated bath (H2O, saline) Large areas Removes crusts, scales, old meds Relieves itching/inflammation Colloidal Medicated tars Bath oils Skin Treatment cont.:  Skin Treatment cont. Nursing Action Tub: ½ full (bath mat) Temp: not too hot 15 – 30 minutes Apply lubricating agent Dry by blotting Cotton clothing Warm room Skin Treatment cont.:  Skin Treatment cont. Sterile wet dressing (ulcers, crusted surfaces, erosions) Saline ↓inflammation by vasoconstriction cleans skin of crust, scales maintains drainage of infected areas Skin Treatment cont.:  Skin Treatment cont. Nursing Actions Keep patient warm ~ treat only 1/3 of body 4x4’s: moist, slightly dripping Cover with dry ABD Apply for 15 – 30 min. q 3 - 4 hours (or as ordered) Discard solution q 24 hours (date, hour, initials) tap water, NS, Burrow’s solution Skin Treatment cont.:  Skin Treatment cont. Topical medications Calamine Kenalog (steroid) Antibiotic cream Powders Systemic medications Steroids Antihistamines Sedatives Antibiotics Cancer of the Skin http://www.cancersource.com/LearnAboutCancer/core/index.cfm?DiseaseID=22:  Cancer of the Skin http://www.cancersource.com/LearnAboutCancer/core/index.cfm?DiseaseID=22 Skin surface area 15 – 20 square feet (weight: 9lbs) 99% cure rate with early diagnosis Majority cases of skin cancer between ages 30 - 60 years 40 - 50% of individuals will have skin cancer 1900 deaths (1999) Skin Cancer:  Skin Cancer Causes Exposure to sun over a period of time ↓pigment (melanin) Exposure to radiation Exposure to chemical agents Burn scars Genetic susceptibility Environment Viruses Skin Cancer:  Skin Cancer Assessment Chronic sunburn Sun damage Precancerous lesions Change in a skin lesion Skin Cancer:  Skin Cancer Diagnosis Biopsy Physical Exam Basal Cell Carcinoma:  Basal Cell Carcinoma Most common skin cancer (5th layer, “rodent ulcer’) Lesions small nodules with ulcerated centers pigmented, superficial, cystic head, neck, cheeks, trunk uncommon on palms and soles rarely spreads tend to reoccur (larger than 2 cm) Squamous Cell Carcinoma:  Squamous Cell Carcinoma Invasive carcinoma (epidermis) Lesions Rough, thickened, scaly tumor Lower lip, rims of ears, head, neck, hands (75% head, 15% hands, 10% elsewhere) Greater chance of metastasis Medical Treatment:  Medical Treatment Tx depends on: tumor location, cell type (location & depth) hx of previous tx (whether or not invasive & metastatic nodes are present.) Curettage followed by electrosurgery (small tumors, < 2cm) Excision of tumor by scraping with curette Low voltage electrode to destroy tumor Surgical excision Wide excision (verified by microscopic study of specimen) Skin grafting or skin flap for large tumors Cont…:  Cont… Mohs micrographic surgery Fresh tissue excised in layers Frozen, stained at each level to determine tumor margin Most accurate and conserving of normal tissue Cure rates 99% basal, 94% squamous Radiation therapy Eyelid, tip of nose, in or near vital structures (1 - 8cm) Painless tx, 3 - 4 weeks Reddening & swelling of skin (by 3rd tx) Cont…:  Cont… Cryosurgery Deep freezing of tumor tissue Liquid nitrogen applied by cryospray -40 to –60 C, tissue is frozen, thawed, refrozen Healing takes 4 - 6 weeks Topical chemotherapy 5-FU Cream, reaches only skin surface Used for premalignant lesions Redness, sensitivity for a few weeks Patient Teaching:  Patient Teaching Avoid sunlight Apply protective sunscreen Wear protective clothing Avoid tanning parlors Moles Inspect skin Caution children/grandchildren http://www.aad.org/ Malignant Melanoma:  http://www.aad.org/ Malignant Melanoma 4% of skin cancers 79% of skin cancer deaths Has doubled since 1973 from 6 – 13 people per 100.000 Less common then basal and squamous cell carcinoma 10 times more common in fair-skinned people Highest incidence: Caucasian upper middle class working indoors More common in women (20’s - 30’s, 2nd only to breast Ca) than men Gene p16 Cont…:  Cont… Appearance Pigmented (black, gray, brown, blue, red, white) 1/3 develop in existing moles > than 6 mm in diameter (3 - 6mm) Eroded or ulcerated Irregular outline Itching Satellite lesions Location Any cutaneous area Trunk (men) Legs (women) A-asymmetry B-border irregularity C-color variegation D-diameter >than 6mm Cont…:  Cont… Tx: Surgery (tumor & lymph nodes) Chemotherapy Interferons Radiation Vaccine Survival rate Stage I: 90% Stage II & III: 50-80% Stage IV & V: 20-30% Systemic Lupus Erythematous (SLE):  Systemic Lupus Erythematous (SLE) Chronic, inflammatory, autoimmune disease Damage to connective tissue (blood vessels, mucous membranes, joints) Involving multiple organ systems Discoid Lupus (DLE) Chronic eruption of skin (not life-threatening) May become systemic SLE cont…:  SLE cont… Clinical features Etiology is not understood (genetic link→ runs in families, viral, hormonal, environmental) Most frequently in women with skin & joint problems (9:1 over men), average age 30 years Majority African-American women Spontaneous remissions & exacerbations Often difficult to validate diagnosis SLE cont…:  SLE cont… Clinical manifestations (vary greatly, mimic other diseases) Arthritis & arthralgia, low-grade fever Skin rash (butterfly), photosensitivity, bruising, alopecia Lymphadenopathy, anemia, leukopenia, thrombocytopenia CV – pericarditis, pleural effusion Renal – proteinuria, blood, renal failure CNS – depression, neurosis, psychosis, convulsions SLE cont…:  SLE cont… Diagnosis Clinically documented multisystem disease Presence of antinuclear antibodies ↑SED rate Rheumatoid factor test CBC, renal function tests Nursing Interventions:  Nursing Interventions Skin integrity Joint pain Nutritional intake Nursing Interventions:  Nursing Interventions Medication SE Counseling Onset of new S/S Syphilis (shame, repulsive) http://www.cdc.gov:  Syphilis (shame, repulsive) http://www.cdc.gov 1530 – poem published by Fracastorius Summarized hx of syphilis (syphilis or the French disease) Italians-French-New World Indians-Spanish-English-Germans-Russians-Poles-Turks-Japanese-Portuguese Cont…:  Cont… Cause Treponema pallidum Acquired by sexual contact Needs moisture, warmth Transported across placenta (25%: stillbirth or neonatal death) 1996: 11,387 primary & secondary cases S & S:  S & S Primary syphilis 1st symptom: chancre (“shan-ker”) 10 days to 3 months after exposure (2 - 6weeks) Painless (inside the body) Penis, vagina Cervix, tongue, lips Disappears in a few weeks (with or without tx) S & S cont…:  S & S cont… Secondary syphilis Skin rash (3 - 6 weeks) Physical contact will spread infection Mild fever, sore throat, swollen lymph glands fatigue HA, hairloss Symptoms may come and go over next 1 - 2 years S & S cont…:  S & S cont… Latent stage No symptoms, not contagious Tertiary stage CV CNS Skeletal system Late syphilis (final stage) Mental illness Psychosis Diagnosis:  Diagnosis “Great imitator” S & S Bacteria (scraping of surface of chancre) Blood tests VDRL RPR FTA-ABS Spinal tap Treatment:  Treatment Penicillin – IM Erythromycin Periodic blood tests Screening Prevention Vaccine Dx test using saliva and urine 5A PVD (Peripheral vascular disorders):  5A PVD (Peripheral vascular disorders) S & S Chronic ischemia Initial Symptom: Intermittent Claudication (if only Sx, extremity may appear normal, but pulses are reduced/absent) Pain, aching, cramping Most commonly in calf (foot, thigh, hip, buttocks) Tired feeling when walking Relieved quickly by rest (usually in 1 - 5 min.) Sitting is not necessary – relief can be gotten by standing Pain ↑ by walking rapidly or uphill Cont…:  Cont… Claudication never occurs at rest If ischemic pain occurs at rest, disease may be advanced Rest pain Most distal parts of leg Aggravated by elevation/prevents sleep Symptoms of ischemic foot Cold (numb), painful) Skin (dry, scaly with poor nail and hair growth) Arterial Ulcers (complete or partial arterial blockage→tissue necrosis and/or ulceration):  Arterial Ulcers (complete or partial arterial blockage→tissue necrosis and/or ulceration) S/S Absent pulses of the extremity Painful ulceration (small areas, well confined) Cool/cold skin, dependent redness (pain when legs↑) Delayed capillary refill Atrophic appearing skin (shiny, thin, dry) Loss of digital and pedal hair (top of foot) Outer side of ankle, tips of toes Arterial Ulcer:  Arterial Ulcer Diagnosis:  Diagnosis Noninvasive Doppler studies Scanning Invasive Arteriogram Surgical: Angioplasty Removal/bypass part of large artery (blocked) Lasers, ultrasonic catheters, stents, rotational sanders, mechanical cutters Treatment:  Treatment Surgery Grafting (connecting 2 blood vessels with good blood flow) Walking 60 min/day, if possible No tobacco Vasodilators ↑HOB 4 - 6 “ Trental Buerger-Allen Exercises:  Buerger-Allen Exercises Lie flat – legs up for 2 min. or until blanching Place legs in dependent position, until cyanotic/red Lie in horizontal position for 1 min. Repeat exercise 4x – 3x daily Foot care:  Foot care Inspect/feel feet daily (cracks, calluses, fissures, corns, ulcers) Wash feet in lukewarm water, using mild soap Dry gently Use lubricant Use nonmedicated foot powder Cut toe nails straight across Calluses/corns should be treated by podiatrist Cont…:  Cont… No tapes/adhesive plasters Change socks daily, no constricting garments No hot water bottles/electric pads Wear wide-toed shoes Do not walk barefoot Amputation:  Amputation Uncontrolled infection, gangrene Amputation should be as distal as possible Knee should be preserved for optimal use of prothesis Thrombophlebitis (clot formation in a vein secondary to phlebitis):  Thrombophlebitis (clot formation in a vein secondary to phlebitis) Causes Venous stasis Prolonged sitting Injury to a vein Pressure of a tumor, pregnancy Hypercoagulability High-Risk Factors:  High-Risk Factors Hip fx Major surgery after age 40 MI, CVA Prosthetic joint replacement Contraceptives Assessment:  Assessment Inspect ↓ extremities Note symmetry/asymmetry Note venous distention, edema, puffiness Test for temperature variations Check for signs of obstructions Nursing Interventions:  Nursing Interventions No massaging/rubbing legs Consult Dr. re positioning of leg If prescribed, use heat Anticoagulant therapy Wear support hose Active exercises (unless contraindicated) Do not dangle Walking (10 minutes q hour) ↑Fiber in diet No nicotine Heparin:  Heparin IV or SQ/units 2 nurses to check dosage Do not aspirate/massage Lab test: PTT Normal lab value: 30 to 45 sec. (1.5 – 2.5 higher than normal to be therapeutic) Antidote: Protamine sulfate Dosage: depends on PTT Coumadin:  Coumadin PO Lab test: PT (Protime) Normal lab value 9.6 – 11.8 sec. 9.5 – 11.3 sec. 1.5 – 2 higher than normal to be therapeutic INR (normal 1.3 – 2.0) On coumadin: 2.0 – 3.0 Oral maintenance dose: 2 – 10 mg daily (depends on PT, INR) Antidote: Vitamin K Side Effects/Nursing Interventions:  Side Effects/Nursing Interventions Bleeding (gums, urine, stool, emesis) Bruises Medic Alert bracelet Keep PT appointments Electric razor Wear shoes No ETOH, cigarettes Raynaud’s Disease:  Raynaud’s Disease ↑sensitivity to cold or emotional factors Occurs mainly in hands (fingertips) Cause unknown Women (18 – 40 years old, smokers) Tool Workers Exposure to cold/emotional stress Signs/Symptoms:  Signs/Symptoms Intermittent vasoconstriction in arteries Pain Coldness, paleness Ulceration of fingertips Color changes Blue: stagnant blood flow White: blanching, severe spasms Red: rewarming Nursing Actions:  Nursing Actions Wear warm clothing/gloves Avoid injury to hands No smoking/stress Vasodilators Reserpine, dibenzyline, procardia Varicose Veins:  Varicose Veins Pathophysiology Incompetent valves One-way valves in deep veins maintain direction of venous flow Deep veins back-up into superficial veins Pressure ↑, vein dilates, Wall distends Causes: Heredity (80%) Obesity Pregnancy Injury Standing for long periods Signs/Symptoms:  Signs/Symptoms Large, discolored leg veins Brawny edema Hardened skin Aching/fatigue with weight bearing ↓Sensation Venous ulcers Nursing Interventions:  Nursing Interventions Support hose No constrictive clothing Limit long standing/sitting Do not cross legs Lose weight ↑FOB 15 – 20 cm for night sleeping Avoid injury to legs Surgical Treatment:  Surgical Treatment Ligation and stripping (saphenous system) General anesthesia/scarring Micro-surgical procedure (largest varicose veins) Office procedure/micro-scars Sclerotherapy (no anesthesia, any veins) Injection of a solution/veins shrink Ambulatory phlebectomy micro-extraction Large surface varicosities, small incisions, no stitches Compression bandages for one week Pts. encouraged to walk to re-route the blood thru deep healthy veins Burns:  Burns 50% of burn accidents can be prevented 1 of every 13 fire death was set by a child Most frequently admitted: Children, ages newborn to two-years old 5 to 74 (outdoor burn injuries) 75 and up (kitchen) 30% of total body area ($ 200,000) Severity of a burn:  Severity of a burn Cont…:  Cont… Cont…:  Cont… First Aid:  First Aid 1st degree burn Cool water (not ice water) Cover with sterile non-adhesive bandage or clean cloth OTC meds for pain 2nd and 3rd degree burns Do not remove burnt clothing Check breathing Cover burn with cool, moist sterile or clean cloth Separate burned fingers/toes Do not apply ointment, butter, ice, medications Do not breathe/cough on burned area First Stage:  First Stage Shock Phase (24 - 48 hours) Local blood vessel damage →loss of fluid into injured tissue (FVD) Fluid & proteins move from vascular to interstitial spaces (edema) ↑K (from damaged tissue to blood stream) ↓Na (lost wound exudate & shift into cells) RBC trapped in wounds (↓blood volume, BP, UO, ↑HR, anemia) Metabolic acidosis (Na goes with HCO3) Second Stage:  Second Stage Fluid mobilization/Diuresis Stage (48-72 hours) Hemodilution (↓hct) ↑UO (fluid shift) Na deficit (Na lost with H20) K deficit (K shifts from ECF into cells) Nursing Interventions:  Nursing Interventions Maintain patent airway Replace fluids IV fluids Lactated Ringer’s (isotonic - Na, K, Cl, lactate) D5W Plasma expanders (Dextran) Blood plasma Baxter formula: 4cc/kg x burned BSA 4 x 60kg = 240 x 30% = 7200cc 8hrs - 3600cc 8 hrs – 1800cc 8 hrs – 1800cc Cont…:  Cont… Weigh daily Catheter (observe UO for blood) Accurate I & O (hourly) Peripheral pulses (edema, eschar formation) O2 Breathsounds Infection, sepsis (T, purulent drainage, paralytic ileus, WBC) Cont…:  Cont… NG tube (Curling’s ulcer) Oral fluids when BT’s return, slowly adv. to reg. diet (6000 cal) Pain medication (only IV, small amounts) Body alignment ROM Medications:  Medications Topical antibiotics Silver Nitrate Solution Wet-to-dry Electrolyte imbalance (Na, K) Silvadene (sulfa) Cream Sulfamylon Cream Metabolic acidosis Grafts (3rd degree, some 2nd degree burns):  Grafts (3rd degree, some 2nd degree burns) Autograft pt’s own skin care of donor site Temporary coverage Homograft (allograft) living or deceased human being Heterograft (Xenograft) animals (pigs) Skin Substitutes:  Skin Substitutes 1997 – Dermagraft-TC Made from living human cells Artificial “interactive” burn dressings (interact directly with body tissues) Integra 2-layers Top layer: temporary synthetic epidermis Bottom layer: foundation for re-growth Biobrane Nylon material containing gelatin Interacts with clotting factors Interaction causes better adherence, forms protective layer

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