Med-Surg_Chap05.indd 58
Med-Surg_Chap05.indd 58 8/3/2011 7:28:38 PM8/3/2011 7:28:38 PM
Management ❍ 59
● Use the sheet to lift or reposition the patient in bed; don’t drag the patient up in bed
● Have an overhead trapeze bar installed for a patient who has enough strength in his upper extremities to reposition himself
● Use a slide board for transferring the patient from a bed to a stretcher
● Place sheepskin directly under the patient (unless he’s incontinent)
● Elevate the head of the bed to no more than 30 degrees, unless contraindicated
◗ Lift the patient’s heels off the bed, or use a device that totally relieves pressure on the heels
◗ Consider using a pressure-reducing or pressure-relieving mattress for a patient who is at high risk for developing pressure ulcers
◆If the patient is chair bound, take steps to minimize pressure on vulnerable skin areas
◗ Make sure the patient shifts his weight frequently
◗ Seat the patient on a 4” pressure-reducing, high-density foam pad—not a doughnut-type device
◗ Consider postural alignment, distribution of weight, balance and stability, and pressure relief when positioning a patient in a chair or wheelchair
◗ Use elbow and heel pads to protect skin and minimize friction Treatment
◆Protect the wound from further trauma
◗ Use pressure-reducing devices
◗ Reduce friction and shear
● Elevate the head of the bed no more than 30 degrees
● Use a sheet to reposition the patient in bed
● Remove dressings gently
◗ Use nonadhering dressings or those with minimal adherent
◗ Use wraps, such as a stockinette or soft gauze, to protect areas at high risk of skin tearing
◆Prevent infection and promote a clean wound base
◗ Cover the wound to protect it from infection
◗ Remove or debride any necrotic tissue
● Mechanical debridement is the manual removal of devitalized tissue using physical forces, such as whirlpooling, wet-to-dry gauze dressings, and wound irrigation
● Sharp debridement is the removal of foreign material or devitalized tissue with a sharp instrument, such as a scalpel or scissors
● Autolytic debridement uses synthetic dressings to cover the wound; this allows the enzymes natu- rally present in the wound fl uid to digest devitalized tissue
● Chemical or enzymatic debridement involves the topical application of a proteolytic substance (such as enzymes) to break down devitalized tissue
◗ Use pressurized irrigation (a 35-mL syringe with a #18 needle or angiocatheter) to clean the wound surface or cavity; use a noncytotoxic agent such as normal saline solution
◗ Absorb excess exudate with collagen or calcium alginates or absorbent powders, beads, or paste
◗ Pack dead space with collagen or calcium alginates or moistened saline nonwoven gauze dressings
◆Use a moisture-retentive dressing that keeps the wound bed moist but leaves the surrounding skin dry
◗ Use one of the following dressings for a wound with light to moderate exudate
● A transparent fi lm is a clear, adherent, nonabsorptive, polymer-based dressing that is perme- able to oxygen and water vapor but not to water; it’s used to treat partial-thickness wounds and wounds with eschar (to promote autolysis)
● A hydrogel is a nonadherent dressing composed of water and a polymer that has some absorptive properties; it’s used to treat partial- to full-thickness wounds, dry wounds, wounds with minimal drainage, wounds with necrosis or slough, and infected wounds
● A foam dressing is made up of a spongelike polymer; it can be adherent and has some absorp- tive properties, and is used to treat partial- to full-thickness wounds and wounds with minimal to heavy drainage (including around tubes)
● A hydrocolloid is an adhesive, moldable wafer made of a carbohydrate-based material, usually with a backing that’s impermeable to oxygen, water, and water vapor; the thin version has some absorptive properties; it’s used to treat partial- to full-thickness wounds, wounds with minimal to moderate drainage, and wounds with necrosis or slough
◗ For a wound with moderate to heavy exudate, use a foam dressing, a collagen or calcium alginate dressing (a nonwoven, absorptive dressing made from seaweed), or a hydrocolloid dressing, which is more absorbent than the thin dressing
◆Take steps to improve the patient’s overall condition
◗ Provide nutritional support
● Arrange for a nutritional consultation
● Provide nutritional supplements as needed
● Make sure the patient is hydrated
◗ Maintain the patient’s oxygenation and circulation
● If the patient experiences venous insuffi ciency, use compression to optimize venous return
● If the patient is diabetic, take steps to control his blood glucose level
● Institute measures to optimize the patient’s arterial blood supply and avoid circulatory impairment
◗ Help the patient reduce his stress level by involving him and his family in his care; contact the appropriate community resources
◆Minimize the patient’s pain
◗ Provide suffi cient analgesia before, during, and after dressing changes
◗ Choose dressings that maximize the time between dressing changes and that cause minimal tissue trauma
◗ Teach the patient relaxation techniques and guided imagery to help control pain and maximize the effects of pain medication
Review questions
1. A patient with an arterial ulcer over the left lateral malleolus complains of pain at the ulcer site. The nurse caring for this patient understands that the pain is caused most commonly by which of the following?
A. Infection B. Exudate C. Ischemia D. Edema
Correct answer: C Severe pain at an arterial ulcer site typically results from ischemia caused by reduced arterial blood fl ow. Option A is incorrect because infection is a complication of arterial ulceration that may not occur in all patients with arterial ulceration. Option B is incorrect because arterial ulcers have minimal exudate. Option D is incorrect because edema isn’t present with arterial ulcers.
2. A patient, age 54, is admitted with a diagnosis of venous ulceration unresponsive to treatment. Which of the following is the nurse most likely to fi nd during an assessment of a patient with venous ulceration?
A. Gangrene B. Heavy exudate C. Deep wound bed D. Pale wound bed
Correct answer: B Moderate to heavy exudate is one characteristic of a venous ulcer. Other characteris- tics include irregular wound margins, superfi cial wound bed, and ruddy, granular tissue. Options A, C, and D are incorrect because they’re characteristics of arterial ulcers.
Med-Surg_Chap05.indd 60
Med-Surg_Chap05.indd 60 8/3/2011 7:28:39 PM8/3/2011 7:28:39 PM
Review questions ❍ 61
3. The nurse is providing care for a patient who has a sacral pressure ulcer with a wet-to-dry dressing. Which guideline is appropriate when caring for a patient with a wet-to-dry dressing?
A. The wound should remain moist from the dressing.
B. The wet-to-dry dressing should be tightly packed into the wound.
C. The dressing should be allowed to dry before it’s removed.
D. A plastic sheet-type dressing should cover the wet dressing.
Correct answer: C A wet-to-dry dressing should be allowed to dry and adhere to the wound before being removed. The goal is to debride the wound as the dressing is removed. Option A is incorrect because the wet-to-dry dressing isn’t applied to keep a wound moist; a moist saline dressing is applied to keep a wound moist. Option B is incorrect because tightly packing a wound damages the tissues. Option D is incorrect because a wet-to-dry dressing should be covered with a dry gauze dressing, not a plastic sheet-type dressing.
4. The nurse is assessing the laboratory values of a patient with an abdominal wound healing by secondary intention. Which of the following laboratory values indicates that the patient is receiving adequate nutrition?
A. Serum albumin level of 2.5 g/dL B. Prealbumin level of 12 mg/dL C. Transferrin level of 190 mg/dL D. Total lymphocyte count of 1,900 mL
Correct answer: D A total lymphocyte count greater than 1,800 mL indicates adequate nutrition.
Options A, B, and C are incorrect because these laboratory values indicate poor nutrition.
5. What term describes the softening of tissue by wetting or soaking?
A. Eschar B. Maceration C. Sloughing D. Angiogenesis
Correct answer: B Maceration is the softening of tissue by wetting or soaking. Eschar (Option A) is thick, leathery, necrotic, devitalized tissue. Sloughing (Option C) is the separation of necrotic tissue from viable tissue. Angiogenesis (Option D) is the formation of new granulation vessels.
6. After assessing a patient’s pressure ulcer, you note that subcutaneous fat is visible but that bone, tendon, and muscle are not exposed. You observe slough, but it does not obscure the depth of tissue loss. You also note some undermining and tunneling. What stage pressure ulcer is this?
A. Stage II
B. Suspected deep tissue injury C. Stage III
D. Stage IV
Correct answer: C A Stage III pressure ulcer involves full-thickness tissue loss, possibly with visible sub- cutaneous fat but with no exposer of bone, tendon, or muscle; slough may be present but doesn’t obscure the depth of tissue loss, and undermining and tunneling may also be present. A Stage II pressure ulcer (Option A) involves a partial-thickness tissue loss presenting as a shallow, open ulcer with a red-pink wound bed without slough. A suspected deep tissue injury (Option B) involves a purple or maroon local- ized area of discolored intact skin or blood-fi lled blister resulting from damage of underlying soft tissue from pressure, shear, or both. A stage IV pressure ulcer (Option D) involves full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present on some parts of the wound bed.
7. During which stage of healing does granulation tissue form and epithelialization occur?
A. The maturation phase B. The epithelial closure phase C. The infl ammatory phase D. The proliferative phase
Correct answer: D During the proliferative stage of wound healing, granulation tissue forms and epi- thelialization occurs. In the fi nal maturation phase (Option A), collagen reorganizes and strengthens. In the epithelial closure phase (Option B), the wound contracts and begins to close. The infl ammatory phase (Option C) starts right after injury and doesn’t involve granulation tissue formation or epithelialization.
8. Which of the following are external factors that subject the skin to injury?
A. Emaciation and infections B. Allergens and radiation C. Radiation and emaciation D. Allergens and infections
Correct answer: B Allergens and radiation are external factors that subject the skin to injury. Emacia- tion (included in Options A and C) and infection (included in Options A and D) are internal factors.
9. Where is a venous ulcer typically found on a patient?
A. The medial lower leg and ankle B. The plantar aspect of foot C. On a bony prominence D. Under the heels
Correct answer: A A venous ulcer is typically found on the medial lower leg and ankle. A diabetic ulcer is usually found on the plantar aspect of the foot (Option B) or under the heels (Option D). A pressure ulcer is usually found on a bony prominence (Option C).
10. Which substance enables the transport of oxygen during wound healing?
A. Zinc B. Vitamin B6 C. Folate D. Vitamin C
Correct answer: C Folate enables the transport of oxygen during wound healing. Zinc (Option A) enables protein synthesis and tissue repair. Vitamin B6 (Option B) decreases collagen and protein synthe- sis, and vitamin C (Option D) is needed for collagen synthesis.
Med-Surg_Chap05.indd 62
Med-Surg_Chap05.indd 62 8/3/2011 7:28:39 PM8/3/2011 7:28:39 PM
Disruptions in homeostasis
6
❖ Stress
General information
◆Stress is the body’s response to stressors or stimuli that are perceived as threatening
◆Stressors can be biophysical (such as disease, trauma, and overexertion), chemical (such as pollution, drugs, and alcohol), psychosocial (such as job loss, divorce, and bankruptcy), or cultural (such as travel- ing, being separated from family members during hospitalization, and delegating decision making to health care providers)
◆The body responds to stress physiologically and psychologically Selye’s stress theory
◆Hans Selye’s theory describes a general adaptation syndrome that consists of three stages of a hor- monally controlled stress response
◗ The fi rst stage is the alarm reaction, in which the person is alerted to the presence of a stressor and the need to act
◗ The second stage is resistance
● In this stage, the pituitary gland secretes corticotropin
● Corticotropin stimulates the production of glucocorticoids and mineralocorticoids, which pro- mote and inhibit infl ammation, allowing the body to protect or surrender tissue
◗ If resistance continues and the body doesn’t adapt, the third stage is exhaustion, which can lead to disease or death
◆According to Selye, stress can result from positive or negative events Physiologic stress responses
◆Physiologic responses to stress involve the central nervous system, hypothalamus, sympathetic ner- vous system, anterior and posterior pituitary gland, adrenal medulla, and adrenal cortex
◗ Hormones and catecholamines are secreted or stimulated by these organs in response to a stressor
◗ Their release results in the body’s fi ght-or-fl ight response to stress
◆The initial reaction to stress is increased alertness in preparation for fi ght or fl ight
◆Blood vessels dilate, heart rate increases, the rate and depth of respirations increase, and broncho- dilation occurs; these reactions increase the oxygen supply to organs and muscles
◆The arterioles in the skin, kidneys, and abdominal viscera constrict; blood is shunted from the GI tract and periphery to the brain, heart, and major muscles
◆Gluconeogenesis increases; decreased insulin secretion and increased fatty acid metabolism increase the amount of glucose available for energy
◆Localized sweat production increases, and muscles become tense
◆Pain tolerance increases as endorphins (endogenous opiates) are released
◆Repeated physiologic stress responses can damage the body, resulting in problems such as kidney failure, gastric ulcers, and exacerbation of an existing disorder
◆The body’s level of physiologic response to stress varies according to the stimuli; most physiologic stress responses aren’t helpful in coping with the daily stresses of life
Psychological stress responses
◆Psychological stress responses result when the body’s ability to adapt to change is exceeded; a person adapts to psychological stress through coping strategies, such as problem solving, reappraising stress- ors, and rehearsing responses to stress
Disruptions in homeostasis
◆The body’s psychological response to stress varies according to the stressor’s intensity and duration and the perceived control over the stressor
◗ Psychological stress can cause physical manifestations, such as hypertension and digestive disor- ders, and psychological manifestations, such as anxiety attacks and eating disorders
◗ When psychological stress exceeds a person’s coping abilities, crisis (extreme psychological dis- equilibrium) may occur
Nursing assessment of stress
◆The nurse should identify the source and duration of the stress, the patient’s resources and coping strategies, and the effects of the stress on the patient and family members
◆Sources of stress include illness and hospitalization
◗ Stressors related to illness include pain, fear of loss of a body part or function, fear of prognosis, and fear of disfi gurement
◗ Stressors related to hospitalization or treatment include perceived loss of control, increased depen- dence, change in environment, loss of roles as worker and provider for family, change in routine, and lack of trust in the caregivers
◆The duration of the stress depends on the stressor, which can be acute or chronic, intermittent or continuous
◆External resources include family members and signifi cant others; internal resources include past experiences with illness or hospitalization, education, and spirituality
◆Coping strategies consist of past methods that have been effective for the patient, such as information seeking, relaxation techniques, prayer, counseling, physical or mental activity, meditation, discussion of options, and review of events or event rehearsal
◆Repeated stress responses can have physical effects
◗ Immediate responses include rapid speech, restlessness, rapid heart rate, light-headedness, and palpitations
◗ Long-term responses include headaches, neck and stomach aches, muscle cramps, and changes in eating, elimination, and sleep patterns
◆Repeated stress responses can cause psychosocial symptoms, including changes in family or working relationships, denial or anger, hopelessness, silence, or the inability to make decisions
◆The nurse can use life-event questionnaires to measure stressors in a patient’s life and hardiness scales to determine a patient’s ability to cope with or adapt to stress
Nursing interventions
◆Physical interventions reduce tension and support organ function
◆Massage, heat application, warm baths, stretching exercises, and physical activity can reduce muscle tension, serve as distractions, and increase the ability to put stressors in perspective
◗ Activities to protect organ function include monitoring for complications such as ileus and GI bleeding, checking urine output, and assessing glucose levels
◆Educational interventions include teaching the patient or family about stress and the body’s response to it and rehearsing events to prepare the patient for stress-producing events
◗ Teaching plans should include what to expect from the stress-producing situation
◗ Event rehearsal helps the patient to review an expected sequence of events and deal with anxiety- producing situations in a controlled environment before the actual event occurs
◆Emotional support can be given through counseling, encouraging discussions, sharing feelings, ver- balizing diffi culties, and supporting family problem solving; helping patients to separate themselves from the issue can help maintain their self-esteem
◆Social support activities include evaluating fi nancial status, assisting with insurance forms, providing referrals for home health care assistance, and evaluating spirituality needs (with appropriate referrals to clergy)
❖ Shock
General information
◆Shock is an acute state of reduced perfusion of all body tissues
Med-Surg_Chap06.indd 64
Med-Surg_Chap06.indd 64 8/17/2011 3:43:15 PM8/17/2011 3:43:15 PM
Shock ❍ 65
◆Inadequate circulating blood volume results in decreased delivery of oxygen to tissues and decreased gas exchange in the capillaries
◆Inadequate oxygenation leads to impaired cellular metabolism and an inability to excrete metabolic waste products
Pathogenesis of shock
◆Initial stage
◗ Decrease in cardiac output leads to decrease in mean arterial pressure
◗ Sympathetic nervous system is stimulated, leading to initiation of stress response
◗ Signs and symptoms include normal to slightly increased heart rate, normal to slightly decreased blood pressure, thirst, and pale, cool, moist skin over the face
◆Compensatory stage
◗ Decrease in mean arterial pressure stimulates the sympathetic nervous system to release epineph- rine and norepinephrine to try to achieve homeostasis
◗ Stimulation of alpha1-adrenergic fi bers causes vasoconstriction of vessels in the skin, GI organs, kidneys, muscles, and lungs, shunting blood to the heart and brain
◗ Stimulation of beta-adrenergic fi bers causes vasodilation of coronary and cerebral arteries, increases heart rate, and increases force of myocardial contractions, resulting in increased cardiac output
◗ Reduced renal blood fl ow leads to release of renin and production of angiotensin, resulting in vasoconstriction and stimulation of the adrenal cortex to release aldosterone, increasing renal sodium reabsorption
◗ Increased serum osmolarity stimulates the release of antidiuretic hormone, resulting in increased water reabsorption by the kidneys and increased venous blood return to the heart and, ultimately, increased cardiac output
◗ Signs and symptoms include restlessness, normal or decreasing blood pressure, bounding or thready pulse, tachycardia, tachypnea, normal or hypoactive bowel sounds, slightly decreased urine output, and pale, cool skin (fl ushed and warm in septic shock)
◆Progressive stage
◗ Compensatory mechanisms become ineffective and possibly even counterproductive
◗ Falling cardiac output and vasoconstriction cause cellular hypoxia and anaerobic metabolism;
metabolic acidosis occurs as lactic acid levels rise
◗ Renal ischemia stimulates the renin-angiotensin-aldosterone system, causing further vasoconstriction
◗ Fluid shifts from intravascular to interstitial space
◗ Signs and symptoms include falling blood pressure; narrowed pulse pressure; cold, clammy skin;
rapid, shallow respirations; tachycardia; weak, thready, or absent pulses; arrhythmias; absent bowel sounds; anuria; and subnormal body temperature (subnormal or elevated in septic shock)
◆Irreversible stage
◗ Compensatory mechanisms are ineffective
◗ Lactic acid continues to accumulate, and capillary permeability dilation increases, resulting in loss of intravascular volume and tachycardia; this further aggravates falling blood pressure and cardiac output
◗ Coronary and cerebral perfusion decline, and organ systems fail
◗ Signs and symptoms include unresponsiveness; arefl exia; severe hypotension; slow, irregular heart rate; absent pulses; slow, shallow, irregular respirations; Cheyne-Stokes respirations; and respiratory and cardiac arrest
Types of shock (see Comparing types of shock, page 66)
◆Cardiogenic shock results from an inadequate pumping function that causes decreased cardiac output and stroke volume, leading to inadequate tissue perfusion and a precipitous drop in blood pressure and urine output; it results from such occurrences as acute myocardial infarction (MI), acute mitral insuffi ciency, right ventricular infarction, arrhythmias, heart failure, myocarditis, cardiac tamponade, and cardiac surgery