Week 8 Discussion: Medical Surgical Nursing Discuss the correct treatment of pressure ulcers.
Dressing and wound care are the basis for pressure ulcer management. A properly designed dressing can speed healing by removing unwanted debris from the ulcer surface, protecting exposed healthy tissues and creating a barrier between the body and the environment until the ulcer is closed: o Hydrophobic (nonabsorbent, waterproof) dressing materials are used when the wound is relatively free of drainage. They protect the ulcer from external contamination. o Hydrophilic (absorbent) materials draw excessive drainage away from the ulcer surface, preventing maceration. The frequency of dressing ’s depends on the amount of necrotic material or exudate: o Dry gauze dressings are ’d when “strike-through” occurs or when the outer layer of the dressing 1st becomes saturated w/exudate. o Gauze dressings used for debridement, such as those that are wetted and placed on a wound, allowed to become damp, and then removed, are ’d often enough to take off any loose debris or exudate, usually q 4 to 6 hours. Before reapplying any dressing, gently clean the ulcer surface w/saline or a nontoxic wound cleanser as prescribed. Drug therapy w/topical antibacterial agents are often needed to control bacterial growth. Nutrition therapy requires adequate nutritional intake of calories, protein, vitamins, minerals, and H2O. o Perform a nutritional assessment at least q week. o Coordinate w/the dietician to encourage the patient to eat a well-balanced diet, emphasizing protein, vegetables, fruit, whole grain breads and cereals, and vitamins. New technologies may be useful for chronic ulcers that remain open for months. o Electrical Stimulation o Vacuum-Assisted Wound Closure (VAC) o Hyperbaric Oxygen (HBO) Therapy o Topical Growth Factors o Skin Substitutes Surgical management includes removal of necrotic tissue (surgical debridement) and skin grafting or use of muscle flaps to close wounds that cannot heal by epithelialization and contraction.
Why is the nursing process important in our day to day work?
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Week 8 Discussion: Medical Surgical Nursing It allows us to maintain critical thinking skills that we use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness (American Nurses Association, 2010). It gives us the guidelines that we follow to care for our patients. The nursing process is also a standard of practice, which, when followed correctly, protects nurses against legal problems related to nursing care (Austin, 2008). How do we prioritize patient care/nursing diagnosis (what theory can be used)? Maslow’s hierarchy of needs is an interdisciplinary theory that is useful for designating priorities of nursing care. The hierarchy of basic human needs includes five levels of priority.
1st Level – The most basic, includes physiological needs such as air, water, and food. 2nd Level – Includes safety and security needs, which involve physical and psychological security. 3rd Level – Contains love and belonging needs, including friendship, social relationships, and sexual love. 4th Level – Encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. 5th Level – This is the final level. It includes the need for self-actualization, the state of fully achieving potential and having the ability to solve problems and cope realistically w/situations of life.
What is the normal potassium level of the blood and what symptoms might you see with high or low levels?
Normal Value – 3.5 to 5.0 mEq/L (3.5 to 5 mmol/L) Hyperkalemia (High) – bilateral muscle weakness that begins in quadriceps, transient abdominal cramps, diarrhea, and potentially life-threatening cardiac dysrhythmias, and cardiac arrest; possible ECG abnormalities. Must remember to urine output before administering IV solutions containing potassium. Hypokalemia (Low) – bilateral muscle weakness that begins in quadriceps and may ascend to respiratory muscles, abdominal distention, decreased bowel sounds, constipation, and potentially life-threatening cardiac dysrhythmias; signs of digoxin toxicity @ normal digoxin levels.
What is the highest priority prior to feeding a patient who has just had a NGT inserted for enteral nutrition? How is this accomplished definitively? Verify tube placement, which can be done in the following ways:
Inspect posterior pharynx for presence of coiled tube. Page 2 of 5
Week 8 Discussion: Medical Surgical Nursing
Attach Asepto or catheter-tipped syringe to end of tube and aspirate gently back on syringe to obtain gastric contents, observing color. Measure pH of aspirate w/color-coded pH paper w/range of whole numbers from 1.0 to 11.0 or greater. MOST RELIABLE METHOD = Have ordered x-ray film examination performed of chest/abdomen. If tube is not in stomach, advance another 2.5 to 5 cm (1 to 2 inches) and repeat steps to check tube position.
What step in the procedure of inserting a NGT helps prevent the NGT from being inserted into the trachea? With tube just above the oropharynx, instruct patient to flex head forward, take a small sip of H2O, and swallow. Advance the tube 2.5 to 5 cm (1 to 2 inches) w/each swallow of H2O. If patient is not allowed fluids, instruct to dry swallow or suck air through straw. Flexed position closes off upper airway to trachea and opens esophagus. Swallowing closes epiglottis over trachea and helps move the tube into the esophagus. Swallowing water reduces gagging or choking. Suction removes water from stomach once it is connected. What signs might the patient exhibit if the NGT is in the trachea? The patient will begin to cough and gag as the tube passes through the trachea. What is a nurse’s best action if this occurs? At 1st sign of coughing, gagging, or choking, the nurse should withdraw the tube slightly (do not remove it) and stop tube advancement. Instruct the patient to breathe easily and take sips of H2O. However if the patient begins to cough and choke, is unable to speak, has difficulty breathing, or becomes cyanotic during insertion, the nurse should remove the tube immediately, as these signs indicate that the tube is advancing into the airway. How can we help our patients sleep better?
Have patient keep a sleep log for a week. Teach patient sleep hygiene measures. Teach patient relaxation techniques to use to induce sleep. Encourage patient to drink a cup of chamomile tea or warm milk @ bedtime. Help patient develop behaviors conductive to rest and relaxation. Environmental Controls (room temperature, proper ventilation, minimal sources of noise, comfortable bed, and proper lighting). Promote bedtime routines. Page 3 of 5
Week 8 Discussion: Medical Surgical Nursing
Promote safety. Provide a bedtime snack. Reduce stress. Pharmacological approaches such as Melatonin, which helps control circadian rhythms and promotes sleep.
Discuss ways to prevent nosocomial infections. It is now called: Hospital-Acquired Infection (HAI). It is an infection acquired while the patient was in an inpatient setting. It occurs while the patient is receiving health care. HAI’s can be prevented or controlled in at least five major ways:
Hand Hygiene Use of personal protective equipment (PPE), also called barriers. Adequate staffing Disinfection or sterilization Patient placement and transport
Discuss principles of body mechanics. Body mechanics is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems. Body mechanics alone are not sufficient to prevent musculoskeletal injuries when positioning or transferring patients. Although nurses need to understand the physics surrounding body mechanics, lifting techniques historically used in nursing practice that emphasize body mechanics often cause debilitating injuries to nursing and other health care staff. Today nurses use information about body alignment, balance, gravity, and friction when implementing nursing interventions such as positioning patients, determining the risk of patient falls, and selecting the safest way to move or transfer patients. Before lifting, assess the weight to be lifted, determine the assistance needed, and evaluate available resources. Use safe patienthandling equipment when the patient is unable to assist in transfer. Lift teams, consisting of two physically fit people competent in lifting techniques, reduce the risk of injury to the patient and members of the health care team. Use manual lifting only as a last resort when you need to lift a small portion of the patient’s weight. Discuss protocols for use of restraints. The risks associated w/the uses of restraints are serious. A restraint-free environment is the 1st goal of care for all patients. There are many alternative to the use of restraints, and you should try all of them before using restraints. Per the Centers for Medicare and Medicaid Services (2007) and The Joint Commission (2011a), restraints can be used: Page 4 of 5
Week 8 Discussion: Medical Surgical Nursing
Only to ensure the physical safety of the resident or other residents When less restrictive interventions are not successful Only on the written order of a health care provider
Written orders include a specific episode w/start and end times. Litigation from improper restraint use is a common nursing legal issue (Evans and Cotter, 2008). Nurses are negligent for failure to initiate safety procedures when the patient condition necessitates it. Knowing when and how to use restraints correctly is key. Liability for improper or unlawful restraint and for patient injury from unprotected falls lies w/ the nurse and the health care institution. Nurses who apply restraints in violation of state and federal regulations may be charged w/abuse, battery, or false imprisonment. To the best of your ability discuss each step in the nursing process. The nursing process is used as the framework, which includes assessment, analysis, planning, implementation, and evaluation.
Assessment – Data collection; tools used include patient and family interviews, functional areas, physical assessments, and laboratory tests; subjective aspects are those observed by patients; objective aspects are those observed by nurse. Analysis – Interpretation of collected patient data: determination of nursing diagnosis and plan of care; formation of nursing diagnoses. Planning – Formation of patient’s plan of care; patient goals are outcomes to be achieved by patient Implementation – Nursing interventions; patient’s plan of care is based on assessments, analysis, and expected outcomes. Evaluation – Degree to which patient’s outcomes have been achieved; revision is an alteration in plan of care when expected outcomes are not achieved.
References Peterson, V., & Potter, P. (2013). Clinical companion for Fundamentals of nursing: Just the facts (8th ed.). St. Louis, Mo.: Elsevier Mosby. Potter, P. (2013). Fundamentals of nursing (Eighth ed.). St. Louis, MO: Elsevier Mosby. Winkelman, C. (2013). Clinical companion, Ignatavicius Workman, Medical-surgical nursing: Patient-centered collaborative care. (7th ed.). St. Louis, MO: Elsevier Saunders. Page 5 of 5