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Skin Integrity & Wound Healing 32 C H A P T E R nated with environmental bacteria. ■ Have the patient stay in bed with the knees bent to minimize strain on the incision. ■ Do not put a binder on the patient. ■ Notify the surgeon and ready the patient for surgery (see Chapter 36 for care of the surgical patient). Fistulas Learning Outcomes After completing this chapter, you should be able to: A large dressing covers the incision on Mr. Harmon’s left hip. During your assessment, you loosen the dressing and see that the staples are intact at the incision site, and there is a min- A fistula is an abnormal passage connecting two body cavities or a cavity and the skin. Fistulas often result from infection or debris left in the wound. Fistulas can occur after bowel surgery, especially in compromised patients. It can also occur spontaneously and is associ- ated with certain diseases, such as inflammatory bowel disease (IBD) and cancer (McNichol et al., 2021). An abscess forms, which breaks down surrounding tissue and creates the abnormal passageway. Chronic drain- age from the fistula may lead to skin breakdown and delayed wound healing. The most common sites of fis- tula formation are the gastrointestinal and genitouri- nary tracts. Figure 32-9 illustrates a fistula between the rectum and vagina. ➤ Discuss the factors that affect skin integrity. ➤ Identify wounds based on accepted classification schemes. ➤ Describe the three phases of wound healing. ➤ Distinguish primary intention healing, secondary intention healing, and tertiary intention healing. ➤ Describe the three types of wound drainage. ➤ Review the major complications of wound healing. ➤ Explain the factors involved in the development of pressure injury. ➤ Use the Braden scale to assess risk for pressure injury. ➤ Assess and categorize pressure injuries based on the staging system. ➤ Provide nursing care that limits the risk of pressure injury development. ➤ Differentiate the kinds of chronic wounds. ➤ Accurately chart an assessment of a wound. ➤ Demonstrate appropriate techniques for irrigating a wound. ➤ Describe care of a wound with a drain. ➤ Differentiate the five forms of wound débridement. ➤ Discuss the different kinds of tissue found in wounds. ➤ Discuss when and how to use absorbent dressings, alginate dressings, collagen dressings, gauze dressings, transparent films, hydrocolloids, hydrogels, and foam and antimicrobial dressings. ➤ Describe guidelines to follow when applying heat or cold therapy. ➤ Demonstrate bandage and binder application. Meet Your Patient To explore learning resources for this chapter, Go to www.DavisAdvantage.com and find: Answers and Suggested Responses for all questions in this chapter Concept Map Knowledge Map References and Bibliography

FIGURE 32-9 A fistula is an abnormal passa two body cavities or a cavity and the skin. common in the gastrointestinal and genito

Key Concepts Skin integrity Wound Wound healing Related Concepts See the Concept Map on DavisAdvantage. Example Client TEXT STEP #1 Build a solid foundation. Skin Integrity & Wound Healing

2 to 4 weeks may be considered chr injury is a type of chronic wound. To sure injuries, see the Example Client sure Injury and Figures 32-10 and 32-11 Practical Knowledge knowing how As a nurse, you will care for man have wounds or who are at risk down. The remainder of the chapter

Condition Pressure Injury STUDENT RESOURCES The questions and exercises in this book allow you to practice the kind of thinking you will use as a full-spectrum nurse. Critical-thinking questions usually have more than one right answer, so we do not provide “correct” answers for these features. Try to answer these questions yourself. It is more important to develop your nursing judgment than to just cover content. You will learn more by discussing the questions with your peers. If you are still unsure, see the Davis Advantage chapter resources for suggested responses.

Key Concepts Skin integrity Wound Wound healing Related Concepts See the Concept Map on Davis Advantage. Example Client

Two types of case studies bring concepts to life, connecting what you read to what you will see and do in practice.

William Harmon is a 78-year-old man who fell and frac- tured his left hip 3 days ago.After being admitted to the hospital, he underwent an open reduction and internal fixation (ORIF) of the left hip.Today is his second postop- erative day. He is unable to roll or pull himself up in the bed. Mr. Harmon’s weight on admission was 140 lb (63.64 kg). His height is 73 in (185.42 cm). His family reports that he has been steadily losing weight. He expresses little interest in eating and says he has suffered depression since his wife died last year.

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UNIT 3 Essential Nursing Interventions

Condition Pressure injury

Mobility and activity

4797_Ch32_001-036.indd 1 Poisoning Poisoning death rates have more than quadrupled in the past 20 years. Although young children are frequent victims, the increase has been mainly among adults. In many cases, the person does not die but becomes ill or suffers other effects. Poisoning exposure accounts for more than 2 million emergency department visits per year in the United States (CDC, 2022). ■ Young children are poisoned most often by improper storage of household chemicals, medicines and vita- mins, and cosmetics (see Box 21-1). of home safety hazards in this section should help you answer this question. Except for motor vehicle accidents, most fatal acci- dents occur in the home. The leading causes of death in the home are poisonings, falls, fires and burns, and choking. For children, maternal mental health problems and having older siblings are associated with less safe homes (Zonfrillo et al., 2018). The use of lead in paint has been banned since 1978, but lead-based paint can still be found in older homes and toys produced in some foreign countries. Some soil (which young children often put in their mouths) contains high levels of lead. In the United States, poor, urban, and immigrant populations are at higher risk for lead exposure than other groups. ■ Older children and adolescents may attempt suicide by overdosing with medicines or be poisoned acci- dentally when experimenting with recreational or prescription drugs. ■ Adults experience poisoning as a result of illegal drug use or misuse or abuse of prescription drugs, especially narcotic medications, tranquilizers, and antidepressants. ■ Household cleansers, including oven cleaner, drain cleaner, toilet bowl cleaner, and furniture polish ■ Medicines, including cough and cold preparations, vitamins, pain medications, antidepressants, anticonvulsants, and iron tablets, which may look like candies to children ■ Indoor houseplants, including poinsettia, Dieffenbachia, Philodendron, and many others ■ Cosmetics, hair relaxer, nail products, mouthwash ■ Kerosene, gasoline, lighter fluid, paint thinner, lamp oil, antifreeze, windshield washer fluid, lighter fluid, and other chemicals ■ Alcoholic beverages BOX 21-1 ■ Poisonous Agents Commonly Ingested by Children

imal amount of sero- sanguineous drainage on the bandage. As you ■ Death from prescription analgesics and prescrip- tion opioids has reached epidemic levels in the past decade, greater than deaths from heroin and cocaine combined. A big part of the problem is nonmedical use—using pain medications without a prescription or using them just for the high they cause. In 2018, an estimated 10.3 million people aged 12 years or older misused opioids in the past year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2022).

Time and pressure

1 Caring for the Williams Family Kayla Robinson, Stanley and Nadine Williams’ 3-year-old grandchild, fell at the neighborhood playground. She has abrasions on her knees, a deep puncture wound on her left hand, and a laceration on her scalp. Mr. and Mrs.Williams bring her to the clinic for assessment. She is crying loudly and moving all extremities. No treatment has been given. (Continued)

Sensation

Knowledge Check 32-5 ■ Describe four types of wound closures. ■ Identify five types of wound complications. ■ Describe three signs of internal hemorrhage. ■ Compare dehiscence and evisceration. ■ Treatment choice depends on the poison ingested. For most poisonings, the most effective intervention is professional administration of activated charcoal orally or via gastric tube. However, charcoal is not effective for ethanol, alkali, iron, boric acid, lithium, methanol, or cyanide. Depending on the situation, other options for medical treatment include gastric lavage, dialysis, administration of antidotes (i.e., Narcan), and forced diuresis.

Intrinsic factors

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• Nutrition • Age

Tissue tolerance

658 Carbon Monoxide Exposure Carbon monoxide (CO) is a colorless, tasteless, odor- less toxic gas. Exposure can cause headaches, weakness, nausea, and vomiting; prolonged exposure leads to sei- zures, dysrhythmias, unconsciousness, brain damage, and death. Each year in the United States, CO poisoning causes approximately 350 unintentional deaths (CDC, 2017a). ■ Most CO exposures occur at home. ■ Most CO exposures involve females, children under the age of 17 years, and adults aged 18 to 44 years. ■ CO poisoning accounts for a majority of deaths at the scene of fires and is also a relatively common cause of death by suicide. ■ Many CO deaths occur during cold weather among older adults and the poor who seek nonconventional heat sources (e.g., gas ranges and ovens) to stay warm. Scalds and Burns The following are common causes of scalds and burns: ■ Scald injuries (e.g., from hot water, steam, or grease) are the most common cause of burns in children younger than age 3. Scalding burns (especially on both feet or both hands) and cigarette burns in children and vulnerable older adults should always prompt you to assess for abuse (see Procedure 6-1). ■ Warming food or formula in the microwave may cause the food to become hotter than intended, lead- ing to burns in infants and young children. ■ Sunburn can cause a first- or second-degree burn. ■ Contact burns may occur from contact with metal surfaces and vinyl seats when cars are parked in the sun. The risk of contact burns in all age-groups is greater in the presence of such heating devices as kerosene heaters, wood-burning stoves, and home sauna heating elements. People may use these as heat

Think Like a Nurse 32-2: Clinical Judgment in Action

• Circulation • Underlying

health status

iCare highlights the role of caring in nursing by modeling behaviors and conversations that demonstrate how to provide compassionate care. Extrinsic factors

Recall the case of Mr. Harmon (Meet Your Patient).What form of wound healing (primary, secondary, or tertiary) is he undergoing? How long would you expect it to take before his wounds heal?

• Friction • Shearing •Moisture

UNIT 4 Supporting Physiological Function

4798_Ch32_658-704.indd 658 Think Like a Nurse: Clinical Judgment in Action questions put you in the nurse’s role to develop your clinical judgment skills from day one. CHRONIC WOUNDS A chronic wound is one that has not healed within the expected time frame. Wounds that do not heal within UNIT 11 Factors Affecting Health 212

pain. Key P tion is nor occur as so Sterile wat larly when Ideally,

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32-1

FIGURE 32-10 Several factors contribute to of a pressure injury.

contamination from biofilm in the hospital setting Age and Developmental Stage Age and devel- opmental stage influence the likelihood of becoming ill. Certain health problems can be correlated to develop- mental stage. For example, more than 75% of new breast cancer cases are diagnosed in female patients older than age 50. As another example, adolescent boys have much higher rates of head injury and spinal cord injury than paraplegic who has developed a stage 4 sacral pressure ulcer with a foul odor. He is expecting sFome of his friends from school for a visit. Ken, his nurse, while nonchalantly cleaning up the room, makes sure to remove the garbage liner with the old dressings in it. He also brings in some fresh-cut flowers and a cup of wet coffee grounds. Both the flowers and the coffee grounds are natural odor eliminators. Mr. Brown has a great visit with his friends from school. breast cancer. A genetic marker for this type of breast cancer has been discovered, indicating that some people inherit a tendency to develop breast cancer. Sex Many diseases occur more commonly in one sex than in another. For example, rheumatoid arthritis, oste- oporosis, and breast cancer are more common in female individuals, whereas ulcers, color blindness, and bladder cancer are more common in male individuals. Skin Integrity and Wound Healing ■ Scenario 1— Mary is caring for Mrs. Skylar, a 62-year-old patient with diabetes and venous stasis ulcers on her legs. Since developing these venous stasis ulcers, Mrs. Skylar has become very self-conscious and embarrassed about her legs.When taking Mrs. Skylar to x-ray, Mary covers Mrs. Skylar’s legs with a bath blanket for comfort and privacy. Mary was not only providing comfort and protecting privacy. She was also aware of Mrs. Skylar’s feelings and cared enough to respond to them. ■ Scenario 2— Mr. Robert Brown is an 18-year-old

Social Determinants of Health boxes and icons help you to think about the many conditions that affect health. Social Determinants of Health 8-1 Economic Stability ■ Employment ■ Food insecurity ■ Housing instability ■ Poverty Education Access and Quality ■ Early childhood education and development ■ Enrollment in higher education ■ High school graduation ■ Language and literacy Social and Community Context ■ Civic participation ■ Discrimination ■ Incarceration

Isotonic Nonhem Nontoxi impa Transpa bed. Inexpen volum Warmed Selectin

4797_Ch32_001-036.indd 13 ■ Wild plants and mushrooms ■ Pesticides, rodent poisons

following a ■ Piston sy posable mize han elongate gation flu

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199

CHAPTER 7 Life Span: Older Adults

EXAMPLE CLIENT CONDITION: Elder Abuse Key Point: Like domestic violence, elder abuse is seen in all cultures and socio- economic groups. Abuse Types Abuse takes many forms: Physical Emotional Sexual Financial Neglect Abandonment Risk Factors CLIENT CONDITION

Risk Factors Mental illness Alcoholism or drug abuse in patient or caregiver Dependence on others Past history of abusive relationships Depression Low self-esteem Poor health of patient or caregiver Caregiver stressed or frustrated with difficult caregiving tasks Social Determinants of health: Ageism Social isolation or poor social network Low-income status Financial or other family problems (of patient or caregiver) Inadequate or unsafe housing Lack of health insurance CLINICAL REASONING

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CHAPTER 32 Skin Integrity & Wound Healing

Applying the Full-Spectrum Nursing Model

PATIENT SITUATION Tio Santos is a 66-year-old man with obesity, diabetes, and hypertension. He is being seen for a wound on his right foot that doesn’t seem to be healing. He injured his foot when repairing drywall at home. He is otherwise relatively sedentary at home. The wound is oozing, swollen, tender, and warm to the touch. Mr. Santos is now running a low-grade fever of 100.4°F (38°C) at home. He tells you his foot is very painful, especially with any weight bearing, and throbs when he is sitting or lying still. You measure the wound bed to be 6 cm x 4 cm and note purulent exudate at the distal edge. He is referred to an outpatient wound care center for treatment.

Key Point: The risk of abuse is higher for women and those with physical and cognitive vulnerabilities. Advanced age Physical, functional, or cognitive impairment

CHAPTER 32 Skin Integrity & Wound Healing THINKING 1. Theoretical Knowledge: a. What is the Braden scale and why might it be used for Mr. Santos?

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CLINICAL REASONING

b. What risk factors for delayed wound healing does Mr. Santos have?

Applying the Full-Spectrum Nursing Model

2. Critical Thinking (Considering Alternatives, Deciding What to Do): a. To care for Mr. Santos’ wound, should you use sterile gloves, clean nonsterile gloves, or no gloves? Explain your thinking.

Key Point: If an older adult has an injury such as maxillofacial trauma, dental trauma, subdural hematomas, periorbital and laryngeal trauma, rib fractures, or upper extrem- ity injuries, along with a wasted and unkempt appearance, it is possible that the injury was inflicted. Elder abuse takes many forms, including the following: • Battering • Inappropriate use of drugs and physical restraints • Force-feeding, physical punishment • Nonconsensual sexual contact • Treating an older person like an infant, including infantilizing communication (also referred to as elderspeak ) • Giving an older person the “silent treatment” • Enforced social isolation • Demeaning an older adult • Neglect • Abandonment • Financial or material exploitation, such as illegal or improper use of an older adult’s funds, property, assets, or Social Security checks • Assess older adults for abuse anytime there is a possibility that an injury may have been inflicted rather than accidental. • Assess for social determinants, risk factors, and etiology of the abuse. • For a screening tool and a procedure to aid you in assessing for abuse, DOING 3. Practical Knowledge (Assessment): a. What symptoms of infection does Mr. Santos have? THINKING 1. Theoretical Knowledge: a. What is the Braden scale and why might it be used for Mr. Santos? b. What risk factors for delayed wound healing does Mr. Santos have?

RECOGNIZING CUES

b. To be certain the wound is infected, what would you need to know or do?

Example Client Conditions graphically illustrate the key concepts and need-to-know information in each chapter and reflect the cognitive skills of the NCSBN Clinical Judgment Measurement Model.

CARING 4. Self-Knowledge: Imagine you are Mr. Santos and have had a wound on your foot for 6 weeks. What would be the most troublesome symptom in your daily life? What would concern you the most? Critical Thinking and Clinical Judgment 1. You are caring for a 22-year-old man with paralysis from the waist down secondary to a motor vehicle accident. He has been admitted to the hospital with a urinary tract infection manifested by a fever of 102°F (39°C) and lethargy. His family reports he has been withdrawn and sits in his wheelchair looking at his phone all day. a. What risk factors does this patient have for skin breakdown?

2. Critical Thinking (Considering Alternatives, Deciding What to Do): a. To care for Mr. Santos’ wound, should you use sterile gloves, clean nonsterile gloves, or no gloves? Explain your thinking.

b. What locations of his body should you be most concerned for the formation of pressure injury?

ANANLYZING CUES/ DIAGNOSING

c. What actions should you take to decrease the risk of pressure injury for your patient? What further information do you need?

2. A 63-year-old male patient is admitted to your unit after an emergency appendectomy. His appendix was ruptured, and the surgeon has left the wound open to heal by secondary intention. A Jackson–Pratt drain is in place in the wound bed. A moderate amount of purosanguineous drainage is visible in the drain. The surgeon has ordered saline-moistened gauze packing every 4 hours. a. What actions should you take as you prepare to do the first dressing change?

Go to Procedure 6-1 in Volume 2.

b. To be certain the wound is infected, what would you need to know or do?

(continued) CARING 4. Self-Knowledge: Imagine you are Mr. Santos and have had a wound on your foot for 6 weeks. What would be the most troublesome symptom in your daily life? What would concern you the most? Critical Thinking and Clinical Judgment 1. You are caring for a 22-year-old man with paralysis from the waist down secondary to a motor vehicle accident. He has been admitted to the hospital with a urinary tract infection manifested by a fever of 102°F (39°C) and lethargy. His family reports he has been withdrawn and sits in his wheelchair looking at his phone all day. a. What risk factors does this patient have for skin breakdown? b. How will you secure the dressing?

• Low self-esteem related to physical abuse and demeaning communication • Risk for Injury related to physical or psychological abuse

PRIORITIZING HYPOTHESES 690

UNIT 4 Supporting Physiological Functioning

Procedure 32-13 ■ Shortening a Wound Drain ➤ For steps to follow in all procedures, refer to the Universal Steps for All Procedures on the inside back cover.

the tube (e.g., if the tube diameter is not sufficient size to handle drainage output) or, more likely, an obstruction within the tubing. ■ Assess the characteristics of the drainage, including color, volume of drainage, presence of blood, odor, pus, and any change in the type or amount of drainage through the tubing. A sudden decrease in drainage might indicate a blocked drain. Pres- ence of fresh blood might be a sign of irritation within the wound. Pus and odor in the drainage could indicate wound infection. ■ Check the suction apparatus to be sure it is functioning properly. 4798_Ch32_658-704.indd 701

Equipment ■ Nonsterile gloves ■ Sterile gloves ■ Sterile scissors ■ Two safety pins or other clips (sterile) ■ Sterile gauze

Applying the Full-Spectrum Nursing Model and Critical Thinking and Clinical Judgment exercises guide you in applying your critical-thinking and clinical-reasoning skills to real-world patient scenarios.

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b. What locations of his body should you be most concerned for the formation of pressure injury?

c. What actions should you take to decrease the risk of pressure injury for your patient? What further information do you need?

Delegation Assessment of the incision line or wound and the drain is a registered nurse’s responsibility and cannot be delegated.This procedure should not be delegated to a UAP. The risk for accidently losing the drain into the body or pulling it out of the wound is too high. Preprocedure Assessment ■ Inspect the site around the drain, noting skin excoriation, tenderness, erythema, warmth to the touch, and drainage seeping from the wound. Could indicate a wound infection or irritation of the drain at the skin site. Excoriation can be the result of seeping drainage around

24/03/23 5:17 PM 2. A 63-year-old male patient is admitted to your unit after an emergency appendectomy. His appendix was ruptured, and the surgeon has left the wound open to heal by secondary intention. A Jackson–Pratt drain is in place in the wound bed. A moderate amount of purosanguineous drainage is visible in the drain. The surgeon has ordered saline-moistened gauze packing every 4 hours. a. What actions should you take as you prepare to do the first dressing change? A self-suction apparatus might need to be recompressed from time to time to maintain effective vacuum. Electric suction units can fail, delivering too much suction, which can lead to injury.Too little suc- tion can contribute to insufficient drainage, which can lead to pres- sure on sutures if present, or cause the wound to become infected or heal more slowly.

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b. How will you secure the dressing?

Over 230 step-by-step procedures with rationales teach you how to perform and master essential nursing skills.

➤ When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation.

Procedure Steps 1. Perform hand hygiene and don nonsterile gloves. Remove wound dressings. 2. Remove soiled gloves and discard in a moisture-proof biohazard collec- tion container. Perform hand hygiene. 3. Open sterile supplies (scissors, etc.). 4. Don sterile gloves; use sterile scis- sors to cut halfway through a sterile gauze dressing (for later use) or use a sterile precut drain dressing. 5. If the drain is sutured in place, use sterile scissors to cut the suture. 6. Firmly grasp the full width of the drain at the level of the skin and pull it out by the prescribed amount (e.g., 5 cm [2 in.]).

9. Cleanse the wound, using ster- ile gauze swabs and the prescribed cleaning solution. In some situa- tions, you may use sterile forceps to manipulate the swabs. 10.Apply precut sterile gauze around the drain; then redress the wound.

The pin or clamp keeps the drain from dis- appearing into the wound.

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8.Using sterile scissors,cut the drain about 2.5 cm (1 in.) above the skin and pin.

Content subject to change upon publication.

11. Remove gloves and discard in a

LEARN STEP #2 Make the connections to key topics.

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UNIT 3 Essential Nursing Interventions

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CHAPTER 20 Promoting Asepsis & Preventing Infection

pathogens they have encountered before. This is why people who recover from an infectious disease like mea- sles never get the disease again, even if they are repeat- edly exposed to the virus. The cells involved in specific immunity are the lymphocytes, WBCs produced from stem cells in the red bone marrow. There are two main types of lymphocytes: T cells and B cells. Key Point: Both B cells T cells form in the bone marrow. B cells remain in the bone marrow until they are fully mature. T cells go to the thymus to mature. Both are activated against pathogens within the lymphatic system (lymph nodes, spleen, tonsils) to protect and preserve health and pre- vent infection. The receptors on the surface of these two types of lymphocytes allow them to recognize invaders. Cellular Immunity The cellular (cell-mediated) immune response acts directly to destroy infection-causing pathogens (i.e., viruses, fungi, protozoans, cancers) without using antibodies but, rather, by activating phagocytes and T cells (Fig. 20-2). 1. The immune process starts when the body is exposed to a particular pathogen. Infecting microbes in the body invade cells and signal for more microbes to take over. 2. Antigens are proteins on the outer surface of patho- gens that evoke an immune response. 3. Along comes WBC phagocytes that engulf and swal- low the pathogen. 4. After the pathogen is destroyed, the phagocyte now displays pieces of itself on the antigens of the destroyed pathogen. This is known as an antigen- presenting cell (APC). 5. Now memory T cells bind to the APC to fight similar pathogens in the future. With subsequent infections, memory T cells increase the speed and intensity of the T-cell response to recognize similar intruders. 6. Nearby helper T cells come in and fight against the infecting agent by activating T cells and alerting B cells to get involved. 7. Active T cells multiply to fight the infection by releas- ing proteins and enzymes to destroy the pathogen. These are called cytotoxic (killer) T cells. 8. Suppressor T cells stop the immune response when the infection has been contained (also see Fig. 20-3). Humoral Immunity The humoral immune response (or antibody-mediated response) protects the body by circulating antibodies to fight against pathogens. The body’s defense system acts by producing specialized WBCs (leukocytes) to seek out and destroy invaders (Fig. 20-3). This is how a humoral immune response works to fight against pathogens: ■ A person is exposed to a pathogen. ■ Helper cells in the bone marrow activate proteins, called interleukins, that cause B cells to divide into memory cells and active B cells.

Antigen (pathogen)

Knowledge Check 20-3 ■ Identify and describe the purpose of the body’s three major lines of defense against infection. ■ If a patient’s laboratory work reveals that immunoglobulin M (IgM), but not immunoglobulin G (IgG), is present in the blood, what could you conclude about this infection?

Antigen

Phagocyte

B cell

Antigen

WHAT FACTORS INCREASE HOST SUSCEPTIBILITY?

B cell

Promoting Asepsis & Preventing Infection

T cell

Anything that weakens the body’s defense system makes a person more susceptible to infection. In addi- tion, any factors that increase the person’s exposure to pathogens, such as working at a day care facility or being a nurse, increase the risk for infection. Developmental Stage Young children are vulner- able because their immune systems are immature and they have had limited exposure to pathogens. Children frequently begin to have more infections when they start having contact with people outside their family (e.g., when they attend day care or start school). Acquiring active immunity is a part of the developmental process. Older adults are also susceptible hosts because the immune response declines with aging. Skin, a primary defense, becomes less elastic and more prone to breakdown with aging. Older adults also tend to be less active, tend to have other under- lying illnesses, and their nutrition may be inadequate. Breaks in the First Line of Defense A break in the skin, whether caused by a surgical procedure, injury, skin breakdown, an insect bite, or insertion of an IV device, creates a portal of entry for infectious microorganisms. Illness or Injury A coexisting infection, illness, or injury limits the physical resources available to combat a new pathogen. Tobacco Use ■ Smoking is a major risk factor for pulmonary infec- tions because it interferes with normal respiratory functioning, including the ability to move the chest, cough, sneeze, and have full air exchange. ■ Chemicals in tobacco immobilize cilia; thus, secretions pool in the lower airways, creating a favorable envi- ronment for bacteria to live and replicate. ■ Smoking and vaping adversely affect the immune sys- tem by compromising the antibacterial function of leu- kocytes. As a result, chronic exposure to secondhand smoke increases the risk for respiratory infection, ear and sinus infection, meningitis, and postsurgical and nosocomial infections (Bagaitkar et al., 2008). Substance Abuse ■ Alcohol curbs hunger. As a result, many chronic alco- hol users do not consume an adequate diet, leading to vitamin, mineral, and protein deficiency. Over time,

Helper T cell

APC

Interleukins

Cytotoxic T cell

Helper T cell

Memory T cell

Neutrophil

Promoting Asepsis & Preventing Infection

Memory cell

Helper T cell

FIGURE 20-3 The humoral immune response produces antibodies to destroy antigens.

FIGURE 20-2 The cell-mediated immune response causes white blood cells to attach to antigens.

■ Active B cells produce Y-shaped antibodies that bind to the pathogen’s attachment site (antigen) and interfere with its ability to infect other cells (Box 20-2). This process, called neutralization, does not destroy pathogens; it just makes them ineffective. ■ Antibodies also cause pathogens to clump together (agglutination), reducing their activity and increas- ing the likelihood that the clump will be detected and phagocytized by leukocytes. ■ These antibodies signal leukocytes (macrophages and neutrophils) to come in and engulf the pathogen and break it down. ■ Antibodies also fight infection by triggering inflammatory chemicals to destroy the pathogen. This is called the complement cascade, described earlier. ■ Suppressor cells stop the immune response when the infection is contained.

BOX 20-2 ■ Immunoglobulin (Ig) Classes

Promoting Asepsis & Preventing Infection

■ IgM is the first antibody to appear when an antigen (e.g., pathogen) is encountered. It is also involved in agglutination with incompatible blood types. ■ IgG is the most common immunoglobin in the body. It takes at least 10 days for IgG to be produced in response to an initial infection. IgG is the only immunoglobulin that can cross the placenta to provide temporary immunity to the fetus/infant. ■ IgE is the immunoglobulin primarily responsible for the allergic response. ■ IgA is found in mucous membranes in the intestines, respiratory and urinary tracts, saliva, tears, and breast milk. IgA provides additional immune protection by secreting around the body openings. ■ IgD forms on the surface of B cells and traps the potential pathogen to prevent it from replicating and causing disease.

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Assignments in Davis Advantage correspond to key topics in your book. Begin by reading from your printed text or click the ebook button to be taken to the FREE, integrated ebook.

Following your reading, take a Pre-Assessment to evaluate your understanding of the content. Questions feature single answer, multiple-choice, and select-all-that-apply formats.

Pre-Assessment for Promoting Asepsis & Preventing Infection

Immediate feedback identifies your strengths and weaknesses using a thumbs up, thumbs down approach. Thumbs up indicates competency, while thumbs down signals an area of weakness that requires further study.

Online content subject to change upon publication.

Promoting Asepsis & Preventing Infection

After working through the video and activity, a Post-Assessment tests your mastery.

Post-Assessment for Promoting Asepsis & Preventing Infection

Animated mini-lecture videos make key concepts easier to understand, while interactive learning activities allow you to expand your knowledge and make the connections to important topics.

Your Dashboard provides an at-a-glance snapshot of your performance as you work through your assignments.

• Oxygenation • Hydration & Homeostasis: Acid-Base Balance

Fundamentals

Your Personalized Learning Plan is tailored to your individual needs and tracks your progress across all your assignments , helping you to identify the specific areas that require additional study.

Clinical Judgment Chapter 2 Promoting Safety Chapter 21 Measuring Vital Signs Chapter 18 Facilitating Hygiene Chapter 22 Administering Medications: Safety Chapter 23 Bowel Elimination Chapter 26

APPLY STEP #3

Develop clinical judgment skills & prepare for the Next Gen NCLEX. ®

Promoting Asepsis & Preventing Infection

Real-world cases mirror the complex clinical challenges you will encounter in a variety of health care settings. Each case study begins with a patient photograph and a brief introduction to the scenario.

The Patient Chart displays tabs for History & Physical Assessment, Nurses’ Notes, Vital Signs, and Laboratory Results. As you progress through the case, the chart expands and populates with additional data.

Promoting Asepsis & Preventing Infection

NGN format questions that align with the cognitive areas of the NCSBN Clinical Judgment Measurement Model require careful analysis, synthesis of the data, and multi-step thinking.

Promoting Asepsis & Preventing Infection

You answered 2 out of 6 questions correctly.

Immediate feedback with detailed rationales identifies the cognitive skills practiced according to the NCSBN Clinical Judgment Measurement Model and includes page references to the text for further remediation.

Test-taking tips provide important context and strategies for how to consider the structure of each question type when answering.

ASSESS STEP #4 Improve scores and build confidence with NCLEX ® -style questions

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Vital Signs

antihypertensive

The nurse is caring for a 52-year-old client coming to the emergency department with peripheral edema, periorbital edema, flank pain, and shortness of breath. The nurse is preparing to notify the provider of the client’s status. Complete the below using the dropdown choices.

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MEDS2-RDC-16

Renal Disorders

Clinical Judgment, Elimination, Fluid and Electrolytes, Oxygenation Perfusion

Evaluation [Evaluating]

Chapter 62: Coordinating Care for Patients with Renal Disorders

Vital Signs

pp. 1452-1459

antihypertensive

Rationale: The client is demonstrating signs of acute kidney injury, oliguric phase. This is identified by low urine output, edema, shortness of breath, hypertension, hyperkalemia, elevated BUN/creatinine, anemia, and hyponatremia. It is anticipated that this client has a compromised GFR due to risk factors of poorly controlled diabetes and reoccurring UTIs. The risks for developing acute kidney injury include infection and medications. Fever, elevated WBCs, flank pain are signs of a kidney infection, and extended to excessive use of NSAIDS will impair kidney function, leading to injury. In evaluating the client data, the nurse should be most concerned about the changing vital signs, including a rising temperature, heart rate, respiratory rate, and blood pressure, as the SpO2 decreases. This indicates a deterioration of oxygenation and perfusion. Priority medical management is the delivery of oxygen and an antihypertensive to prevent tissue hypoxia and stroke. The nurse should also notify the provider about the hyperkalemia, hyperglycemia, anemia, renal impairment shown in the lab results, and the assessment findings of oliguria, edema, crackles, and bounding pulses.

Navigate the EHR trends by looking at how the cues presented relate to each other. Make the connection between the information to reach priority conclusions.

Health Assessment

Create your own practice quizzes to focus on topic areas where you are struggling, or to use as a study tool to review for an upcoming exam.

Clinical Judgment

GET STARTED TODAY! Use the access code on the inside front cover to unlock Davis Advantage for Wilkinson’s Fundamentals of Nursing!

Table of Contents Unit 1: How Nurses Think 1.

Evolu(on of Nursing Thought & Ac(on

2. 3. 4. 5.

Clinical Judgment

The Steps of the Nursing Process

Evidence-Based Prac(ce: Theory & Research

Ethics & Values for Nursing Prac(ce

Unit 2: Factors Affec9ng Health 6.

Life Span: Infancy Through Middle Adulthood

7. 8. 9.

Life Span: Older Adults

Promo(ng Wellness: Health and Illness

Stress & Adapta(on

10. 11. 12. 13.

Psychosocial Health & Illness Promo(ng Family Health

Caring in Mul(cultural Healthcare Environments

Spirituality

14. Experiencing Loss Unit 3: Essen9al Nursing Interven9ons 15.

Communica(ng & Therapeu(c Rela(onships

16. 17. 18. 19. 20. 21. 22. 23.

Pa(ent Educa(on

Interprofessional Partnerships: Documen(ng & Repor(ng

Measuring Vital Signs Health Assessment

Promo(ng Asepsis & Preven(ng Infec(on

Promo(ng Safety Facilita(ng Hygiene

Administering Medica(ons Unit 4: Suppor9ng Physiological Func9oning 24. Nutri(on 25. Urinary Elimina(on 26. Bowel Elimina(on 27. Sensa(on, Percep(on, & Response 28. Pain 29. Physical Ac(vity & Mobility 30. Sexual Health 31. Sleep & Rest 32. Skin Integrity & Wound Healing 33. Oxygena(on 34. Circula(on & Perfusion 35. Hydra(on & Homeostasis 36. Caring for the Periopera(ve Pa(ent Unit 5: The Context for Nurses’ Work 37. Community & Home Health Nursing 38. Informa(cs 39. Legal Accountability 40. Leading & Managing

Contents subject to change upon publica2on.

C H A P T E R 2

Clinical Judgment

Learning Outcomes After completing this chapter, you should be able to:

Key Concepts Clinical judgment Clinical reasoning Critical thinking Full-spectrum nursing Nursing knowledge Related Concepts See the Concept Map on Davis Advantage.

➤ Give one definition and one example of clinical judgment. ➤ List and describe at least one clinical judgment model. ➤ List the four types of nursing knowledge. ➤ Discuss the relationship between critical thinking and clinical judgment. ➤ Discuss the relationship between clinical reasoning and clinical judgment.

➤ Explain ways in which nurses use clinical judgment. ➤ Name and describe the main concepts of the full-spectrum nursing model. ➤ Explain how nursing knowledge, clinical reasoning, critical thinking, nursing process, and clinical judgment work together in full-spectrum nursing. ➤ Relate clinical judgment to person- centered care.

Jan graduated from nursing school 8 months ago and has worked on the medical-surgical unit for 3 months. She completed orientation 6 weeks ago and is on the 1900-to-0700 shift. She has five clients.At 2045, Jan received an admission from the postanesthesia care unit (PACU) and was given the following report: Mr.Anderson, 72-year- old patient, had a colon resection several hours earlier. He is accompanied by his wife, Lilly. Mr.Anderson had an uneventful recovery.Vital signs stable (VSS) at 2025: blood pressure (BP) 158/82, pulse (P) 78, respirations (R) 14, tempera- ture (T) 98.9. Oxygen saturation 99% on room air, IV fluid (IVF) intake 500 mL, urinary output via Foley catheter, 200 mL, clean and yellow. Abdominal dressing clean, dry, and intact. Nasoga- stric tube patent with 100 mL of gastric drainage. Jan did not have any questions and documented the following information in the nurses’ notes: 2100: Admission vital signs (VS), BP 160/84, P 82, R 16, and T 99.1. Abdominal dressing clean, dry, and intact. Drowsy, oriented. Skin warm and dry. Rated Explore Your Nursing Role

his pain as 2 on a 10-point scale (2/10). IVF infus- ing at 125 mL/hour. History positive for non–insulin- dependent diabetes (type 2), high blood pressure, and early-stage Alzheimer disease.The nursing plan of care discussed with the Andersons. No questions asked. —Jan Watsone, RN 2200:VS stable at BP 150/78, P 90, R 20,T 99.5. He rates his pain as 4/10 but refuses pain medication. He is drowsy, sleepy. His wife says he has been sleeping since admission. — Jan Watsone, RN

CHAPTER 2 Clinical Judgment

Explore Your Nursing Role (continued)

assessment and notifies the hospitalist. Mr.Anderson is transferred to the intensive care unit (ICU) with a diagno- sis of shock from abdominal bleeding. As Jan completes her documentation, she wonders, “Lisa has been a nurse for 10 years—how did she know something was wrong? Should I be a nurse? Did I miss anything? What went wrong?” You will be asked to apply full-spectrum thinking to Jan’s case throughout the chapter as you learn the major concepts associated with the devel- opment of clinical judgment.

2400: Mr. Anderson appears lethargic. States that he is on his boat fishing and asks if I see the fish he has caught. VSS: BP 138/68, P 102, R 24,T 100. Skin cool, moist.Abdominal dress- ing dry and intact.The surgeon notified of client’s confusion. Pre- scriptions received for pain medication and hourly vital signs. He explains that Mr. Anderson is experiencing sundowning, which is late-evening or late-night confusion in clients with dementia. —Jan Watsone, RN Feeling uncomfortable, Jan discusses Mr.Anderson with the charge nurse, Lisa, who immediately conducts an

Theoretical Knowledge knowing why

KEY CONCEPTS Keep the key concepts in mind as you read this chapter. They will give you the “hooks” on which you can “hang” the other details in the chapter. As you gain an understanding of clinical judgment, critical reasoning, critical thinking, nursing knowledge, and the nursing process, you will begin to see how they all work together in full-spectrum nursing. WHAT DOES NURSING INVOLVE? Chapter 1 introduced you to nursing roles, respon- sibilities, and activities and to the profession of nursing. Throughout this text, you will learn that nurses need to have technical skills; a sound knowledge base; and skills in therapeutic commu- nication, critical thinking, and critical reasoning to develop sound clinical judgment. Much of nursing emphasis is on thinking, which is the foundation of being activity oriented (doing) , and now more than ever, the importance of caring. So, another way to describe nursing is to say that nursing involves think- ing, doing, and caring. Thus, your view of the essen- tial roles nurses have in the care of their clients will expand as you progress in your studies. To track your progress, you can later compare your developing view with the baseline you will establish in the exer- cises in this chapter. Think Like a Nurse 2-1: Clinical Judgment in Action What are your thoughts about Jan as a nurse? What strengths do you see, and in which areas, if any, is improvement needed?

Nursing practice has increased in complexity as a result of sicker clients, shortened hospital stays, and increas- ing demands. This requires that in the context of mul- tiple responsibilities (e.g., interacting with different healthcare providers; administering numerous medica- tions; performing various treatments; documenting in the electronic health record; admitting, transferring, and discharging clients; addressing client and family issues and concerns), you will need to multitask, prioritize, delegate, and make decisions to safely address client care needs (Manetti, 2019). As a new nurse, you must use sound clinical judgment to ensure safe client care and outcomes. WHAT IS CLINICAL JUDGMENT? Common factors in definitions of clinical judgment are processes that promote safe client care decisions and outcomes. ■ The National Council of State Boards of Nursing (NCSBN, 2019) acknowledges that clinical judgment integrates critical thinking and decision making. Nurses must apply nursing knowledge “to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evi- dence-based solutions in order to deliver safe client care” (p. 2). ■ Tanner (2006) defines clinical judgment as the “interpre- tation or conclusion about a patient’s needs, concerns, or health problems, and/or the decision to take action

UNIT 1 How Nurses Think

(or not), use or modify standard approaches, or impro- vise new ones as deemed appropriate by the patient’s response” (p. 204). This definition emphasizes the impor- tance of understanding the disease process, pathophys- iology, diagnostic aspects, and impact of the illness experience for the client and family. ■ Benner et al. (2009) note that clinical judgment is the “ways in which nurses come to understand the prob- lems, issues, or concerns of client and patients, to attend to salient information, and to respond in con- cerned and involved ways” (p. 201). This definition includes the processes of acquiring, analyzing, and using information to address client needs. Inherent in each of these definitions is the requirement to use processes to achieve desired client outcomes. They require nurses to assess/recognize evidence of client problems, interpret the problems, prioritize a response, take action, evaluate outcomes, and modify actions to ensure the client’s needs are met. You must also consider the context of practice, which includes environmental factors in clinical activities (e.g., staffing, resources, client/family roles) and individual factors (e.g., skill level, knowledge, prior experience). WHAT ARE THE DIFFERENT KINDS OF NURSING KNOWLEDGE? Theoretical knowledge — knowing why —consists of information, facts, principles, and evidence-based theories in nursing and related disciplines (e.g., phys- iology, psychology). It includes research findings and rationally constructed explanations of phenomena. It also includes an understanding of the pathophysi- ology of the disease process, medical treatment (e.g., dietary, medications, activity), surgical treatment and perioperative care, and client and family factors. You will use it to describe your clients, understand their health status, explain your reasoning for choosing interventions, and predict client responses to interven- tions and treatments. Practical knowledge — knowing what to do and how to do it —is an aspect of nursing expertise. It consists of processes (e.g., the decision process, nursing process) and procedures (e.g., how to give an injection). Practical knowledge requires an understanding of the “how and why” of correctly performing nursing skills. Self-knowledge is self-understanding. Clinical judg- ment requires you to be aware of your beliefs, values, and cultural and religious biases. You can gain self- knowledge by developing personal awareness—by reflecting (asking yourself), “Why did I do that?” or “How did I come to think that?” Ethical knowledge is knowledge of obligation, or right and wrong. Ethical knowledge consists of infor- mation about moral principles and processes for mak- ing moral decisions. Ethical knowledge helps you to

fulfill your ethical obligations to clients and colleagues. Chapter 5 will help expand your ethical knowledge. Key Point: Sound clinical judgment requires the nurse to integrate various types of knowledge (e.g., theoreti- cal, practical, ethical, self-knowledge). Refer to the sce- nario in Explore Your Nursing Role. As you probably realize, knowledge is essential in nursing practice. Let’s examine some of the theoretical and practical knowl- edge Jan needed to identify signs of a deteriorating client condition and initiate appropriate interventions for Mr. Anderson. Foundational Knowledge Required: ■ Handoff report (SBAR) ■ Care of the general postoperative client ■ Care of postoperative client after abdominal surgery ■ IV fluids: types, infusion rates, indicators of complica- tion, size and type of access device ■ Care of client with drains (nasogastric tube, Foley, wound; type, drainage, patency) ■ Care of surgical wounds ■ Pain management ■ Diabetes and its management ■ Types and management of dementia ■ Role and responsibilities of members of the interpro- fessional team ■ Complications (potential, signs and symptoms) As you can see, the care of one client may require you to synthesize lots of areas. You will obtain this knowl- edge and more in your nursing program. You will learn how to put it all together. As you cover topics in your courses, always ask yourself, “How will I apply this knowledge to provide safe, quality care to my clients? Knowledge Check 2-1 ■ Define the term clinical judgment in your own words. ■ What is the difference between theoretical and practical knowledge? What Are Models of Clinical Judgment? A model is a set of interrelated concepts that represents a way of thinking about something—much in the same way that the shape of a lens affects what you see. For example, you would look through a telescope to view a distant star. Looking at the star through reading glasses or a magnifying glass would give a different view. You will learn more about models in Chapter 4. The clinical judgment models used throughout this book provide ways of making sense of the concept of clinical judgment. They define the processes involved in arriving at sound client care decisions. Tanner Model of Clinical Judgment This model describes the four aspects of the clinical judg- ment process used by experienced nurses. The critical- reasoning processes that nurses use to foster clinical

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