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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.
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. DOING 3. Practical Knowledge (Assessment): a. What symptoms of infection does Mr. Santos have?
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.
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11. Remove gloves and discard in a
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