Compare changes in the exudate with the patient’s pre- vious status. ■ Amount. Describe the amount as none, light, moder- ate, or heavy. Drainage amounts vary according to the type of wound (i.e., venous stasis ulcers usually pro- duce more drainage than arterial ulcers). ■ Drains. If a drain is present, measure the amount of fluid in the collection container. ■ Color. Describe the color or consistency as serous or clear, serosanguineous, sanguineous, purulent, or seropurulent (composed of serum and pus).
■ Odor. Describe odor as absent, faint, moderate, or strong. ■ Clean the wound of all exudate or foreign material before assessing for odor because odor characteris- tics vary depending on wound moisture, organisms present, amount of nonviable tissue, and types of dressings used. ■ Odor may indicate fistula formation or bacterial con- tamination. For example, if a patient has an abdom- inal wound that was odorless but begins to smell of bile or feces, you should carefully assess for the pres- ence of a fistula. If confirmed, notify the provider. service providers, including names and contact information, that are appropriate resources for the patient. Having easily accessible information about reliable care would lessen the burden on the patient. Think about it. ➤ What considerations are important when building an interprofessional team? ➤ What practical challenges may need to be addressed within the context of a wound care team? ➤ How can technology play a role in effective implementation of wound care teams? Source : Buggy,A., & Moore, Z. (2017).The impact of the multidisciplinary team in the management of individuals with diabetic foot ulcers:A systematic review. Journal of Wound Care, 26 (6), 324–339. https://doi. org/10.12968/jowc.2017.26.6.324; Moore, Z., Butcher, G., Corbett, L. Q., McGuiness,W., Snyder, R. J., & van Acker, K. (2014).AAWC,AWMA, EWMA position paper: Managing wounds as a team. International Journal of Wound Care, 23 (5), S1–S38. https://doi.org/10.12968/jowc.2014.23.Sup5b.S1
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CHAPTER 7 Life Span: Older Adults
Safe, Effective Nursing Care boxes emphasize how to provide safe and effective care by highlighting an example of a competency expressed in practice.
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
Improving Wound Care With Interprofessional Teams Key Concept: Wound Healing Competency: Collaborate with the interprofessional healthcare team Interprofessional collaboration is essential to providing quality patient care and strengthening the healthcare system.The use of a team approach in treating both acute and chronic wounds, including diabetic foot ulcers, venous stasis ulcers, and pressure injuries, has been a topic of research.Within this model, the patient remains central, with care efforts being provided based on patient needs and desires. Characteristics such as trust, effective communication, role clarity, and mutual respect are needed to create high-functioning teams.
Key Point: The risk of abuse is higher for women and those with physical and cognitive vulnerabilities. Advanced age Physical, functional, or cognitive impairment
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,
RECOGNIZING CUES
The World Health Organization suggests a “wound navigator” as a wound care team leader.The navigator functions as a patient advocate, focusing on patient-perceived needs and involving the expertise of healthcare professionals.The wound navigator collaborates with other professionals to determine the best plan of care for each patient, using a referral and follow-up system. For example, the wound navigator could provide each patient with a list of care/
26
UNIT 4 Supporting Physiological Function
ANANLYZING CUES/ DIAGNOSING
6/22/23 4:52 PM pain. Key Point: The mo tion is normal saline. B occur as soon as 24 hour Sterile water may also larly when other solutio Ideally, the irrigation Isotonic to prevent in Nonhemolytic to pre Nontoxic to healing impair wound hea Transparent to allow bed. Inexpensive for frequ volume of solution Warmed to room temp Selecting an Irriga following are common m ■ Piston syringe for irr posable syringe has a mize hand slippage a elongated tip is able to gation fluid.
32-1
Go to Procedure 6-1 in Volume 2.
contamination from biofilm in the hospital setting and in patients with a higher risk of acquiring infec- tion (compromised immune system, other comorbid- ities). Biofilm (a coating of bacteria that adheres to a surface) forms in hospital water delivery systems. Biofilms impede wound healing by reducing the effectiveness of fibroblasts in repairing the wound bed. This substance also reduces the effectiveness of antimicrobials. 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 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.
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UNIT 11 Factors Affecting Health
• Low self-esteem related to physical abuse and demeaning communication • Risk for Injury related to physical or psychological abuse
PRIORITIZING HYPOTHESES
EXAMPLE CLIENT CONDITION: Elder Abuse—cont’d
(continued)
Key Point: Prevention is key: listen, intervene, educate. Prevention Measures • Screen for social determinants and risk factors associated with elder abuse. • Observe for injuries indicative of elder abuse. • Determine congruence of injury and the description of cause. • Remove patient from dangerous situation. • Notify appropriate authorities of suspected abuse.
GENERATING SOLUTIONS
Stop Elder Abuse: REPORT IT. • Suspicion of elder abuse must be reported to adult protective services and/or the authority designated by law in each state to investigate and prosecute elder abuse. • Call the police or 9-1-1 immediately if someone you know is in immediate, life-threatening danger. Elder Abuse Resources • The National Center on Elder Abuse (NCEA) (https://ncea.acl.gov/) • Clearinghouse on Abuse and Neglect of the Elderly (CANE) (https://www.nsvrc.org/ organizations/133)
TAKING ACTION
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• Remains safe and free from physical and/or psychological harm • Maintains dignity • Verbalizes positive self-worth
EVALUATING OUTCOMES
remain alert to early signs or symptoms of cognitive impairment (for example, problems with memory or language) and evaluate as appropriate. Assessing the mental status of older adults can help guide decisions about when it may be appropriate to screen for cogni- tive impairment in the primary care setting. Also see the Example Client Condition: Dementia. For a step-by-step procedure for a complete assess- ment of mental status, Go to Procedure 19-16, Assessing the Sensory-Neurological System, in Volume 2. Assessing Functional Status Functional status is the ability to perform self-care and other ADLs and IADLs. ■ Activities of Daily Living. You can use the Katz Index of Independence in Activities of Daily Living to rate a
environment, for example, shopping, using the tele- phone, housekeeping, managing money, preparing food, and managing one’s medications. Loss of ability to per- form IADLs frequently marks a need for assisted living, nursing home placement, or the aid of family or home- maker services to allow an older adult to age in place. Assessing for Depression For more information about depression in older adults, see the box Example Client Condition: Depression in Chapter 10. To assess for depression, you may wish to use the Geriatric Depression Scale (GDS), a 30-item questionnaire that screens for depression. It is tailored to the concerns that older adults face. To learn more: Go the The Geriatric Depression Scale (GDS): http://www. stanford.edu/~yesavage/GDS.html AU: please verify cross- reference
Example Client Conditions are graphically driven exemplars that tie together key concepts within a chapter and reflect the cognitive skills of the NCSBN Clinical Judgment Measurement Model . iCare boxes and icons highlight the important role of caring in nursing by modeling behaviors and conversations that demonstrate how a nurse can provide compassionate care. Request preview access • Schedule a walkthrough • Learn more | Contact us at Hello@FADavis.com or visit FADavis.com/DavisAdvantage
The use of a bulb increases the risk of aspira ing granulation tissue.
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7 ■ Commercial irrigatio agitators, whirlpool h isters, and pulsed lav an uninterrupted stre wound’s surface. Puls
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