NR 224 Exam 2 Nursing Fundamentals Review | Skin Integrity, Wound Care & Bowel Elimination | Pressure Ulcer Staging & Ostomy Care | Graded A+ Study Guide

Excel in your nursing fundamentals course with this comprehensive NR 224 Exam 2 Study Guide. This resource provides a deep dive into Chapter 48: Skin Integrity and Wound Care, featuring detailed explanations of Pressure Ulcer Staging (Stages I-IV and Unstageable), wound drainage types (serous, serosanguineous, purulent), and the physiological process of ischemia. Master critical nursing interventions for pressure injury prevention, including the use of support surfaces, continence care, and the Braden Scale risk assessment. Additionally, the guide covers Chapter 47: Bowel Elimination, focusing on ostomy management (ileostomy and colostomy), stoma assessment, and the proper technique for fecal occult blood testing (gFOBT). Whether you are studying wound healing by scar formation or the clinical signs of stoma ischemia, this verified resource offers the essential clinical knowledge and safety protocols required for exam success and patient safety. NR 224 EXAM 2 Fundamentals Review (Chapters 41, 45,46,47,48) CHPT 48 SKIN INTEGRITY AND WOUND CARE Pressure ulcers localized injury on bony prominence from shear (force parallel to skin) friction(dragged), moisture Ischemia Blanching - red tones are absent (not in dark skin patients) Older adults, decreased consciousness @ high risk Urine maceration S skin breakdown Use incontinence cleanser, dry skin , moisture barrier ointment contusion : close wound laceration : jagged irregular edges serous : watery , clear serasangious : watery, pink, blood tinged frank : fresh blood purelent : infection , thick , WBC, bacteria, tissue debri , odor Skeleton balance suspension traction shift weight while immobile, Bucts traction restriction of movement (hip fracture) Halo brace can ambulate with halo brace Nutrition Observation of skin Ulcers (up walking, position changing) Lifting Clean skin/continence care Elevate the heels Risk assessmentSupport surfaces for even distributions Stage 1: nonblanchable redness, intact skin (don’t massage) Stage II: Partial thickness , skin loss (epidermis S dermis), blister, w/o slough, abrasion (ex: shallow open reddish w/o slough (scab like) on heel of foot) Stage III: full thickness tissue loss with fat, slough may be present, drainage and infection may be present , purulent discharge (thick milky), full had to toe Stage IV: full thickness tissue with exposed bone, muscle, or tendon , escare (black), HEAL BY SCAR FORMATION ! Unstageable : depth is unknown, completely obscured by slough (yellow, tan , green) or escar (tan to black), can be a III or a IV, suspected deep tissure injury, purple or marron, localized, intact skin, blood filled blister Assess the type of tissue amount, appearance(color), viable/nonviable tissue, granulation tissue (red moist new blood vessels healing) , slough must be removed by skilled tech or wound dressing Protein is important for skin (wound healing) albumin level 3.5 to 5 (less than 3.5 means lacking protein skin breakdown) hydrogel/hydrocolloid dressing (moisture) provided for healing low air therapy units decrease pressure Q2 turns! Healing:Nutrition Perfusion Infection Age Psychosocial Primary intention approximated (surgical by stables) Secondary intention not approximated Complications of healing Hemorrhage Hematoma Infection 2nd most HAI, microorganisms invading wound tissue Urithemia , increased wound drainage, warmth, pain, edema, fever, tenderness, color , elevated WBCs, inflamed edges, odorous, Dehiscence partial or total separation of wound layer Evisceration visceral organ from total separation of wound , EMERGENCY, do not attempt to put organ back in , wet sterile gauges over the site , inform surgical team, observe for shock, supine, knees and hip should be bent, vital signs Q5min, prepare client put in trandelgenberg Braden scale risk factors on 6 subscales 0.9 % NA doesn’t kill the good cells promote healing noncytotoxic Assessment-patient , skin , pressure ulcers, body fluids , pain , head to toe, wounds , drains, culture wound (suspect purulent obtain specimen , never from old drainage), clean infected wound with normal 0.9 saline solution remove skin flora before!, do not irrigate with antiseptic (false negative), obtain sample from cleansed wound (not intact skin) Diagnosis: -risk for infection -acute/chronic pain -impaired mobility -ineffective perfusion -impaired integrity Planning: - prevent pressure ulcers - promote wound healing Implement: - provide w/ high protein - avoid massaging red skin - incontinence management - Q2 turn - 30 degree elevation - wound management (debridement irrigation , wound cleansing of necrotic tissue) - hemoglobin :males 14-18 , females 12-16 (below = low delivery of oxygen to tissue) -WBC 5,000-10,000 NORMAL -theraputic PTT 1.5- 2.5 decrease blood supply to promote clotting S wound healing - control bleeding allow puncture to bleed, don’t remove penetrated object Drain -pin rolls drain comes out passively on it’s own , pin prevents it from slipping back in-JP drain closed suction medical devices, post op drain from surgical site promote healing by draining fluid from wound , prevent pooling of blood, prevent infection , threaded through the wound, LOW PRESSURE fully compressed Dressings - wet to dry gauze remove wound exudate S necrotic tissue (small amounts of exudate), sticks to the wound, - transparent film protects ulcers from moisture and bacteria yet allows oxygen to reach skin, minimized fiction and shear, NO absorption , STAGE 1 - hydrocolloid support healing in clean granulating wound, debris necrotic wounds, forms gel where exudate is absorbed, change as soon as absorption is maxed - stage 3 - hydrogel rehydrate and promote debriment , STAGE 2-4, (necrosis, infection, and need for moist environment NOT dry gangrene) water/glycerin based -alginate STAGE 2-4 pressure uclers, moderate to heavy drainage, moist environment, seaweed, healing and absorption of exudate, packing wound. Large. NOT FOR DRY WOUNDS Tape Tape is used to secure dressing, silicone/non allergenic tape to prevent irritation Secure all sides , adheres to several inches of skin , gentle, exert pressure away from wound , don’t use skin protection (wont resolve) Ties (montgomery)– avoid repeated removal, secure with ties Binders: support to wound, immobilize part of the body, put over dressingCleaning Cleaning in the direction from least contaminated to most contaminated (center outwards) Gentle friction Stables must be removed by someone certified Heat and cold therapy need a health care order Check correct temperature, placement Warm compresses increase blood flow, improve circulation, reduces edema, moves lymph fluid in the body. Cold compresses @ 30 mins at a time but check client skin after 15 minutes! HYGEINE Implementation: Bathe arm, face, legs Long firm strokes digital to proximal , ankle to the knee, knee to the thigh (infection) Increase circulation Not excessively, may loosen DVT Work @ waist level Client may help, improve independence Document : bath and type of response Denture care (personal property) -clean dentures w/ soft toothbrush, toothpaste S tepid water (warm) horizontal avoid gingivitis -label in a denture cup with water, or emesis, or wash cloth on sink (discourage napkin) -removed at night to rest gums and reduce denture stomatitis (painful sores on gums and roof of the mouth) Shave in the growth of the hair w/ the grain Changing bed w/ client in it-bed @ waist level -roll client on side, make sure bed rails in up on side turning -don’t reach over the bed Unoccupied bed -lower all side rails ‘ CHAPTER 41 OXYGENATION Blood is oxygenated through ventilation, perfusion,transportation Atmosphere lungs alveoli exchanged for deoxygenated blood CO2 Alveoli capillary membrane gas exchange of oxygen transfer to the blood through respiration (diffusion) Surfactant chemical in lungs for tension to keep alevoli from collapsing Acteletasis – decreased surfactant Collapsed lungs preventing normal exchanged of oxygen to CO2 -USED INCENTIVE SPIRAOMETER increased lung volume 10xs an hour breathing out ! Prolonged bedrest pneumonia Bicarbonate kidneys take awhile Hypoventilation Alveolar ventilation inadequate to meet the body’s oxygen demand or to eliminate sufficient carbon dioxide (retaining CO2) Hyperventilation Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism.. blowing off CO2 (CO2 elevated) Cyanosis late sign of hypoxia -reliability is oral mucosa (tongue , lips) central cyanosis -NUMBER 1 PRIORITY ABC -dark skin clients conjunctiva, sclera, soles of feet, oral mucosa Clients w/ asthma airways constrict- wheezing, fatigue, agitated, SOB, increased mucus Pnuemonia small air sacs (alveoli) - dry coughing, chest pain, fever, breathing issues, severity varies - increase fluid to 15-25 ML a day to thin secretions for productive cough mechanical ventilation good oral care to prevent pneumonia - coughing, turning, deep breathing Q2 Left sided heart failure (pulmonary congestion from pooling) -fatigue, SOB, dizzy, confusion , frothy sputum , crackles Right sided heart failure (systemic circulation) -acietes, JVD, pheripheral edema, enlarged spleen Myocardial infraction -radiate to jaw, back, neck (women =back pain) Angina -mimics MI -nitroglycerins with relive angina WBCs elevated w/ infection Suctioning remove thick secretions - keep bamboo bag in room keep pulse ox on -2/3 times with 60 second pause in between passes to prevent hypoxia -vomiting turn on the side -keep obutrator in room EVALUATE effectiveness lung sounds clear vesicular lung sounds Pneumothorax – collapsed lung Hemothorax – collection of blood Nasal cannula (22-44%) 1-6L/minHumidifier if more than 4-6L to prevent drying mucus membrane Skin protections for ears, nose, and neck COPD @2-3 L Venti mask (34-60%) @ 4-12L/min Short term (35-50%) @ 6-12 L/min Simple face mask (40-60%) @ 5-8L w/ humidifier Partial rebreather mask (40-70%) @6-10L Nonrebreather (60-100) @ 10-15L/min Diaphramatic breathing deep breathing using muscles in abdominal cavity through nose, chest expansion is maximized , increasing air trapping Purse lip breathing suck air in by the lips , prolonged expiration prevent alveoli collapse Trach care sterile use sterile saline to clean DO NOT use mild soap and water hyper oxygenate to 100% suction when withdrawing the cather to avoid trauma 10 to 15 seconds alsculate lung sounds afterwards for vesicular lung sounds Identify patient Access the need sterile gloves sterile cap to tube suction follow policies reassess secure in place with Velcro or tie to prevent dislodgement keep the old ties in place while putting in the new ties Kidneys ureters bladder urethra CHAPTER 46 URINATION ELIMINATION Bun and creation levels w/ kidney Bladder prostate urethra (male) Enlarged prostate – BPH constricted urethra Lasik water pill monitor potassium (heart arrythmia) S fluid electrolytesVoiding: contraction + sphincter S pelvic floor muscle relaxation ( KEGALS TID) Signals micturition , responds or ignores urge Assessment: Personal habit: when you go, how you go, routine Symptoms of urinary alterations Color, clarity, odor Implementation Normal mictutition maintain routine S fluid intake Catheterization Inserting indwelling on female 1. hand washing 2. open outer flap first, side, then closet towards you 3. apply sterile drape and put on sterile gloves, 4. perineal care with soap and water prior reduce bacteria, 5. open outer flap first, side, then closet towards you 6. tip is coated with water soluble lube (reduces the risk of tissue trauma), 7. tell them to gently bear down to relax (don’t contract), 8. use nondominant hand to separate labia DIRTY (don’t let go), 9. dominant hand to insert (STERILE), 10. urine begins to flow in (flashback), 11. 1-2 inches further inside for space to inflate the balloon (keeps stable). -no urine obtain, leave catheter in for landmark for the new sterile catheter (reduce infection) bladder/kidney infection w/ indwelling catheter hematuria assess tubing for kinks if no output in bag (ASSESS !!!!) bag below to keep urine going back into urethra on non-movable part of the bed Specific gravity normal is 1.0053 to 1.030do not change unless there is a problem leakage or blockage avoid irrigation unless obstructed Removing catheter make sure you have an order -assess client until bladder regains full tone -temp urinary retention (6-8 hours) afterwards might have to reinsert Condom cath -1-2 inches of space from head of the penis -never use tape Urinary retention inability of bladder to empty urine accumulate -dripple of urine, going to the bathroom 2/3 times an hour Urinary tract infection catheterization or procedure (CAUTI) -pain w/ urination, cloudy concentration urine from bacteria/WBC/RBC, odor, amber color , not elevated bun level (not kidney disease) -closed urinary drain system -perineal wash x2 a day (don’t use antiseptic) Glucose in urine diabetes Urinary incontinence involuntary leakage of urine -chronic retention of urine -older adults w/ mobility issues S clothing -dementia : avoid adult depends maceration can occur -routine allows clients to know when to gostress incontinence – increased abdominal pressure (laughing, coughing..) urge incontinence – loss of urine after urge to void -kegal exercise reflex incontinence – loss of urine w/o sensation of need to void urinary diversion due to external source urostomy bag nephrostomy tubes small tubes tunneled through skin into renal pelvis -drain when ureter is obstructed dysuria – painful urination hesitancy – difficulty initiation hematuria – blood in urine nocturia – urine 1 or more times night avoid drinking before night, especially cafffiene and alcohol oliguria – small urinary output, LESS than 30 ml/hour, 400 mL per 24 hours. Access for bladder distension, adequate intake?, bladder sphincter = retention? Inadequate renal perfusion Anuria – no urine output Residual – urine remaining after voiding up to 100 mL Frequency – every 2 hours Dribbling – small drops of urine Adults produce 1500 to 2000 ml of urine per day Sitting urine = cloudy (normal) Perineal skin maceration skin breakdown (red on bony prominence) -moister barrier ointment Urine specimen reach lab in 2 hours or preserve them bacteria can growClean catch midstream (female) 1. cleanse perineal area w/ wipe front to back , 2. use each wipe only once , 3. urinate first to get rid of bacteria, 4. move container to urine stream, 5. don’t touch the inside . Cannot delegate culture to a UAP CHAPTER 45 NUTRITION Carbohydrate 4ccals per gram -brain, muscles, cell function of renal medulla -main source of glucose energy-mostly plants except lactose Proteins 4ccals a gram Nuitrogren balance Fats 9ccals per grams -trigylercides and fatty acids -mostly in animal Adaptive equipment helps clients eat and promote independence and antomy Clear liquids grape/apple juice, black coffee, broth ,carb beverages, not red juices Full liquid pureed vegetables, pureed meats, juice, liquid dairy, cream soups Mechanical soft clear S full liquids, plus diced and ground foods Ex: cream soup, flake fish, cottage cheese, rice, potatoes, pancakes, cook veggies, bananas, cook/can food, scrambled eggs (NOT WHEAT TOAST), pureed bread Pureed clear and full liquids plus pureed meats , fruits, scrambled eggs Cultural considerationsDysphagia coughing, abnormal movements with swallowing, voice changed, “silent” -suction as needed, turn to the side (vomiting ) -smaller bites , extra time for chewing and swallowing , high fowlers, Enteral Tube Feeds Nutrients into GI tract ng tube, gastric tube, or jenual tube -risk for aspiration high fowlers 30-45 degrees -place feeding on hold when turning -30 cc of water after going through gtube (FLUSHING) -inability to swallow PEG tubes -when no other entry NG tube -plastic tube from nose, throat, to stomach to carry food S meds -extra calories for balanced nutrition -get Xray to ensure placement , Normal PH 0-4 and green NG tube is placed Parenteal nutrition TPN accuchecks b/c dextrose -intravenous -lethargic , thirst, headaches , polyuria (HYPERGYLCEMIA) Dobhoff for continuous feeds -sallium stum tube dual lumen can used for gastric decompression Complications diarrhea (need a new prescription, dilute the formula, change the rate, dirutic formula)Measuring tubes from tip of nose, earlobe, to xyphiod process □ Peptic ulcer etiology • Helicobacter pylori • Stress • Acid overproduction Peptic ulcer treatments • Avoid caffeine • Avoid spicy foods • Avoid aspirin, nonsteroidal antiinflammatory drugs (NSAIDs) • Consume small, frequent meals Chapter 47 BOWEL ELIMINATION Large intestine Ascending, transverse, descending colon, sigmoid colon, rectum (left to right) Ascending : liquid to semi fold, rich in digestive enzymes, NO HARD MASS Transverse : transfer to liquid to semi form, absorption – NO MASSES Descending : semi form Rectum: anus opens and empty feces Normal defecation begins with movement in the left colon to the anus - FACTORS: AGE, FLUID, DIET, SURGERY, PREGNANCY, MEDICATIONS, PAIN, POSITION o Older adult gets dysrhymthmia b/c of strain hemorrhoids Distenstion relaxation of internal sphincter abdominal distends knows need to pass stool (intra rectal pressure)Paralytic Ileus intestinal obstruction, reduced mobility bowel manipulation during surgery S anesthesia, medication -no food material, gas, liquid moving through 24-48 HRS monitoring closely NG tube: decompression, enteral feeding, compression, lavage - remove gastric secretions - salum sump tube ( air vent S remove gastric contents) continuous suction - risk for hypokalemia Constipation (hard, dry, small stool, infrequent, hard to eliminate) Increase raw vegetables and raw fiber, older 6-8 glasses of fluid -kale, lettuce, spinach, green beans Ignore the urge to defecate alterations in bowel habits (ex: constipation) Fecal impaction -bowel sounds (hypo or hyperactive) Diarrhea -irritation in rectal and perianal (tux wipes can help) -loss of fluid and electrolytes Flatulence -accumulation of gas causing walls to stretch Cathartics rapid stronger and rapid than laxatives (hypo be hyper or hyperactive) Suppositories quickly Not w/ diary or anti acids decreases absorption Enemas – promote defecation by stimulating parastylsis -left side , right knee forward ACE enema – done in children , neuropathic or anal sphincterCleansing enema can develop cramping (normal) , don’t terminate enema unless acute distress , temporarily slow the flow to prevent the cramping Tap water (hypotonic) osmotic pressure lower than fluid in intestinal space, into colon w/ tap water, movement of water is low. Infused volume stimulates defecation -position left side lying w/ right knee flexed Normal saline complete evacuation of feces , equal osmotic pressure Hypertonic pulls fluid out of spaces Soapsuds irritate mucosa and stimulates to defecate Oil retention – lubricate and softens stool Carminative improve to pass gass Kayexulate excrete excess potassium (check labs prior) Digital remove of stool -last resort after enema -using fingers for impaction (must have an order) -baseline vitals , clean gloves, massage around and bring it down (can stimulate vagus/cardiac nerve) Bowel diversions temp or permanent -create a stoma -- ileostomy or colostomy – empty when 1/3-1/2 full sigmoid – formed stool transverse- thick to soft liquidloopend- turtle neck and sutured around blood in ostomy ? call the doctor Illeonal pouch anastomosis – surgical and ulcerative colon Continent ileostomy – Ostomy care -new oozy red drainage immediately after surgery -stoma is bright pink, pink red beefy red , shiny and moist – purple is ischemia (doctor immediately) -pouch opening is appropriate size 1/16-1/8th (large is irrosion of skin, small can affect perfusion) -write measurements on wafer then pizza pie 4 -pouch in place hear a click -pouch should be empty when half full -avoid scrubbing peristoma skin Bedpan raise head 30-45 degrees Assessment: Bowel sounds, normoactive soft clicking (5-30 per minute) Elimination factors Routine Lab test UAP does not collect stool w/ sterile swapFecal occult test: FIT – prescence of blood that cannot be seen w/ eyes GFOBT – diagnosis screening for colon CA or gastric ulcers (not bacteria, no steorrhea, no parasites) Diagnosis: problems Disturbed body image Incontinence Constipation Diarrhea (alteration in bowel by evidence by ..) Nausea Planning Reinforcing routines Educate on dietary Educate on fluid intake Evaluating Normal defecation Effectiveness Evaluate patient knowledge