Chap 15: Documenting and Reporting c.

Plan of care
– generated by the person who lists the problems.
Terms Related
d. Progress notes
Report – made by all professionals involved in a client’s
– an oral, written, or computer based care; they all use same type of sheets.
communication intended to convey information to
others S – Subjective data
O – Objective data
Record – written or computer based A - Assessment
P – Plan
Recording, charting or documenting I – Intervention
– the process of making an entry on a client record E – Evaluation

Purposes of client records Sample SOAPIE Charting

S : “Nahihirapan akong huminga, napagod agad ako
 Communication
nung pagkatayo ko” as verbalized by the client.
 Planning client care
 Auditing health agencies
O : with cyanotic nail beds
 Research
- respiratory rate = 45 breaths/min
 Education
- with clavicular retractions upon respiration
 Reimbursement
 Legal documentation A : Ineffective breathing pattern related to fatigue
 Health care analysis
P : After a series of nursing interventions, the patient
Documentation Systems will be able to decrease his breathing difficulties and
restore a normal breathing pattern.
1. Source-oriented record
- the traditional client record I – Administered oxygen inhalation at 2-3
- in this type of record, information about a liters/minute via nasal cannula to increase oxygen
particular problem is distributed throughout the levels.
record.
- Positioned on high back rest to promote better
Example: lung expansion.
Narrative charting (It consists of the written notes
that include routine care, normal findings, and client - Advised to minimize body movements to prevent
problems.) lung exhaustion.

2. Problem-oriented medical record - Respiratory rate referred to attending physician.

– here, the data are arranged according to the
problems the client has rather than the source of - Observed for other signs of respiratory difficulties.
information.
E – After a series of nursing interventions, the
4 BASIC COMPONENTS patient’s difficulty of breathing subsided and was
able to restore his breathing pattern as evidenced by
a. Database a respiratory rate of 28 breaths per minute, absence
– it consists of all information known about the of cyanosis, and absence of breathing complaints
client first enters the healthcare agency.

b. Problem list
– derived from the database
- usually kept at the front of the chart and serves as
an index to the number of entries in the progress
notes.
Focus Charting Flow Sheets
 Intended to make the client and the client  Enables nurses to record nursing data quickly
concerns and strengths the focus of care. and concisely and provides an easy-to read
record of the client’s condition over time.
 The FOCUS may be a condition, a nursing
diagnosis, a behavior, a sign or symptom, a change  Examples:
in the client’s condition, or a client strength. 1. Graphic record
2. Fluid balance record
 It is organized into DAR. 3. Medication administration record
(Data, Action, and Response) 4. Skin assessment record

SAMPLE Focus (DAR) Charting Guidelines for Recording

 Date and time
 Timing
 Legibility
 Permanence
 Accepted terminology
 Correct spelling
 Signature
 Accuracy
 Sequence
 Completeness
 Legal prudence

Reporting
KARDEX
 Used to communicate specific information to a
 A widely-used, concise method of organizing, person or group of people.
recording data about a client, making information
quickly accessible to all healthcare professionals.
 Whether oral or written, it must be pertinent
information, but no extraneous detail
 The system consists of a series of cards kept in a
portable index file or on computer-generated Reports used in Hospital Settings
forms.
 Change of shift reports
 Telephone reports
SAMPLE Kardex
 Telephone orders
 Care plan conference
 Nursing Round
 Chap 16 – Vital Signs Factors Affecting Body’s heat production

Vital/Cardinal Signs 1. Basal metabolic rate

– the rate of energy utilization in the body required
- Includes body temperature, pulse, respirations, to maintain essential activities such as breathing.
and blood pressure.
2. Muscle activity
- Recently, many agencies such as the Veterans
Administration, designated PAIN as the 5th vital 3. Thyroxine output
sign.
4. Epinephrine, Norepinephrine, and sympathetic
- When and how often to assess a client’s specific stimulation
vital signs are chiefly nursing judgments; physicians
may specifically order a vital sign 5. Fever

Body Temperature Heat is lost from the body through the following
- It reflects the balance between the heat produced
and the heat lost from the body, measured in units Radiation
called DEGREES. – transfer of heat from the surface of one object to
the surface of another without contact between 2
2 KINDS OF BODY TEMPERATURE objects.

1. Core temperature Conduction

– temperature from the deep tissues of the body, – transfer of heat from one molecule to a molecule of
such as the abdominal and pelvic cavity. lower temperature.
- It remains relatively constant.
Convection
2. Surface temperature – dispersion of heat by air currents
– temperature of the subcutaneous tissue, skin, and
fat. It rise and fall, in response to the environment. Vaporization
– continuous evaporation of moisture from the
Normal Body Temperature respiratory tract and the mucosa of the mouth and
the skin
* The normal body temperature of a person varies
depending: Regulation of body temperature
 Gender
When the skin becomes chilled over the entire body, 3
 recent activity
physiologic processes take place to increase body
 food
temperature.
 fluid consumption
 time of day
1. Shivering increases heat production.
 in women, the stage of the menstrual cycle. 2. Sweating is inhibited to decrease heat loss.
3. Vasoconstriction decreases heat loss.
Normal body temperature, according to the
American Medical Association, can range from HYPOTHALAMUS
– part of the brain that regulates the body
97.8° F to 99° F temperature
36.5° C to 37.2° C
Factors affecting body temperature
 Age
 Diurnal variations (circadian rhythms)
 Exercise
 Hormones
 Stress
 Environment
Alliteration in Body Temperature  Provide adequate nutrition and fluids.
 Measure intake and output
Pyrexia/Hyperthermia  Reduce physical activity to limit heat
–body temperature above the usual range production
- in lay man’s terms – FEVER.  Administer antipyretics as ordered.
 Provide oral hygiene to keep the mucous
Hyperpyrexia – a very high fever; 41° celsius. membranes moist.
 Provide tepid sponge bath to increase heat
Febrile – the client who has a fever. loss though conduction.
 Provide dry clothing and linens
Afebrile – client without Fever
Hypothermia
4 common types of fevers A core body temperature below the limit of normal.

1. Intermittent fever 3 physiologic mechanisms of hypothermia:

– body temperature alternates at regular intervals
between periods of fever and periods of normal or 1. Excessive heat loss
subnormal temperatures. 2. Inadequate heat production to counteract heat
loss
2. Remittent fever 3. Impaired hypothalamic thermoregulation
– wide range of temperature fluctuations (more than
2° C) occurs over a 24-hour period of time. Clinical Signs of Hypothermia
 Decrease body temperature, pulse and
3. Relapsing fever respirations
– short, febrile periods of a few days are
 Severe shivering (initially)
interspersed with periods of 1 or 2 days of normal
 Feelings of colds and chills
temperature.
 Pale, cool, waxy skin
 Hypotension
4. Constant fever
 Decreased urinary output
– body temperature fluctuates minimally but
remains above normal  Lack of muscle coordination
 Disorientation
Clinical Signs of fever  Drowsiness resulting to coma
 Increased heart rate
 Increased respiratory rate and depth Types of Hypothermia
 Shivering
Accidental hypothermia
 Pallid, cold skin
– occur as a result of exposure to a cold environment,
 Cyanotic nail beds
immersion in cold water, and lack of adequate
 Gooseflesh appearance of the skin
clothing, shelter, and heat.
 Cessation of sweating
Induced hypothermia
Nursing interventions for clients with fever –the deliberate lowering of the body temperature
 Monitor vital signs to decrease the need for oxygen by the body tissues
 Assess skin and temperature
 Monitor white blood cell count, hematocrit Nursing Interventions
and other pertinent laboratory reports  Provide a warm environment
 Remove excess blankets when the client  Provide dry clothing
feels warm, but provide extra warmth when  Apply warm blankets
the client feels chilled.
 Keep limbs close to the body
 Cover the client’s scalp with a cap or turban
 Supply warm, oral, intravenous fluids
 Apply warm pads
4 Common sites for assessing body temperature Factors affecting pulse
 Age
1. Rectal temperature  Gender
– considered to be very accurate.  Exercise
 Fever
2. Axillary temperature  Medications
– preferred site for measuring temperature in  Hypovolemia
newborns because it is accessible and offers no  Stress
possibility of rectal perforation.  Position changes
 Pathology
3. Tympanic membrane
– the nearby tissue in the ear canal; is another site Pulse Sites
for ore body temperature.

4. Forehead
– another site of for measuring body temperature.

Types of Thermometers
 Electronic thermometers
 Chemical disposable thermometer
 Temperature sensitive tape
 Infrared thermometers
 Digital Thermometers

Pulse
- It is a wave of blood created by contraction of the
left ventricle of the heart

- Described in BEATS PER MINUTE. Apical-Radial Pulse Assessment

- Must be assessed for clients with certain
Related Terms: cardiovascular disorders.

1. Peripheral pulse NOTE: Any discrepancy between the 2 pulse rates is

– is a pulse located away from the heart. called PULSE DEFICIT.

2. Apical pulse Bradycardia – abnormally slow pulse rate.

– central pulse; located at the apex of the heart. Tachycardia – pulse rate above the normal range

Age Normal PR Average PR Respiration

(bpm) (bpm) - The act of breathing.
Newborn 100 - 170 140
Infants
80-170 120 2 Types of Respiration:
(1yr or less)
Toddlers
80-130 110 1. External Respiration
(1-3 yrs old)
Pre-schooler – interchange of oxygen and carbon dioxide between
75-120 100
(3-6 yrs old) alveoli of the lungs.
School child
70-100 90
( 7-12 yrs old)
2. Internal Respiration
Adolescent
60-90 75 – interchange of the same gases between the
(12-17 yrs old)
Adults circulating blood and the cells of the body tissues.
60-110 80
(up 18yrs old)
 Age Normal RR Average RR During normal respiration, an adult takes in 500ml
(bpm) (bpm) of air and this volume is called TIDAL VOLUME.
Newborn 30-50 40
Infants
(1yr or less)
20-40 30  Body position
Toddlers  Respiratory rhythm – refers to the regularity of
20-30 25
(1-3 yrs old) the expirations and inspirations.
Pre-schooler  Respiratory Quality/Character – aspects of
16-22 19
(3-6 yrs old) breathing that are different form normal,
School child
14-20 17 effortless breathing.
( 7-12 yrs old)
Adolescent  Sound of breathing
12-20 16  The RESPIRATORY RATE is described in
(12-17 yrs old)
Adults
12-20 18
BREATHS PER MINUTE.
(up 18yrs old)
 Eupnea- Breathing that is normal in rate and
Inhalation depth.
– the intake of air into the lungs.
 Bradypnea – abnormally slow respirations.
Exhalation/Expiration
– refers to breathing out of the movement of gases  Tachypnea/Polypnea – abnormally fast
from the lungs to the atmosphere. respirations.

2 Types of Breathing
 Apnea – the absence of breathing.
Costal/Thoracic Breathing –involves the external
Factors affecting Respirations
intercostal muscles and other accessory muscles.
THOSE THAT INCREASE RESPIRATORY RATE:
Diaphragmatic/Abdominal Breathing
 Exercise
– involves the contraction and relaxation of the
 Stress
diaphragm, and is observed by the movement of the
 Increased environmental temperature
abdomen.
 Lowered oxygen concentration at increased
Assessing Respirations altitudes
Before assessing a client’s respirations, the nurse
must be aware of the following: THOSE THAT DECREASE RESPIRATORY RATE:
 Decreased environmental temperature
1. The client’s normal breathing pattern  Certain medications
2. The influence of the client’s health problems that  Increased intracranial pressure
might affect respirations.
3. Any medications or therapies that might affect Blood pressure/ Arterial Pressure
respirations - It is the measure of the pressure exerted by the
4. The relationship of the client’s respiration to blood as it flows through the arteries; measures
cardiovascular function. in millimeters of mercury (mmHg)

Assessment Parameters 2 blood pressure measures:

Depth - can be established by watching chest
movements. It is generally described in terms of: 1. Systolic pressure – pressure of the blood as a
result of the contraction of ventricles.
1. Deep Respirations
– large volume of air is inhaled and exhaled; very 2. Diastolic pressure – pressure when the
deep respirations are called HYPERVENTILATION. ventricles are at rest.

2. Shallow respirations
– involve the exchange of small air volume and
minimal use of lung tissues; very shallow
respirations are called HYPOVENTILATION.
 Assessing Blood Pressure
Age Systolic Diastolic Average
Newborn 65-95 30-60 80-60 Blood pressure is measured with a
Infants (1) BLOOD PRESSURE CUFF,
65-115 42-80 90-61
(1yr or less)
(2) SPHYGMOMANOMETER,
Toddlers
76-112 46-84 99-65 (3) STETHOSCOPE
(1-3 yrs old)
Pre-schooler
85-115 48-64 100-56
(3-6 yrs old) Blood pressure sites
School child The blood pressure is usually measured in the
( 7-12 yrs 93-125 48-68 100-56 client’s arm using a BRACHIAL ARTERY and a
old)
standard stethoscope.
Adolescent
(12-17 yrs 93-137 51-71 118-61
old) Assessing blood pressure on the client’s thigh is
Adults usually indicated in these situations:
100-140 60-90 120-80
(up 18yrs old)
 When blood pressure cannot be measured on both
arms
Determinants of Blood Pressure  When blood pressure in one thigh is to be
 Pumping action of the heart compared with the pressure on the other thigh.
 Peripheral vascular resistance
 Blood volume Blood pressure cannot be measured on a client’s
 Blood viscosity arm or thigh in the following situations:

Factors affecting blood pressure  When the shoulder, arm, or hand is injured or
 Age diseased.
 Exercise  A cast or bulky bandage is on any part of the limb
 Stress
 Race Methods of Measuring Blood Pressure
 Gender
 Medications Direct Invasive Monitoring
 Obesity  involves the insertion of a catheter into the
 Disease process brachial, radial, or femoral artery.
 Through the OSCILLOSCOPE, blood pressure is
Abnormal Blood Pressures read as represented by wavelike forms.
 With correct placement, this measurement is
A. Hypertension - a blood pressure persistently highly accurate
above normal.
Non-invasive Methods
2 TYPES OF HYPERTENSION:  includes the AUSCULTATORY & PALPATORY
1. Primary hypertension METHOD.
– elevated blood pressure of unknown cause.
1. Auscultatory methods
2. Secondary Hypertension - Most commonly used in hospitals, clinics, and
– elevated blood pressure of known cause. homes.
- When carried out correctly, the auscultatory
B. Hypotension – blood pressure below normal. method is relatively accurate

1. Orthostatic hypotension
– blood pressure that falls when the client sits or
stands.
Korotkoff’s Sound Chap 17 – Asepsis
BACTERIOCINS
- Microorganisms found in the intestines which are
lethal to related strains of bacteria.

- It also produces antibiotic like substances and toxic

metabolites that repress the growth of other
microorganisms.

RESIDENT FLORA
- The collective vegetation in one area/part of the
2.Palpatory Methods body, yet produce infection in another.
– sometimes used when the Korotkoff’s sounds
cannot be heard and electronic equipment to Example: Escherichia coli
amplify sounds is not available, or to prevent
misdirection from the presence of auscultatory INFECTION
gaps. - Invasion of body tissue by microorganisms and
their proliferation there.
AUSCULTATORY GAPS –temporal disappearance of
sounds normally heard over the brachial artery, COMMUNICABLE DISEASE
when the cuff pressure is high followed by the - The resulting condition if the infectious agent can
reappearance of sounds at lower level. be transmitted to an individual by direct or indirect
contact, through a vector or a vehicle, or as an
Common Errors in Assessing Blood Pressure infection.
 Bladder cuff too narrow or too wide.
 Arm unsupported PATHOGENICITY
 Insufficient rest before assessment - The ability to produce disease.
 Repeating assessment too quickly - A true pathogen causes disease or infection in a
 Cuff wrapped too loosely or to evenly healthy individual.
 Deflating cuff too quickly or too slowly. - An opportunistic pathogen causes disease only in
 Failure to use the same arm consistently susceptible individual.
 Arm above level of the heart
 Assessing immediately after a meal or ASEPSIS
while a client smokes or in pain. - It is the freedom from disease-causing
 Failure to identify auscultatory gap microorganisms.

2 basic types:

1. Medical asepsis
– refers to all practices intended to confine a specific
organism to a specific area, limiting the number,
growth, and transmission of a specific
microorganism.

2. Surgical asepsis/Sterile technique

– refers to those practices that keep an area or object
free from microorganisms
- involves practices that destroys microorganisms
and spores.

Sepsis – the state of infection.

 TYPES OF MICROORGANISMS CAUSING BACTEREMIA & SEPTICEMIA
INFECTIONS Bacteremia – a condition wherein a culture of the
person’s blood reveals microorganisms.
Bacteria
– the most common infectious agent Septicemia – results when bacteremia becomes a
- can cause human diseases and can be transported systemic infection.
through air, water, food, soil, body tissues and
inanimate objects. Chain of infection

Viruses 1. Etiologic agent

– consist primarily of nucleic acid - the disease- causing microorganism.
- must enter living cells in order to reproduce.
2. Reservoir
Fungi – yeasts and molds. - the sources of the microorganisms.
(Ex. Organisms, plants, animals, environment)
Parasites – live on living organisms.
3. Portal of exit of reservoir
COLONIZATION – it is here where the microorganism leaves before
- The process by which strains of microorganisms an infection can establish itself in a host.
become resident flora.
4. Method of transmission
TYPES OF INFECTIONS – a means of transmission to reach another person
or host through a receptive portal of entry.
Local infection – limited to a specific part of the
body where the microorganisms remain. 5. Portal of entry
– here, microorganisms enter the body.
Systemic infection – infection where the
microorganisms spread into different parts of the 6. Susceptible Host - any person at risk for
body. infection.

Acute infection – generally appear suddenly or last METHODS OF TRANSMISSION

a short time.
1. Direct transmission
Chronic infection – may occur slowly, over a long – involves and immediate and direct transfer of
period, and may last months or years. microorganisms from person to person through
touching, biting, kissing or sexual intercourse.
NOSOCOMIAL INFECTIONS
 Classified as infections associated with the Ex: Droplet spread
delivery of health care services in a health care
facility 2. Indirect transmission
 It can develop either during the client’s stay in – may either be vehicle-borne or vector-borne.
the hospital or after discharge.
a. Vehicle-borne – microorganism is transmitted
LATROGENIC INFECTIONS through a vehicle, which is any substance that serves
– direct result of diagnostic or therapeutic as an intermediate means of transport and introduce
procedures. an infectious agent into a susceptible host through a
suitable portal of entry.
Endogenous – infection originates from the clients
(Ex. Fomites: handkerchiefs, toys, clothing, etc.)
Exogenous – infection originates from the hospital
environment/hospital personnel. b. Vector-borne - microorganism is transmitted
through a vector, which is usually a flying or
crawling insect that serves as an intermediate
means of transporting the infection.
3. Airborne transmission – may involve droplets
or dust. Here, the material may be transmitted by air 3 major types of exudates
currents to a suitable portal of entry, usually, the 1. Serous
respiratory tract of another person. 2. Purulent
3. Hemorrhagic (Sanguineous)
Droplet nuclei - the residue of evaporated droplets 4. Serosanguineous
emitted by an infected host.
3. Reparative phase
BODY DEFENSES AGAINST INFECTION – involves the repair of the injured tissues by
1. Nonspecific defenses regeneration/replacement with fibrous tissue/scar
– protect the person against all microorganisms, formation.
regardless of prior exposure.
Regeneration – the replacement of destroyed tissue
2. Specific defenses cells that are identical or similar in function.
– directed against identifiable bacteria, viruses,
fungi, or other infectious agents. When regeneration is not possible, repair occurs by
fibrous tissue formation.
EXAMPLES OF NONSPECIFIC DEFENSES
 Moist mucous membranes and cillias in the nasal EXAMPLES OF SPECIFIC BODY DEFENSES
passages
 Saliva in the mouth
 Tears in the eyes
 High acidity of the stomach
 Secretions in the vagina

Inflammation
– a local and nonspecific defensive response of the
tissues to an injurious or infectious agent. It has 5
signs, namely:

1. Pain (Dolor)
2. Swelling (Tumor)
3. Redness (Rubor) 2 TYPES OF IMMUNITY
4. Heat (Calor)
5. Impaired function of the body part, if the injury is Active immunity
severe. – host produces antibodies in response to a natural
or artificial antigen.
3 STAGES OF INFLAMMATORY RESPONSE
Passive/Acquired immunity
1. Vascular/Cellular responses – the host receives natural or artificial antibodies
– constriction of the blood vessels at the site of the produced by another source.
injury, lasting a few moments; then, dilation of the
blood vessels, causing more blood to flow in the 2 COMPONENTS OF THE IMMUNE SYSTEM
injured area, called HYPEREMIA. I. Antibody-mediated defenses
- the “Humoral/Circulating Immunity”
- Here, there is altered permeability of the - defenses reside ultimately in the B-lympocytes and
interstitial spaces due to accumulation of fluid, are mediated by antibodies produced by B-cells.
causing pain and swelling.
II. Cell-mediated defenses
2. Exudate production - The “Cellular Immunity”
– inflammatory exudate is produced, consisting of - Occur through the T-cell system
fluid that escape from blood vessels, dead
phagocytic cells, dead tissue cells and products that
they release.
 FACTORS INCREASING SUSCEPTIBILITY TO STERILIZATION
INFECTION - The process that destroys all microorganisms
 Age including spores and viruses.
 Heredity
 The nature, number, and duration of METHODS USED IN STERILIZATION
physical and emotional stressors 1. Moist heat 2. Gas 3. Boiling water
 Individual’s resistance to infection 4. Radiation
 Certain medications like antineoplastic drugs
 Disease TRANSMISSION-BASED PRECAUTIONS

SUPPORTING DEFENSES OF A 1. Airborne precautions

SUSCEPTIBLE HOST – used for clients known to have or were suspected
 Hygiene of having serious illnesses transmitted by airborne
 Nutrition droplet nuclei smaller than 5 microns.
 Fluid (Ex. Rubeola, Varicella, TB)
 Rest and sleep
2. Droplet precautions
 Immunizations
– used for clients known or suspected to have
serious illnesses transmitted by particle droplets
CLEANING
larger than 5 microns. (URTI, LRTI)
Antiseptics
3. Contact precautions
– agents that inhibit the growth of some
- used for clients known or suspected to have serious
microorganisms.
illnesses transmitted by direct client contact or
contact with the client’s environment (Wound
Disinfectants
infection, Hepa A)
– a chemical preparation such as phenol or iodine
compounds, used on inanimate objects.
PERSONAL PROTECTIVE EQUIPMENT
STEPS WHEN CLEANING OBJECTS IN HOSPITALS
Gloves – worn for 3 reasons:
1. Rinse the article with cold water to organic
1. First, they protect the hands when the nurse is
material.
likely to handle any substances.
2. Wash the article in hot water and soap.
2. Second, it reduces the likelihood of nurses
transmitting their own endogenous microorganisms
3. Use an abrasive, such as stiff-bristled brush, to
receiving individual care.
clean equipment with grooves and corners.
3. Third, it reduces the chance that the nurse hands
4. Rinse the article well with warm to hot water.
will transmit microorganisms from one client or
fomite to another client.
5. Dry the article; it is now considered clean.
Gowns – worn during procedures when the nurse’s
6. Clean the brush and sink.
uniform is likely to become soiled. After it is worn,
the nurses discard it or places it in a laundry hamper.
ISOLATION PRECAUTIONS
Masks – worn to reduce the risk for transmission of
Isolation – refers to measures designed to prevent
organisms by the droplet contact and airborne
the spread of infectious microorganisms to health
routes and by splatter of body substances.
personnel, clients, and visitors.
UNIVERSAL PRECAUTION – Hand washing.
Eyewear – may be indicated in situations where
body substances may splatter to face.
CDC isolation precautions:
1. Standard precautions
Examples: Goggles, glasses, or face shields
2. Transmission-based precautions
 Chap 18 – Skin Integrity and Wound Care Pressure Ulcers
- Also called decubitus ulcers, pressure sores, or bed
Skin Integrity sores.
- Any lesion caused by unrelieved pressure that
Skin – the largest external organ of the body. results in damage to underlying tissue.

Intact skin – refers to the presence of normal skin ETIOLOGY:

and skin layers uninterrupted by wounds.
1. Localized ischemia
Types of Wounds According How they were – deficiency of tissue blood supply.
acquired
2. Friction
A. Clean wounds – force acting parallel to skin surface
– uninfected wounds in which minimal
inflammation is encountered and respiratory, 3. Shearing force
genital, and urinary tracts are not entered. – combination of friction and pressure.

B. Clean-contaminated wounds Risk Factors for Pressure Ulcers

–surgical wounds in which the respiratory, genital,
and urinary tracts are entered; but no evidence of  Immobility – reduction in the amount of
infection movement and control that a person has.
 Inadequate nutrition
C. Contaminated wounds  Fecal and urinary incontinence
– open, fresh, accidental and surgical wounds  Decreased mental status
involving a major break in sterile technique or a  Diminished sensation
large amount of spillage from GI tract; with evidence  Excessive body heat
of inflammation.  Advanced age
 Chronic medical conditions
D. Dry/Infected wounds
– contains dead tissue and with evidence of clinical Stages of Pressure Ulcers
infection, such as purulent drainage.

Types of Wounds According to depth

Incision – caused by sharp instrument

Contusion – blow from a blunt instrument

Abrasion – surface scrape; either intentional

or not.

Puncture – penetration of the skin and often the

underlying tissues by a sharp instrument
Wound Healing
Laceration – tissues torn apart; often from A quality of living tissue; also referred to as
accidents REGENERATION.

Penetrating wound –penetration of the skin TYPES OF WOUND HEALING:

and the underlying tissues
1. Primary intention healing
– occurs when tissue surfaces has been
approximated (closed); characterized by minimal
formation of granulation tissue and scarring.
2. Secondary intention healing Yellow wounds are characterized primarily by
– cannot or should not be approximated; repair time liquid to semiliquid slough that is often accompanied
is longer, scarring is greater and with higher by purulent drainage or previous infection.
susceptibility to infection.
Black wounds are covered with thick necrotic
Exudate tissue, or eschar; it requires debridement, or
- It is a material such as fluids and cells, that has removal of the necrotic material.
escaped from blood vessels during the inflammatory
process and is deposited in tissue or on tissue Types of debridement
surfaces.
Sharp debridement – uses scalpel or scissors to
TYPES OF EXUDATE: separate or remove dead tissue

1. Serous exudate Mechanical debridement – accomplished through

– consists chiefly of serum derived from blood and scrubbing force or moist to moist dressings.
the serous membranes of the body
Autolytic debridement
2. Purulent exudate – dressings that contain wound moisture and clear
– thicker than serous exudate because of the absorbent acrylic dressings, trap the wound
presence of pus; pus formation is called drainage against the eschar
SUPPURATION.
Wound Dressings are applied for the following
3. Sanguineous exudate purposes
– consists of large amounts of RBC, indicating
damage to capillaries.  To protect the wound from mechanical injury.
 To protect the wound from microbial
4. Serosanguineous exudate contamination
– commonly seen in surgical inscisions.  To provide or maintain moist wound healing.
 To provide thermal insulation
Complications of Wounds  To absorb drainage or debridea wound or both
1. Hemorrhage  To prevent hemorrhage
2. Infection  To splint or immobilize a wound site and thereby
3. Dehiscence and possible evisceration facilitate healing and prevent injury

Dehiscence – partial or total rupturing of a sutured Types of Dressings

wound.
Transparent dressings
Evisceration – protrusion of an internal viscera – often applied to wounds including ulcerated or
through incision burned skin areas.

Factors Affecting wound healing Hydrocolloid dressings

 Nutrition – frequently used over pressure ulcers
 Lifestyle
 Medications Securing dressings
– nurse tapes the dressings over the wound,
The RYB COLOR CODE ensuring that the dressings cover the entire wound
This concept is based on the color of an open wound and does not become dislodged
– red, yellow, or black rather than the depth or size
of the wound.

* Wounds that are Red are usually in the late

regeneration phase of tissue repair; they need to be
protected to avoid disturbance of regenerating
tissue through gentle cleansing.