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ADVANCED NURSING.pdf

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ADVANCED NURSING.pdf

  1. 1. ADVANCED NURSING JOYCE KUMAH (DIP, BSC, MPHIL NURSING)
  2. 2. COURSE DESCRIPTION • • • • • The course will equip the student with skills to manage patients at the medical, surgical, theatre, recovery public health, adolescent health and the infectious disease unit. The students will have demonstrations and return demonstrations in the skills laboratory. Students will have the opportunity to utilize the nursing process to manage patients with several problems. Students will be expected to spend 6 hours in the skills lab per week as part of this course. The course will also help the students develop skills that will enable them administer medications, infusions and oxygen safely, dress wounds and remove stitches and drainage tubes, insert urethral and nasogastric tube appropriately and also apply the principles of infection prevention in their care.
  3. 3. COURSE OBJECTIVES • • • • • • • • • By the end of the course, the students will: • Develop skills for safe administration of drugs • Administer prescribed oxygen safely • Demonstrate skills in administering intravenous (I.V) infusions and blood transfusion. • Give health education to patients and relatives • Medical and surgical asepsis • Pre-operative preparation of patient for surgical procedure • Manage surgical wounds and remove stitches and clips aseptically • Pass Naso-Gastric Tube
  4. 4. COURSE CONTENT • • • • Administration of drugs: Calculation of dosages, dilution of lotions, correct handling and assembling of equipment for preparation and administration of drugs. Routes of administration: oral, skin, rectal, ear, nose, eye, injections. Inhalation - moist, dry, oxygen therapy; local applications: hot, cold; Abbreviations used in prescription, Interpretation of prescription; Dangerous Drugs Act. Removal of drainage tubes, clips and stitches from wounds, care of colostomy wounds. • Preparation and administration of I.V. therapy; Trolley for intravenous therapy e.g. blood transfusion, infusion and drugs. • Setting trays and trolleys for cardiac catheterization, positioning of patients with cardiac problems etc. • Positioning of patient with respiratory problems, use of suctioning machines, setting trays and trolleys for special procedures e.g. thoracentesis, strapping
  5. 5. COURSE CONTENT • • • • • • • Pre-operative preparation of patient for surgical procedure (psychological, skin preparation, physiological) • Education of patients and family on their condition and medications • Setting of sterile strays and trolleys, and performing the following procedures • Urethral catheterization (the procedure and care of indwelling catheter of males and females) • Passage of Naso-Gastric Tube • Administration of oxygen (via the various oxygen delivery devise) • Assessment of client for family planning services; Counselling clients for informed choice of family planning methods; visiting client at home for follow ups.
  6. 6. WOUND • Wound is the break in the continuity of the skin
  7. 7. TYPE OF WOUNDS WE HAVE INTENTIONAL AND UNINTENTIONAL WOUND. INTENTIONAL WOUNDS • • • • • • Intentional wounds are as result of planned therapy causes or examples. Surgical incisions lumbar puncture, thoracentesis and paracentesis. Characteristics of intentional wounds These wounds have clean edges, bleeding is controlled risk of infection is decreased done under sterile conditions UNINTENTIONAL WOUNDS • • • • • • Unintentional wounds are caused by accidents, forceful injuries, burns and scars. Characteristics wound edges are not clean occur under unsterile conditions bleeding is uncontrolled could be multiple trauma
  8. 8. CARE OF SURGICAL WOUNDS • • • • • • Preparation of a trolley for wound dressing Put on mask Set a trolley Wash hand thoroughly and put on disposable gloves Clean shelves and the rails with soap and water. Rinse and dry. Clean again with spirits to keep the trolley dry or use bleach of 1:10 to clean and dry with spirit. All sterile equipment are set on the top shelves and then non sterile equipment on the bottom shelves.
  9. 9. TOP SHELF • • • • • • • • 3 galipots for lotions 2 pairs of dressing forceps 2 pairs of dissecting forceps 1 sinus forceps A probe A stitch scissors A kidney dish for cotton and gauze swabs A clip removal forceps A sterile dressing towel
  10. 10. BOTTOM SHELF • • • • • • • • • • • Bottles of lotions e.g. normal saline, methylated spirit, povidone iodine, hydrogen peroxide. an adhesive or plaster a pair of scissors bandages a covered receiver or a bowl with 1:10 bleach solution A receptacle for soiled dressings A mackintosh Sterile gloves Disposable gloves Sterile packs in a drum or box Face mask
  11. 11. PROCEDURE/STEPS FOR WOUND DRESSING • • • • • • • • • Review the physician’s order and agency policy. Inform and explain procedure to the patient Put on face mask Wash and dry hands Ensure privacy Move trolley to bedside Wash your hands again and dry Go to patient, ask the assistant to adjust the bed and position the patient comfortably Avoid exposing the patient
  12. 12. PROCEDURE/STEPS FOR WOUND DRESSING • • • • • • • • • • Pour out lotions into the galipots Assistant should remove the plaster and bandages and proceed to wash hands Remove tape by pulling toward wound small sections at a time while holding down the skin in front of the tape. Prevents skin breakdown and injury to newly formed tissue. Remove soil dressings with dissecting forceps and discard Assess wound. Wash hands. Open supplies and set up sterile field. Using aseptic technique, place fine mesh gauze into sterile container. Pour enough solution into container. Put on sterile gloves or pick up the instruments. Clean and/or irrigate wound as ordered by physician, from center of wound outward using a new swab for each stroke. Clean the wound with series of swabs or clean until the wound is clean
  13. 13. PROCEDURE/STEPS FOR WOUND DRESSING • • • • • • • • Apply enough dressing to ensure the wound is always dry Apply your adhesive tapes or plaster and stroke your plaster with bandages Assist patient to position of comfort and assess level of comfort and thank him/her for cooperation Remove your screen Discard the trolley Decontaminate, clean and disinfect your instruments Wash your hands and dry Record and report on the state of the wound
  14. 14. NOTE: Dressing should be done after bed making, dusting, checking and recording of vital signs No visitors allowed during wound dressing Clean or incisional wounds should be done before working on the dirty wounds Bandage from the distal to the proximal and from the proximal to the distal.
  15. 15. FREQUENCY OF WOUND DRESSING • • In the absence of slough, debris, feaces, devitalized tissue or infection in the wound bed frequent wound dressing is not recommended because it may damage newly formed capillaries and disrupt fragile new tissue growth. The body perceive this as a new injury and re-initiate the inflammatory process.
  16. 16. FACTORS THAT PROMOTE WOUND HEALING • • • • • • Frequent dressing of infected wound Aseptic techniques Proper use of anti-biotic Adequate rest and sleep Adequate nutrition Sufficient blood supply to the wound area
  17. 17. FACTORS THAT IMPAIRS WOUND HEALING • • • • • • • • • • Disease conditions like Coronary Artery Disease, Congestive Heart Failure, Peripheral Vascular Disease, Peripheral Arterial Disease Old age Prolong use of some drugs e.g. corticosteroids cancer Poor aseptic technique Smoking i.e. (hardens the blood vessels leading to arteriosclerosis) Obesity Inadequate nutrition Foreign bodies Necrotic tissues
  18. 18. ADVANTAGES OF WOUND DRESSING • • • • • • • absorb drainage to promote wound healing protect from mechanical injury promote homeostasis aid in wound edge approximation prevent further trauma prevent contamination from external environment Provide physical, psychological and external comfort.
  19. 19. SUTURE • • • • • • A suture is a stitch or series of stitches made to secure apposition of the edges of a surgical or accidental wound. Types of suturing materials These sutures are grouped into absorbable and non – absorbable Examples of absorbable are facia, cutgut, kangaroo, ribbon gut and synthetic types like polyglycolic acid, polydioxanone and caprolactone. Examples of non – absorbable are silk, nylon, linen, wire silver, clips (thyroidectomy), polyprophylene suture, polyamide suture. Clips are metal fastening used on the skin. It can also be grouped into retention and skin sutures. The skin sutures are black synthetic materials, clips wires etc. Retention is used for obese people and dehiscence/gaping wounds. There are also tension stitches.
  20. 20. SUTURES
  21. 21. TYPES OF SUTURES • • • • • • continuous suture blanket sutures subcuticular continuous suture (done on skin) simple interrupted suture simple running suture running locked suture buried absorbable sutures • • • • • • • • interrupted vertical mattress plain mattress vertical mattress suture figure of eight sutures interrupted horizontal mattress pulley suture far- near near –far mattress suture staples
  22. 22. LIGATURE (TIE) • a free peace of sutured material of considerable length about 10 – 15 inches, for the purpose of tying blood vessels that have previously been clamped by a forceps
  23. 23. SUTURING OF WOUNDS (LACERATIONS) • • • • • • • • • • • Requirements A sterile tray containing Sterile gloves Sterile towels Suturing needles (curve, straight and cutting) Needle holder Tooth dissecting forceps Dressings (gauze swabs clean lotion) Strapping’s (celotape, plaster etc) Local anaesthetic agent e.g. xylocaine Syringe (5cc)
  24. 24. STEPS • • • • • • • • • • • Explain procedure to the patient Scrub hands and dry with a sterile towel Wear sterile gloves Clean area around the wound with antiseptic lotion Protect area with sterile towel Check for bleeding after cleaning and arrest haemorrhage with gauze swab Tread needle with desire suture material, grab wound edge with dissecting forceps, pass the treaded needle through the two sides of the wound making a reef knot and cut leaving 0.65 or ¼ inch from the knot. Then space stitches evenly, continue with stitches Clean suture line with antiseptic Apply dressing and strapping Remove gloves, discard tray Wash hands and document procedure.
  25. 25. ASSESSMENTS OF SURGICAL WOUNDS • • • • • • Inspection Appearance – redness, wound edges, drainage tubes, signs of dehiscence Skin sutures – metal staple, status of sutures, drains and tubes Pain – most important in terms of detecting complication and planning for future wound care. If the wound is extensive and discomfort seems to be related to dressing removal of application, the nurse plans to administer analgesics before dressing changes. If discomfort is related to plaster removal, institute measures to relieve the pain such as careful removal of the plaster
  26. 26. WOUND ASSESSMENT • • • Related assessment – vital signs, WBC Palpitation – the nurse gently applies finger tips along the wound edges. If pressure causes wound to be expressed, the nurse notes the character of the drainage. It may be necessary to collect the drainage for culture. Extreme tenderness may indicate infection. Signs of infection such as fever, chills or elevated white blood cells (WBC)
  27. 27. WOUND ASSESSMENT • • • i. ii. • • • Assess patient for history for factors that impairs wound healing process Tissue types – Assess characteristics, amount (document in percentage) & location a. Necrotic Tissue – dead; non-viable Slough – yellow, green, grey, nonviable (necrotic) tissue, usually lighter in color, thin, wet stringy Eschar – black, brown, dry, nonviable (necrotic) tissue, usually darker in color, thicker, hard b. Epithelial tissue – deep pink to pearly pink, light purple from edges in full thickness wounds or may form islands in superficial wounds c. Granulation tissue – beefy red, puffy or mounded bubbly appearance d. Hypergranulation tissue – granulation tissue forms above the surface of the surrounding epithelium. Delays epithelialization.
  28. 28. GRANULATION/EPITHELIAL TISSUE
  29. 29. ESCHAR/SLOUGH
  30. 30. COLOR • • • • • • • • Red – healthy, good blood flow Pale pink – poor blood flow; ischemia, anemia Purple – engorged; edema; excessive bioburden; trauma Black or brown – nonviable, necrotic tissue Yellow – nonviable, necrotic tissue Gray – nonviable, necrotic tissue Green – infection; nonviable tissue White – ischemia; maceration, may be confused with bone or fascia
  31. 31. EXUDATE • • • • • a. Type 1) Serous – thin clear watery plasma (seen in partial thickness wounds/venous ulcerations). Moderate to heavy amount may indicate heavy bio-burden or chronicity due to sub-clinical infection. Normal in the acute inflammatory stage 2) Sanguinous – bloody (fresh bleeding) seen in deep partial thickness & full thickness wounds during angiogenesis. Small amount normal in the acute inflammatory stage. 3) Serosanguineous- thin, watery, pale red to pink, plasma with RBC‘s 4) Purulent – thick, opaque, tan, yellow, green or brown color, never in wound
  32. 32. AMOUNT • • • • • • b. normal None – wound tissues dry Scant – wound tissues moist, no measurable drainage Small/minimal – wound tissues very moist/wet, drainage <25% of bandage Moderate – wound tissues wet, drainage involves 25 – 75% bandage Large/copious – wound tissues filled with fluid – involves >75% of bandage
  33. 33. ODOR • • • • • a. Clean wound prior to assessment b. Descriptors – strong, foul, pungent, fecal, musty, sweet Presence of Foreign Bodies Sutures, staples, drain tubes, hardware Environmental debris (wood, metal, dirt, asphalt, etc.)
  34. 34. WOUND MEASUREMENT- LINEAR • • • • i. ii. iii. iv. Always measure & document in centimeters and measure wound edge to edge in a straight line. Always measure Length first then measure width and Document - Length x Width x Depth a. Length: Consider wound as face of clock. 12:00 points to patients head, 6:00 points toward patient’s feet b. Width = 3:00 – 9:00 side to side c. Depth – distance from visible surface to the deepest area Cotton tip applicator into deepest portion of wound Grasp applicator with the thumb & forefinger at the point corresponding to the wounds margin Withdraw applicator while maintaining the position of the thumb and forefinger Measure from tip of applicator to position against centimeter ruler
  35. 35. WOUND RULER AND PROBE
  36. 36. DOCUMENTATION OF SURGICAL WOUND • • • • • • • • sight of the incision e.g. abdominal incision wound edges (well approximated) edges of incision (oedematous) dressing on wound – whether it is saturated with pus solutions used sterile technique used/applied Example of wound documentation Four inch midline abdominal incision cleaned with 0.9% sterile normal saline, wound edges well approximated, skin sutures intact. Crust along suture line, edges of incision slightly oedematous and dark pink. Penrose drain present in lower ¼ of incision. Old dressing moderately saturated with serosanguinous drainage. New dressing applied with sterile technique, using telfa for 4 x 4s and two ABPs applied with non allergic tap.
  37. 37. COMPLICATIONS OF WOUND HEALING • • • • • • bleeding – detected by swelling or distention in the area. (haematoma) Nursing management – greatest during the first 24hours after surgery haemorrhage is an emergency: Apply pressure dressing to the area Monitor the clients vital signs (temperature, pulse, respirations and blood pressure) Call the doctor if bleeding persist Infection – change in wound colour, pain or drainage confirmed by performing culture of the wound. Severe infection causes fever and elevated WBC.
  38. 38. • • • • • Dehiscence – the total or partial rupturing of a sutured wound usually abdominal wound. Evisceration – protrusion of internal viscera (organs) through an incision caused by factors like obesity, poor nutrition, multiple and dehydration. Nursing management – The wound should be supported by large sterile dressings soaked in sterile normal saline. Place the client in bed with knees bent to decrease pull on the incision Notify the surgeon immediately for surgical repair
  39. 39. NURSING DIAGNOSIS • • • • • • • Impaired skin integrity related to surgical incision (laparotomy) High risk for infection related to Assignment: Pressure ulcer assessment (written) Using a foam demonstrate suturing Use Bates Jenson wound assessment tool to assess a wound with picture evidence Total marks 15

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