Identify ten (10) risk factors for pressure

Identify ten (10) risk factors for pressure injury development. Discuss the use of evidence-based assessment tool (Braden Scale for Predicting Pressure Ulcer Risk) to mitigate client risk for pressure injuries in nursing practice. Discuss RNAO best practice guidelines related to the assessment, prevention, and management of pressure injuries. Recognize the different stages of pressure injury, appropriate documentation, and integration of interventions/strategies to promote desired health outcomes. Distinguish between the therapeutic uses of selected types of wound care products. 6. Explore the different process of wound healing. Identify common barriers to wound healing, complications, and appropriate nursing interventions/strategies to promote healing. Based on current evidence-based guidelines, discuss current issues, trends and research related to prevention and treatment of wounds, and/or pressure injuries. Examine a case study, to apply the nursing process, including establishing priorities in nursing care, to develop a care plan for the client with impaired skin or tissue integrity. Identify developmental and cultural factors that influence the pain experience. Describe subjective and objective data collection in completing a comprehensive pain assessment. Identify research evidence-based symptom assessment tools and valid pain scales for verbal and nonverbal client populations. Explore the treatment strategies and barriers to effective pain management. Review the role of the nurse and interprofessional healthcare team relating to the use of pharmacological and non- pharmacological methods in pain management and integrative therapies (complementary & alternative practices). Define breakthrough pain, equianalgesic dosing, titration and co analgesia/adjuvants. Explore the RNAO BPG for the assessment and management of pain, current issues/challenges, trends and research related to pain management. Identify best practices for relieving symptoms using pharmacological and non- pharmacological nursing interventions in pain management. Discuss the lived experience of a client living with acute and/or chronic pain. Use of a case study, apply the nursing priorities for nursing care in order to develop a care plan for a client living with acute and/or chronic pain. Use appropriate evidence-based guidelines to identify the appropriate nursing diagnoses (potential/actual), client outcomes and nursing interventions for the client experiencing pain. Assess client health needs, strength and preferences; prioritize, plan and implement nursing interventions to meet client desired health goals/outcomes. Evaluate the efficacy of nursing interventions/health education by comparing expected client outcomes to actual outcomes. Refine/revise diagnoses, outcomes and plan of care in collaboration with the client and health team in order to meet goals/outcomes. Explore the nursing implications for the administration of opioid analgesics (hydromorphone),Non-opioid analgesics, NSAIDS (ibuprofen,ketarolac, naproxen sodium)Salicylates ROLE OF THE NURSE IN THE CARE OF A CLIENT AT RISK FOR OR WITH A WOUND OR PRESSURE ULCER Readings as per course outline (Kozier, Potter et al., Lewis et al., & Best Practice Guidelines (BPG)) Review from patho notes: 2 types of wound healing 1. 2. 3 phases of healing 1. 2. 3. 3 types of drainage 3 wound complications Identify ten (10) risk factors for pressure ulcer development. Review the factors that influence wound healing – your knowledge of these factors is applicable in data/analysis. *When you assess a wound, you need to know if the intention is to heal the wound, prevent further injury (maintain) or treat as palliative – need to know “heal-ability” of wound and this is dependent on the following: Developmental state / age Nutrition Life Style Medications Health status (especially vascular supply to wound bed/location) Environment Be able to state how the above factors impact wound healing & give an example for each. 2. Discuss the use of the Braden Scale for Predicting Pressure Ulcer Risk as a risk assessment tool in nursing practice. Review RNAO’s BPG. Does your clinical agency incorporate the Braden scale as part of their client assessment? If yes, how often is this tool completed? How is the Braden scale useful for developing a nursing care plan? 3. Discuss best practice guidelines related to the assessment, prevention and management of pressure ulcers. ASSESSMENT – refer back to the Needs guide for skin integrity *CHECK THIS OUT – clinical application! – The Best Practice Guidelines included in the readings for this week have a variety of tools in the Appendices that you can use in the clinical setting – take one of these tools to clinical with you this week and use it to assess your client! Objective and Subjective: history of wound healing Braden / Norton skin guide (see Kozier & Potter & Perry; Lewis text p. 242, Table 14-14) – also see if your clinical agency uses a Braden or Norton scale (some agencies will use this tool as part of the initial admission assessment). Any factors Any pain Physical: *helpful mnemonic for clinical “WOUND PICTURES”- (Adapted from Wound Care made Incredibly Easy!! Springhouse, PA: Lippincott Williams & Wilkins; 2003. p 42 – See more at: http://www.nursingcenter.com/lnc/journalarticle?Article_ID=520122#sthash.OpVV9str.dpuf) Where is the wound (location?) Odour – note the wound bed odour (not just the old dressing) Ulcer category (staging) Necrotic tissue Drainage (colour, consistency, amount) Pain (don’t forget a comprehensive pain assessment!) Induration (hard or soft surrounding tissue – edema) Colour of wound bed (red, yellow, black or combination) Tunnelling (length and direction) Undermining (length and direction – use clock references to describe) Redness or other discolouration in surrounding skin (peri-wound) Edge of skin (peri-wound – assess for maceration) Size/Shape (length, width, depth) Systemic temperature malaise diaphoresis What diagnostic tests are relevant? NURSING DIAGNOSIS Impaired skin integrity/Impaired Tissue Integrity (depending on depth of wound) Risk for infection But will also include: pain, body image changes, anxiety, may be even knowledge deficit PLANNING Goal – to restore skin integrity & prevent infection Nursing Interventions: Support healing – nutrition – fluids – positioning – Asepsis – see principles and practices of surgical asepsis- practise and testing in Wound Lab (from PNUR125) Prevent pressure ulcers- See Braden or InterRAI Scale skin hygiene nutrition avoid trauma Client teaching 4. Distinguish between the therapeutic uses of selected types of wound care products. HELPFUL STUDY HINT: Develop FLASHCARDS with various wound care products labelled on one side and the description of uses on the other! View the videos on woundeducators.com. and identify the wound care supplies that are available in your clinical setting. (NOTE: When considering treatment of wounds, you need to connect this content to PNUR125. See Kozier 3rd ed. p. 978-979 Table 34.8; Kozier 4th ed.p 900-901) (Potter et al., 6th Ed. p. 1323-1327; Table 46-9) What are the 9 principles of establishing and maintaining a sterile field? Review the practices which are associated with each of the principles. You will be applying these practices in lab and clinical. Consider: When dropping commercially packaged sterile gauze onto an established sterile field, the gauze lands with one corner almost off the edge of the field. Does this present any concerns regarding its sterility? Explain. How would you handle this situation? After establishing a sterile field and applying sterile gloves, you realize that you have forgotten to open the bottle of saline that needs to be poured into the dressing tray. The bottle is not sterile on the outside. What are 2 ways you could solve this dilemma? 5. Discuss the factors to consider in wound care and choosing an appropriate wound care product. Refer to RNAO BPG (Assessment & Management of Stage I to IV Pressure Ulcers) p. 98 Dressing choices – note purpose of each & when it would be used – will be taught more in lab (hands on) What dressing supplies are available in your clinical placement? What dressing/wound care supplies would you use to treat? A skin tear? An incision draining small serous drainage? A stage 2 pressure ulcer with purulent exudate? A black necrotic heel ulcer? A reddened coccyx with non-blanchable erythema? Heat & Cold – review notes from inflammation / fever class Immobilization – (note types & uses for the different bandages.) 6. Discuss current issues, trends and research related to prevention and treatment of wounds, and/or pressure ulcers. Review the Canadian Association of Wound Care: Quick Reference Guide in Kozier 4th ed. P. 974-975 There are 5 steps in the Wound Prevention and Management Cycle. What are the steps? What process are you familiar with that you can compare this cycle to? What other content have we covered in this course (and your other courses) that also is relevant for you to understand when looking at the recommendations? (make connections to your learning here!) Visit RNAO’s website and be prepared to discuss the BPG related to assessment, prevention and management of pressure ulcers. What irrigation solution is recommended for Silver-based dressings? 8. Explore the nursing implications for the administration of anticoagulant therapy: •platelet inhibitors •anticoagulants What diet changes/monitoring does the client need to make while on these medications?

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