1
Q
risk factors for altered tissue integrity
A
- age
- nutrition
- genetics
- activity level
- health/chronic illnesses
- medications
- incontinence
- altered mental status
- altered sensation
2
Q
diagnostics to diagnose tissue integrity
A
- skin biopsy-differentiates a benign skin lesion from skin cancer
- cultures to identify infections
- immnofluroescent studies, wood’s lamp, potassium hydroxide, and Tzanck test; identify infections
- patch tests or scratch tests determine allergies
3
Q
laboratory tests used to diagnose tissue integrity
A
- leukocyte- decreased count may delay healing and increase possibility of infection
- hemoglobin- below normal level indicates poor oxygen delivery to tissues
- blood coagulation- prolonged-results in excessive blood loss; hypercoagulability- leads to clotting
- serum protein analysis- provides indication of body’s nutritional reserves for rebuilding cells
- wound cultures- confirm or rule out presence of infection
- sensitivity studies- helpful in selecting appropriate antibiotic therapy
- albumin- important indicator of nutritional status (should not be below 3.5g/dL)
4
Q
classifications of alterations in tissue integrity (infectious, inflammatory, neoplastic)
A
- infectious- bacterial, fungal, viral, and parasitic infections (boils, athlete’s foot, ticks, cold sores)
- inflammatory- acne, burns, eczema, dermatitis, psoriasis
- neoplastic- malignant melanoma and basal cell carcinoma
5
Q
classifications (primary vs. secondary lesions)
A
- primary lesions- arise from previously healthy skin (macules, patches, papules, nodules, tumors, vesicles, pustules, bullae, and wheals)
- secondary lesions- result from changes in primary lesions (crusts, scales, lichenification, scars, keloids, excoriation, fissues, erosion, ulcers)
6
Q
classifications (intentional vs. unintentional)
A
- intentional- occurs during therapy (operations or venipunctures)
- unintentional- accidental (fracture of an arm)
7
Q
classifications (closed vs. open)
A
- closed- tissues are traumatized without break in the skin
- open- skin or mucous membrane surface is broken
8
Q
classifications (clean wounds, clean-contaminated wounds, contaminated wounds, dirty or infected wounds)
A
- CLEAN WOUNDS- minimal inflammation; uninfected; mostly closed wounds; respiratory, alimentary, genital, and urinary tracts are NOT entered
- CLEAN-CONTAMINATED WOUNDS- surgical wounds; respiratory, alimentary, genital, or urinary tract HAS been entered; no evidence of infections
- CONTAMINATED WOUNDS- open, fresh, accidental wounds and surgical wounds; involve a break in sterile technique or large amount of spillage from the GI tract; show evidence of inflammation
- DIRTY OR INFECTED WOUNDS- wounds containing dead tissue; evidence of clinical infection (purulent drainage)
9
Q
classification (partial vs. full thickness wounds)
A
- partial thickness- confined to skin (dermis and epidermis); heal by regeneration
- full thickness- involve dermis, epidermis, subcutaneous tissue, and muscle and bone; require connective tissue repair
10
Q
classifications (incision, contusion, abrasion, puncture, laceration, penetrating wound)
A
- incision- sharp instrument
- contusion- blow from a blunt instrument
- abrasion- surface scrape
- puncture- penetration of the skin and often underlying tissues by sharp instrument
- laceration- tissues torn apart (often from accidents)
- penetrating wound- penetration of skin and underlying tissues
11
Q
goals of nursing care related to tissue integrity
A
-control severity of the disease, prevent infection, and promote healing, control discomfort, healing of skin alteration
12
Q
collaboration with other health care professionals (r/t tissue integrity)
A
- physical therapist
- dietician
- home health agency
- would care nurse/enterostomal nurse
13
Q
skills needed to care for patient with tissue integrity issue
A
- dressing changes
- skin care
- privacy
- aseptic technique
- documentation
14
Q
What are pharmocological options for tissue integrity issues?
A
- antibiotics
- antifungals
- antiinflammatory
- glucocorticoids
- pain control
15
Q
What are potential complications regarding to tissue integrity?
A
- infection
- mobility issues
- metabolism
- comfort
- elimination
- fluid/electrolyte imbalance
- perfusion
16
Q
manifestations of pressure ulcers (stages 1-4)
A
- stage 1- nonblanchable erythema of intact skin
- stage 2- partial-thickness loss involving epidermis and/or dermis
- stage 3- full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to underlying fascia
- stage 4- full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (tendon or joint capsule)
17
Q
treatment of pressure ulcers
A
- minimize direct pressure on the ulcer (reposition every 2 hours)
- clean pressure ulcer with every dressing change
- clean and dress ulcer with surgical asepsis
- obtain culture if ulcer is infected
- teach client to move
- provide ROM exercises
18
Q
diagnosis of pressure ulcers
A
- determine size and depth of bedsore
- assess for bleeding, fluids, or debris in wound
- assess for odors that can indicate infection or dead tissue
- assess for damage around wound
- check for other pressure sores on the body
19
Q
diagnostic tests to diagnose pressure ulcers
A
- blood tests; assess nutritional status to see if there is an infection (wbc count)
- tissue cultures to diagnosis infection; to check for cancerous tissue if it’s chronic, non-healing wound
20
Q
further treatment of pressure ulcers (wounds w/ necrotic tissue)
A
- DEBRIDEMENT (removal of necrotic tissue)
1. sharp debridement- scalpel or scissors are used to separate and remove dead tissue
2. mechanical debridement- scrubbing force or moist-to-moist dressings
3. chemical debridement- collagenase enzyme agents
4. autolytic debridement- dressings that contain wound moisture trap the wound drainage against the eschar; most selective method and the least damage occurs to healthy tissue
21
Q
nursing interventions for impaired skin integrity/risk for (R/T pressure ulcers)
A
- conduct a systematic skin inspection at least once a day
- clean the skin at time of soiling and at routine intervals; avoid hot water; use mild cleaning agents; clean skin gently
- minimize environmental factors leading to skin drying; use moisturizers
- avoid massage over bony prominences
- minimize skin exposure to moisture (incontinence, wound drainage, perspiration); change briefs and underpads frequently
- use proper positioning, transferring, and turning techniques to minimize skin injury from friction and shearing (protective films, protective dressings, protective padding)
- for client who is immobile, reposition client every 2 hours; use positioning devices; NO DOUGHNUT TYPE DEVICES
- avoid side-lying position
- maintain head of bead a lowest degree of elevation
- use assistive devices
- place at-risk client on pressure-reducing device (foam, static air, alternating air, gel, or water mattress; turn every 2-3 hours; lifting rather than dragging
- use pressure reducing devices for chair-bound clients; shift weight every 15 minutes; avoid uninterrupted sitting in chair or wheelchair
22
Q
interventions for risk of infection (R/T pressure ulcers)
A
- maintain skin hygiene
- maintain appropriate nutrition and hydration
- recognize early stages of pressure ulcer
- contact officer at earliest appearance of pressure ulcer
- maintain or improve current activity levels
23
Q
interventions for imbalanced nutrition: less than body requirements (R/T pressure ulcers)
A
- assess factors involved in inadequate dietary intake of protein of kilocalories
- offer nutritional supplements
- consult with dietition about other dietary interventions
24
Q
interventions for risk for compromised human dignity/situational low self-esteem (R/T pressure ulcers)
A
- conduct physical examination that includes examining indicators of abuse or neglect
- develop a caring, trusting relationship with client
- teach family members to reposition every 2 hours; skin hygiene; and positioning properly
- assist family members with obtaining supportive devices for client
25
how to prevent pressure ulcers
- providing nutrition
- maintaining skin hygiene
- avoiding skin trauma
- providing supportive devices
26
types of wound healing
-primary intention healing- occurs where tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; minimal granulation tissue and scarring (ex. closed surgical incision)
- secondary intention healing- extensive wound and involves considerable tissue loss and in which the edges cannot or should not be approximated (ex. pressure ulcer)
- the repair time is longer
- the scarring is greater
- the susceptibility to infection is greater
-tertiary intention healing- left open for 3-5 days to allow edema or infection to resolve or to permit exudate to drain and then are closed with sutures, staples, or adhesive skin closures
27
phases of wound healing (inflammatory phase)
- initiated immediately after injury and results for 3-6 days
- hemostasis- cessation of bleeding; vasoconstriction of larger blood vessels to affected area, retraction of injured blood vessels, deposition of fibrin (connective tissue), and formation of blood clots
- scab forms on surface of wound (inhibits contamination of wound)
- blood supply to wound increases (brings o2 and nutrients to wound)
- macrophages engulf microorganisms
28
phases of wound healing (proliferative phase)
- extends from day 3 or 4 to day 21 after injury
- fibroblasts begin to synthesize collagen (adds strength to a wound)
- capillaries grow across wound, increasing blood supply
- fibroblasts move into wound, depositing fibrin
- granulation tissue forms (translucent red and fragile)
- when granulation tissue matures, marginal epithetial cells migrate to it, proliferating over this tissue base to fill the wound
29
phases of wound healing (maturation phase)
- being day 21 and extends for 1 or 2 years after injury
- fibroblasts continue to synthesize collagen
- collagen fibers reorganize into more orderly structure
- scar becomes stronger
30
factors effecting wound healing
- developmental considerations- healthy children and adults heal more quickly
- nutrition- clients require a diet rich in protein, carbs, lipids, vit A&C, and minerals; malnourished clients may require time to improve status before surgery; obese clients are at a risk of wound infection and slower healing because adipose tissue usually has minimal blood supply
- lifestyle- exercise regularily=good circulation, heal more quickly; smokers are at risk for delayed healing (less hemoglobin)
- medications- anti-inflammatory drugs and antineplastic agents interfere with healing; prolonged use of antibiotics may make person susceptible to wound infection by resistant organisms
31
complications of wound healing
- hemorrhage- massive bleeding
- infection- as evidenced by change in wound color, pain, or drainage; confirmed by culture of the wound
- dehiscence with possible evisceration- rupturing of wound with possible protruding internal viscera through incision; sudden straining can cause this; if this happens, would should be supported quickly by large sterile dressings soaked in sterile normal saline; decrease pull on incision by placing client with knees bent
32
nursing interventions for moist wound healing (R/T wounds)
-dressing and frequency of change should support moist wound bed conditions; wound beds that are too try fail to heal
33
nursing interventions for nutrition and fluids (R/T wounds)
- take in at least 2500 mL of fluids a day
- adequate amounts of vitamins and minerals
- receive sufficient protein
- meet with dietician to ensure needs are met
34
interventions for preventing infection (R/T wounds)
- preventing microorganisms from entering wound
| - preventing transmission of bloodborne pathogens to or from the client to others
35
interventions for positioning (R/T wounds)
- keep pressure off wound
- no friction or shear damage
- assisted to be as mobile as possible
- ROM exercises and turning schedule can be implemented if client cannot move independently
36
manifestations of would healing
- serous exudate- accompanies mild inflammation and is clear or straw colored; thin and watery
- purulent exudate- thicker; opaque or milky in appearance; PUS; formation of pus is referred to as suppuration and the bacteria that produces pus is pyogenic bacteria
- sanguineous exudate- large amount of red blood cells; open wounds; serosanguineous exudate (clear and blood-tinged drainage) is commonly seen in surgical incisions; purosanguineous discharge (pus and blood) seen in new wound that is infected
Nursing II
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Decks in class (6)
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