Module 1 > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

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1
Q

Florence Nightingale quote

A

If the patient has a bedsore, it is not the fault of the disease, but the nursing

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2
Q

Skin

A

-Largest organ
-Protective barrier
-Nursing responsibility to assess and monitor skin integrity

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3
Q

Vitamin D synthesis

A

Calcitriol- activated form of vitamin D

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4
Q

Natural Flora

A

Staph, Strep, E.coli

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5
Q

Dermis

A

-Eccrine sweat gland
-Apocrine sweat gland

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6
Q

Assessment of the skin

A

-Inspect entire body
-ESPECIALLY BONY PROMINENCES
-Visual & tactile
-Assess any rashes or lesions
-Hair distribution
-Skin color
-Blanch test

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7
Q

Healthy skin should

A

Blanch

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8
Q

What light is the best for skin assessment?

A

Natural light

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9
Q

Assess the skin when?

A

On initiation of care, then a least once a shift

High-risk patients- assess every 4 hours or more

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10
Q

Friction

A

Skin dragging against surfaces
-can cause skin tears and blisters

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11
Q

Shear

A

Sliding movement of skin and subq tissue while the underlying muscle and bone are stationary.
Causes stretching and tearing of blood vessel which reduce blood flow increase blood pooling and can lead to cell damage

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12
Q

Avoid shearing when

A

Raising the HOB

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13
Q

Sensory perception

A

Ability to respond meaningfully to pressure-related comfort

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14
Q

Moisture

A

Degree to which skin is exposed to moisture

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15
Q

Activity

A

Degree of physical activity

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16
Q

Mobility

A

Ability to change and control body position

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17
Q

Nutrition

A

Usual food intake pattern

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18
Q

Braden Scale Low Risk

A

15-18
-Regular turning schedule
-Enable as much activity as possible
-Protect heels
-Manage moisture, friction, and shear

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19
Q

Moderate risk

A

13-14
-Position patient at 30 degree lateral incline using wedges or pillows

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20
Q

High risk

A

12 or less
-position patient at 30 degree lateral incline using wedges or pillows
-make small shifts in position frequently
-pressure redistribution surface

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21
Q

Tissue integrity interventions

A

-frequent-repositioning
-sitting in chair for 2 hour intervals
-keep HOB at 30º

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22
Q

HOB no higher than 30º for

A

Skin integrity purposes
If patient can’t breathe, raise higher

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23
Q

C.H.A.N.T

A

Cleanse
Hydrate (and protect) skin
Alleviate pressure
Nourish
Treat

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24
Q

Red/Excoriated Peri/Rectal area

A

-Cleanse
-Dry thoroughly
-Moisture barrier daily and prn

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25
Redness/Excoriation between skin folds
-Cleanse -Dry thoroughly -Place inter dry or dry AG textile in skin folds
26
Red Heels
-Position pressure off of heels -Elevate on pillows -Sage boot -Reduce friction
27
Red Sacral/Coccyx area
-Change positions q 1-2 hours -HOB <30º unless contraindicated -Avoid excess moisture -Frequent peri care -Wrinkle free linen
28
sequential response to cell injury
-Neutralizes and dilutes inflammatory agent -Removes necrotic materials -Establishes an environment suitable for healing and repair
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Inflammation ≠ Infection
Inflammation is always present with infection, but infection is not always present with inflammation
30
Inflammatory response occurs with multiple conditions
-Surgical wounds, other skin injuries -Allergies -Autoimmune diseases -Skin infections
31
Wound
Any disruption of the integrity and function of tissues in the body
32
What is important to wound healing
Wound assessment and classification
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Mast cells
Secrete factors that mediate vasodilation and vascular constriction. Delivery of blood, plasma, and cells to injured area increases
34
Neutrophils
New white blood cells, secrete factors that kill and degrade pathogens
35
5 cardinal signs of inflammation
Pain Heat Redness Swelling Loss of function
36
Type of exudate
Serous Purulent Serosanguineous Sanguineous
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Serous
Clear, watery plasma
38
Purulent
Thick, yellow, green, tan, or brown
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Serosanguineous
Pale, red, watery: mixture of serous and sanguineous
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Sanguineous
Bright red, indicates active bleeding
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Systemic response to inflammation
-Increased WBC count -Malaise (Lethargic) -Nausea and anorexia -Increased pulse and respiratory rate -Fever
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Types of inflammation
-Acute -Subacute -Chronic
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Acute inflammation
-Healing in 2-3 weeks, no residual damage -Neutrophils predominant cell type at site
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Subacute inflammation
Same features, but lasts longer
45
Chronic inflammation
-May last for years -Injurious agent persists or repeats injury to site -lymphocytes and macrophages -May result from changes in immune system
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Final phase of inflammatory process is
Healing
47
Regeneration healing
Replacement of lost cells and tissues with cells of the same type
48
Repair healing
A result of lost cells being replaced by connective tissue, results in scar formation -more common -more complex -occurs by primary, secondary, or tertiary intention
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Healing by primary intention
-Initial phase: acute inflammatory response -Granulation phase: wound pink & vascular, resistant to infection -Maturation phase: scar formation: 7 days after injury, mature scar forms
50
Eschar
Dead tissue
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Wound approximation
Edges of wound able to be pulled together
52
Healing by secondary intention
-Wounds from trauma, ulceration, & infection have large amounts of equate and wide, irregular wound margins -Edges cannot be approximated -Wound may need to be derided before healing can take place
53
Healing by tertiary intention
-Delayed primary intention due to delayed suturing of wound -Occurs when contaminated wound is left open and sutured close free infection is controlled
54
Factors that affect wound healing
-Nutrition -Tissue perfusion -Infection -Age
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Complications of wound healing
Hemorrhage Hematoma Infection Dehiscence Evisceration
56
Dehiscence
Separation/splitting open layers of surgical wound
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Hemorrhage
Bleeding
58
Hematoma
Bleeding under skin (bruise)
59
Evisceration
Extrusion of visceral or intestine through a surgical wound
60
Wounds are classified by
Cause: Surgical or non-surgical, acute or chronic Depth: Superficial, partial thickness, full thickness
61
Skin tear
Wound caused by shear, friction, and/or blunt force
62
Wound assessment, include:
Location Size Condition of surrounding tissue Wound base Any drainage (consistency, color, odor) Factors that could delay healing
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What is the enemy of wound healing
Dryness
64
Never use __________ on a wound
Peroxide
65
Granulating
Tissue that is in the process of healing
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Goal is for wound to be as moist as
Healthy skin
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Surgical wounds may have a drain placed to
Help remove excess fluid (Jackson-Pratt drain is common)
68
Purpose of dressings
-Protects from microorganisms -Aids in hemostasis -Promotes healing by absorbing drainage or debrieding a wound -Supports wound site -Promotes thermal insulation -Provides moist environment
69
Types of dressings
-Gauze -Transparent film -Hydrocolloid -Hydrogel -Foam -Composite
70
What do you need to do to dressings?
Put date and time
71
Removing sutures
-Remove every other suture -Document how many -Clip near skin -Steri strips
72
Pressure ulcer/injury
-Localized injury to skin and/or underlying tissue (usually over bony prominences) -Results from prolonged pressure or pressure in combo with shearing -Will generally heal by secondary intentio
73
Pressure ulcer/injury influencing factors
Pressure intensity Pressure duration Tissue tolerance factors Shearing forces Moisture
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Pressure ulcer/injury risk factors
-Age -Anemia -Diabetes -Increased temp -Friction -Impaired circulation -Low BP -Obesity -Shear
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Slough
Thick yellow/white/grey covering of the wound bed
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Stage I
-Intact skin — non-blanchable redness of a localized area -most common over bony prominence
77
Stage II
-Partial thickness loss of dermis -Shallow open ulcer with red/pink wound bed -May also present as intact or ruptured blister Fat and deeper tissues not visible
78
Stage III
-Full thickness skin loss -Subq tissue may be visible,but bone, tendon, or muscle are not -Presents as deep crater
79
Stage IV
-Full thickness loss, extends to muscle, bone, or supporting structures -Bone, tendon, or muscle may be visible or palpable -Slough or eschar may be present -Undermining and tunneling may also occur
80
You cannot stage a wound if
Slough is covering it
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Unstageable ulcer
-Full thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed
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Suspected deep tissue injury
-Purple or maroon localized area of discolored intact skin or blood filled blister
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Cellulitis
Systemic infection caused by localized skin injury
84
Stage III and IV pressure injuries acquired after admission
NEVER want to happen
85
Venous leg ulcrs
-Poor blood return to heart -Surrounding skin may be red, scaly, weepy, and thin -Shallow, irregular shape
86
Diabetic ulcers
-Located on sole of floor, under heels and on toes
87
Cellulitis
-Inflammation of subq tissue, often following break in skin -Treatment:moist heat, immobilization, elevation
88
The most important treatment for infection is
Prevention!
89
Psoriasis
-Common, chronic autoimmune inflammatory disorder characterized by plaque formation with varying degrees of severity
90
Mild psoriasis
red patches covered with silvery scales on scalp, elbows, knees, palms, and soles
91
Severe psoriasis
May involve entire skin surface and mucous membranes, superficial pustules, high fever, painful fissuring of the skin
92
Psoriasis treatment
Avoid: -Scrubbig -Long exposures to water -Trying to remove scales
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