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Nursing II > concept: tissue integrity > Flashcards

concept: tissue integrity Flashcards

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1
Q

risk factors for altered tissue integrity

A
  • age
  • nutrition
  • genetics
  • activity level
  • health/chronic illnesses
  • medications
  • incontinence
  • altered mental status
  • altered sensation
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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
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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)
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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
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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)
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6
Q

classifications (intentional vs. unintentional)

A
  • intentional- occurs during therapy (operations or venipunctures)
  • unintentional- accidental (fracture of an arm)
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7
Q

classifications (closed vs. open)

A
  • closed- tissues are traumatized without break in the skin

- open- skin or mucous membrane surface is broken

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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)
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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
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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
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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

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12
Q

collaboration with other health care professionals (r/t tissue integrity)

A
  • physical therapist
  • dietician
  • home health agency
  • would care nurse/enterostomal nurse
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13
Q

skills needed to care for patient with tissue integrity issue

A
  • dressing changes
  • skin care
  • privacy
  • aseptic technique
  • documentation
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14
Q

What are pharmocological options for tissue integrity issues?

A
  • antibiotics
  • antifungals
  • antiinflammatory
  • glucocorticoids
  • pain control
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15
Q

What are potential complications regarding to tissue integrity?

A
  • infection
  • mobility issues
  • metabolism
  • comfort
  • elimination
  • fluid/electrolyte imbalance
  • perfusion
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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
Q

how to prevent pressure ulcers

A
  • providing nutrition
  • maintaining skin hygiene
  • avoiding skin trauma
  • providing supportive devices
26
Q

types of wound healing

A

-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
Q

phases of wound healing (inflammatory phase)

A
  • 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
Q

phases of wound healing (proliferative phase)

A
  • 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
Q

phases of wound healing (maturation phase)

A
  • 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
Q

factors effecting wound healing

A
  • 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
Q

complications of wound healing

A
  • 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
Q

nursing interventions for moist wound healing (R/T wounds)

A

-dressing and frequency of change should support moist wound bed conditions; wound beds that are too try fail to heal

33
Q

nursing interventions for nutrition and fluids (R/T wounds)

A
  • 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
Q

interventions for preventing infection (R/T wounds)

A
  • preventing microorganisms from entering wound

- preventing transmission of bloodborne pathogens to or from the client to others

35
Q

interventions for positioning (R/T wounds)

A
  • 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
Q

manifestations of would healing

A
  • 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 (6 decks)

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