EXAM 4- Tissue Integrity Flashcards
what is the largest organ?
skin
who is responsible for assessing & monitoring skin integrity?
RN
can the RN delegate skin integrity monitoring?
yes
responsibility still falls on RN
what is the skin’s main function?
protective barrier
what is the purpose of the skin?
- proteciton
- sensory
- vintamin D (gut)
- fluid balance
- natural flora (fights bacteria/infection)
true or false
you only have to assess the parts of the skin that are damaged/not intact when assessing
false
inspect the entire body
where should you assess skin on the body?
inspect the entire body
* bony prominences (low fat/muscle, coccyx, shoulders, head)
what senses do you use to assess the skin?
- visual & tactile- texture, temp
what do you assess the skin for?
- rash & lesions
- hair distribution
- skin color
- blanch test (lack of blood flow)
all are @ risk for skin breakdown
what can put a pt at risk for skin breakdown?
- age (young/old)
- diabetic
- incontinence
- bedbound
- poor level of sensation
- poor movement
- s/s of skin integrity
how often should you assess the skin?
- on admission
- at least once/shift (2x/day)
- all @ risk pts: Q4, high risk/wounds Q2
what might indicate a skin integrity problem?
- areas of redness
- non-blanchable
- pay attention to bony prominences, medical devices, adhesive tape
what areas does the braden scale measure?
- sensory perception (able to feel & communicate pain)
- moisture (how wet is the skin usually?)
- activity (ambulation)
- mobility (movement/ position shift)
- nutrition (adequate protein, vitamins, frequency)
- friction & shear (sliding in bed)
braden scale: sensory perception
- completely limited (unresponsive, limited ability to feel pain over most of body)
- very limited (painful stimuli, can’t comunicate discomfort, sensory impairment over 1/2 body)
- slightly limited (verbal commands, can’t always communicate discomfort, sensory impairment on 1-2 extremities)
- no impairment (verbal commands, no sensory deficit)
braden scale: moisture
- constantly moist (perspiration, urine, etc., always)
- very moist (often but not always, linen changed Qshift)
- occasionally moist (extra linen changed Qday)
- rarely moist (usually dry)
incontinece, folet catheter, brief, sweat
braden scale: activity
- bedfast (never OOB)
- chairfast (ambulation severly limited to non-existent, can’t bear weight, assisted to chair)
- walks occasionally (short distances daily w/ or w/o assistance, mostly in bed/chair)
- walks frequently (outside room 2x/day, inside room Q2)
braden scale: mobility
- completely immobile (makes no change in body/extremity position)
- very limited (occasional slight changes in position, unable to make frequent changes independently)
- slightly limited (frequent slight changes independent)
- no limitation (major & frequent changes w/o assistance)
braden scale: nutrition
- very poor (no complete meals, little protein, NPO, clear liquids, IV > 5 days)
- probably inadequate (rare complete meals, some protein, occasional dietary supplement, less that optimum liquid diet/tube feeding)
- adequate (eats over 50% of meals, adequate protein, usual supplement, tube feeding/TPN probably meets needs)
- excellent (eats most of meals, never refuses, plenty of protein, snacks, supplements not req)
braden scale: friction & sheer
- problem (mod-max assistance in moving, frequently slides down in bed/chair, agitation/contractions leads to constant friction)
- potential problem (mooves feebly, req min. assistance)
- no apparent problem (moves in bed/chair ind., sufficient muscle strength to lift up completely during move, good position)
braden scale: low risk
LOW RISK: 15-18
* regular turning schedule
* as much activity as possible
* protect heels
* manage moisture, friction & sheer
if a pt is a low risk on the braden scale, do you still have to do skin assessments?
yes!! all pts are at risk!
frequent assessment & prevention is required
braden scale: moderate risk
MODERATE RISK: 13-14
* regular turning schedule
* as much activity as possible
* protect heels
* manage moisture, friciton, & sheer
* HOB 30º, elevate w/ pillows/wedges
braden scale: high risk
HIGH RISK: < 12
* regular turning schedule
* as much activity as possible
* protect heels
* manage moisture, friciton, & sheer
* HOB 30º, elevate w/ pillows/wedges
* small, frequent position shifts
* pressure redistribution
what is the #1 thing you can do to promote skin & tissue integrity?
frequent repositioning
how long should a pt sit in the chair?
2 hours
what education should you teach your pt/family upon discharge?
turning schedule & prevention
CHANT
- Cleanse
- Hydrate & Protect (moisture barrier)
- Alleviate pressure
- Nourish
- Treat
early intervention for red/excoriated peri area
- cleanse
- dry
- moisture barrier daily & PRN
early intervention for red/excoriated skin folds
- cleanse
- dry
- place inner dry or AG textil in skin folds
early intervention for red heels
- alleviate pressure
- elevate on pillows
- sage boot
- reduce friction
early intervention for red sacral/coccyx area
- change position Q1-2
- HOB 30º
- avoid excess moisture
- frequent peri care
- wrinkle free linen
steps for skin integrity assessment & interventions
- assess & monitor skin integrity
- identify risks for skin breakdown (braden scale)
- identify present skin problems
- plan, implement, & evaluete interventions
prevent & monitor
what occurs during inflammatory response?
sequential response to cell injury
* neutralizes & dilutes inflammatory agent
* removes necrotic materials
* est. suitable healing/repairing environment
inflammation is NOT infection
* inflammation is always present with infection
* infection is NOT always present with inflammation
when can an inflammatory response occur?
- surgical wounds, skin injuries
- allergies
- autoimmune diseases
- skin infections
wound
any disruption of the integrity & function of tissues in the body
can be intentional (surgery)or accidental (cut, pressure injury, trauma)
what actions are imperative for wound healing?
wound assessment & classification
when does the inflammatory response occur for tissue trauma?
within 24 hours
true or false
the inflammatory response mechanism is the same regardless of the injuring agent
true
inflammatory response intensity depends on what?
- extent/severity of injury
- reactive capacity of the person
vascular response to inflammation
- increased capillary permeability, fluid moves to tissues (swelling), begins as serum fluid, tehn pulls fluid from vessels into the tissues
- redness, heat, swelling
- fibrinogen strengthens blood clots (prevents the spread of bacteria)
cellular response to inflammation
- neutrophils & monocyes move to injury (site of infection), increase WBC
- exudate (fluid & leukocytes) depends on severity (local or systemic)
clinical manifestations of local inflammation
- redness
- heat
- pain
- swelling
- loss of function
clinical manifestations of systemic inflammation
- leukocytosis
- malaise
- nausea, anorexia
- increased HR & RR (fever)
- fever
occur due to the release of cytokines
types of inflammation
3
- acute
- subacute
- chronic
acute inflammation
- healing in 2-3 weeks, no residual damage
- neutrophils predominant cell type
subacute inflammation
- same as acute
- takes longer to heal
potentially affected by comorbidities
chronic inflammation
- may last for years
- injurious agent persists/ repeated injury to site
- lymphocytes & macrophages are predominant cell types
ex: eczema, psoriasis
* symptoms can be treated, but not cured
constant auto-immunity disorders
health promotion for inflammation
- prevention of injury
- adequate nutrition
- early recognition of infeciton/inflammation
- immediate tx
what is an early symptom of inflammation?
general malaise
change in vital signs for pts with infection
increase in:
* temp
* HR
* RR
fever management for infection
- may not be necessary, as mild-mod fevers are usually not harmful
- may make young/old pts more comfortable
- fever > 104 is an emergency
what is the final stage of inflammatory process?
healing
regeneration
replacement of lost cells/ tissue with the same cell type
repair
healing replacement with connective tissue cells, scar forms
* more complex & common
* occurs by primary, secondary, or tertiary intention
healing by primary intention
normal (3 phases)
ex: c-section, sewn, healed
healing by secondary intention
any trauma wound (not approximated)
* sewn the best way possible, not precise wound/scar
ex: MVC injury
healing by tertiary intention
primary intention gone wrong
* must heal from the inside out
ex: c-section, didn’t report signs of infection, wound re-open/surgery
phases of healing by primary intention
3
- initial: (3-5 days) acute inflammatory response
- granulation: fibroblasts secrete collagen, wound is pink & vascular, resistant to infection
- maturation: (begins after 7 days, lasts months/years) scar formation, fibroblasts disappear, wound becomes stronger
process of healing by secondary intention
same as primary proces, but inflammatory reaction may be greater, requires debridement before healing can occur
* uneven wound edges, lots of exudate, tissue loss
process of healing by tertiary healing
delayed primary inention due to delayed suturing of wound
* occurs when a contaminated wound is left open & sutured closed after the infection is controlled
what type of wounds are healed by regeneration?
partial-thickness wounds
what type of wounds are healed by repair?
full-thickness wounds
what factors influence wound healing?
- nutrition: protein, vitamins, sizc & copper, calories
- tissue perfusion: O2 fuels cellular functions (blanch test)
- infection: prolongs inflammatory response, delays collagen synthesis and epithelialization, increase in cytokines
- age: decreased function of macrophages> delayed inflammmatory response (slower healing)
complication of wound healing
- hemorrhage: excess bleeding
- hematoma: collection of blood under the skin
- infection
- dehiscence: when a wound breaks open (stiches/staples)
- evisceration: when something comes out of the wound (body part) (this is why we splint coughs)
skin tear
wound caused by friction
* partial or full thickness
* common for elderly pts (thinner skin)
what does wound identificaiton depend on?
- wound classification
- surgical/ non-surgical
- acute/ chronic
when should you assess wounds?
- on admission
- Qshift (2x/day)
when assessing wounds, what should you look for?
- locaiton
- size
- surrounding tissue
- wound base
- drainage (odor, color, consistency)
- factors that could delay healing (hemorrage, hematoma)
what does management of wounds depend on?
- type of dressing
- extent of injury
- character of wound
- healing phase
management of clean wounds
- cleansing
- closure (adhesive strips, sutures, staples)
management of wound dressings
should be clean & slightly moist
management of surgical wounds
sterile dressing (removed in 2-3 days)
should antimicrobial/bacterial solution be used for wounds & dressings?
no
they can damage new epithelial cells & delay healing
purpose of wound drains
remove excess fluid from surgical wounds
most common is Jackson-Pratt
management of contaminated wounds
- debridement is required first for healing to occur (must be converted to clean wound)
- dressings absorb exudate & clean wound
wound dressing purposes
- protection - bacteria
- aids in hemostasis
- absorbs drainage/ debrides
- thermal insulation
- moist environment
types of surgical dressings
- gause
- transparent film
- hydrocolloid
- hydrogel
- foam
- composite
process of dressing changes
- review previous wound assessment
- evaluate pain> analgesics
- describe procedure
- remove tape
- recognize normal healing signs
- clean wound edges
- date, time, initial dressing
- document
how to clean a wound/drain site?
- clean from least contaminated>surrounding tissue
- irrigation: allow fluid to flow from least>most contaminated
suture/staple removal
- match the number that went in
- clip near skin, opposite of know
- document
steri-strips removal
- don’t pull/ create tension
- allow to fall off naturally (10 days)
- may shower
surgical infection prevention
may be given prophylactic antibiotcs
pt ed for wounds
- healing process, normal changes
- home wound care
- infeciton prevention (hand hygiene)
- adequate nutrition
- s/s to report
