EXAM 4- Tissue Integrity 2 Flashcards
pressure ulcer
localized injury to skin and/or underlying tissue
where do pressure ulcers typically occur?
bony prominences (sacrum/coccyx, heels)
how do pressure ulcers occur?
- prolonged pressure
- shear force/friction
- medical devices
how do most pressure ulces heal?
secondary intention
pathophysiology of how pressure ulcers occur
- prolonged pressure, also affected by BMI
- lack of capillary flow to tissues
- deprives tissues of oxygen & nutrients
- cell death, tissue necrosis
influencing factors for pressure injuries
- pressure intensity- amount, BMI, duration
- braden scale- determines tissue tolerance (comorbidities)
- shear forces- skin tears
- moisture- leads to skin breakdown
risk factors for pressure injuries
- mental- deterioration, neuro disorders, incontinence, age
- vascular- anemia (low bloodflow to tissues), impaired circulation, vascular disease
- physical- friction, immobility, obesity
- medical- diabetes, low diastolic BP (< 60), pain, prolonged surgery, increased temp (sweat)
clinical manifestations of pressure ulcers
depends on the extent
* staged based on visible/palpable tissue in wound bed
* slough/eschar- unstageable until removed
appearance & texture of deep tissue injury
- purple/maroon localized area
- intact
- may be a blood blister
- painful
- mushy, boggy, or firm
how do deep tissue injuries occur?
pressure/shear injury to underlying soft tissue
how do you assess for pressure ulcers in pts with darker skin?
- appearance- darker than surrounding skin, purple, brown, or blue
- texture- warm initially, boggy, painful/itchy for pt
stage I
- intact, non-blanchable redness
- firm, soft, warm or cool
stage II
- partial thickness loss of dermis
- shallow open ulcer
- red/pink wound bed or serum-filled blister
- shiny or dry
like grader on orange peel
stage III
- full thickness skin loss
- subQ visible
- deep crater, possible undermining
like peeling orange peel
stage III
- full thickness skin loss
- subQ visible
- deep crater, possible undermining
like peeling orange peel
stage IV
- full thickness loss
- bond, muscle, or tendon visible
- possible undermining & tunneling
- possible slough/ eschar
chunk out of orange
unstageable ulcer
- full thickness tissue loss
- wound bed completely covered by slough/ eschar (must be removed to stage)
slough
yellow, tan, green, grey, brown
eschar
brown, tan, black
complications of pressure ulcers
INFECTION
* leukocytosis
* fever
* ulcer size, odor, drainage increase
* necrotic tissue
what can infected pressure ulcers lead to?
- cellulitis
- icreased inflammatory, infection of subQ, connective tissue, bone
- leads to sepsis & death
what is the most common complication for skin breakdown?
recurrence
who should you assess for skin breakdown?
all pts are at risk
when should you assess the skin?
- on admission
- at least Qshift (2x/day)
for pts with a pressure injury, how often should you reposition?
at least Q2
how often should all pts be repositioned?
at least Q4
how can you keep the skin healthy?
- dry
- clean
- moisture barriers
how does nutrition prevent pressure ulcers?
adequate nutrition & fluid intake
care plan for pressure ulcers
- prevent skin breakdwon, decrease factors, pressure & infection
- promote healing
- prevent recurrence
what should you document when providing care for a pressure ulcer?
- size
- locaiton
- stage
- exudate
- infeciton
- pain
- appearance (photo)
what do wound care specialists determine?
- cleansing protocol
- type of dressing
how should you generally clean wounds?
- normal saline
- slightly moist
- surgical tx: graft
what should you teach your pt with a pressure injury upon discharge?
- prevention- early s/s of inflammation/infection, turning schedule
- promote- nutrition, care techniques, wound care
other types of skin damage
- moisture assoc. skin damade MASD
- incontinence assoc. dermatitis IAD
- medical adhesive related skin injury MARSI
- skin tear
why is ostomy care important?
they are prone to yeast infections
lower extremity ulcers
r/t changes in blood flow to lower extremities due to chronic diseases
arterial ulcers
skin is thin, shiny, dry, loss of hair on ankles & feet, creates ulcers
what causes arterial ulcers?
- ischemia &nutrition deprivation as a result of decreased circulation
- PAD causes lack of blood flow to to arteries, blocked by plaque, usually caused by atherosclerosis
who is at risk for arterial ulcers?
- atherosclerosis
- PVD
- diabetes
- smoking
- HTN
- age
- obesity
- cardiovascular disease
where do arterial ulcers occur?
- b/w toes
- tips of toes
- lateral malleolus
- anywhere footwear rubs
appearance of arterial ulcers
- round, even margins “hole punch”
- pale
- deep
- painful
arterial ulcer treatment
stents to treat ischemia
venous leg ulcers
venous insuficiency that occurs as bloow cannot flow upward from veins in legs
* valves damaged, leads to venous stasis
who is at risk for venous leg ulcers?
- obesity
- DVT
- pregnancy
- incompetent valves
- CHF
- muscle weakness, decreased activity
- age
- family hx
where do venous ulcers occur?
lower legs
appearance of venous ulcers
- irregular margins
- ruddy, scaley, wet, thin
- painless to mod. painful
tx for venous leg ulcers
compression therapy (SCD)
* promotes blood return
* prevents pooling
how do diabetic ulcers occur? where?
- peripheral neuropathy, immunocompromised, diabetic foot deformities
- occur on plantar foot, under heels & toes (bony areas)
appearance of diabetic ulcers
- even margin
- round w/ callous
- painless
what can a diabetic ulcer lead to? what is the tx?
- leads to cellulitis, osteomyelitis
- tx: decrease pressure, debride, antibiotics
clinical manifestations & cause of cellulitis
caused by inflammation/ infection (staph & strep) of subQ tissue following a skin break
clinical manifestations:
* hot
* tender
* red
* chills
* malaise
* fever
what does cellulitis lead to? what is the tx?
- can lead to gangrene if untreated
- tx: moist heat, immobilization, elevation
what is the best tx for infection?
PREVENTION!
* if infection occurs, tx with antibiotics
which antibiotic is affective for C-diff & MRSA?
vancomycin
what is a side effect of most antibiotics?
nausea
how does bacteria develop antibiotic resistance?
bacteria acquire resistance as DNA for drug resistance is transferred
pt does not follow through with entire perscription
psoriasis
- chronic, autoimmine inflammation w/ plaque formation
- mild- red patches w/ silver scales (scalp, elbows, knees, palms, & soles) (liveable)
- severe- entire skin, high fever, leukocytosis, painfull fissure
- caused by increased maturation of epidermal cells, increased activity of inflammatory cells
tx for psoriasis
- topical- decrease inflammatory cells
- tar- decrease DNA synthesis, cell proliferation
tx for systemic/severe psoriasis
- goal is to decrease epidermal cells proliferation, decrease immune fuction & inflammatory response
- safe sun exposure
- photo therapy
- coal tar
what should pts with psoriasis avoid doing?
- scrubbing/ removing scales
- excessive exposure to water
