IM1-EXAM 4 Material Flashcards
1
Q
True or false: It is important that we keep our skin intact?
A
True
2
Q
Whose responsibility is it to assess and monitor skin integrity?
A
The nurse
3
Q
True or false: The skin is our largest organ?
A
True
4
Q
What purpose does our skin have? List 5.
A
- Protection
- sensory
- Vitamin D Syntheses
- Fluid Balance
- Natural Flora
5
Q
What are the 3 layers of the skin?
A
- Epidermis
- Dermis
- Subcutaneous
6
Q
True or false: Layers do not help with staging wounds?
A
False
7
Q
When we are assessing the skin why are we looking especially at bony prominences?
A
Because those areas are more prone to skin breakdown
8
Q
What area are considered bony prominences?
A
Heels, iliac crests, and the sacrum
9
Q
Why is it important to do the tactile assessment of skin?
A
The temperature of the skin can be an indication of potential issues/skin integrity concerns.
10
Q
What could a cold extremity tell you during the tactile assessment of the skin?
A
This could indicate poor circulation to that extremity
11
Q
What could a hot/inflamed extremity tell you during the tactile assessment of the skin?
A
This could indicate infection.
12
Q
True or False: When assessing the skin, you should make note of only rases or lesions that look bad?
A
False- You should make note of all rases or lesions so that you continue to monitor.
13
Q
True or false: Part of the skin assessment includes noting a patients hair distribution.
A
True.
14
Q
True or false: Skin color is important during the assessment of skin?
A
True
15
Q
What is the blanch test?
A
It is used to monitor dehydration and the amount of blood flow to tissue. If you press down on an area of concern and no blanching occurs this could indicate something concerning with the patient’s skin integrity.
16
Q
What are the parts of the skin assessment? list 6.
A
- Inspect the bony prominences
- Visually and tactilely inspect the skin
- Assess any rases or lesions
- Note hair distribution
- Assess skin color
- Blanch test
17
Q
Why is the skin assessment important? List 6.
A
- Helps identify patients at risk.
- Identifies signs & Symptoms of impaired skin integrity or poor wound healing
- Allows a nurse to examine the skin for actual impairment
- Focus on: level of sensation, movement & continence
- Allows a nurse to assess skin on initiation of care, then at least once/per shit.
- Identifies high risk patients– and allows us to set up a base line of how often to assess our high-risk patients–> every 4 hours or more.
18
Q
When we are doing the skin assessment should we palpate areas of redness to determine if that skin is blanchable?
A
Yes
19
Q
True or false: It is important to pay attention to bony prominences, medical devices and areas with adhesive tape
A
True- more prone to skin breakdown
20
Q
When are ideal times to inspect the patients skin? List 3.
A
- When turning the patient
- When assisting the patient to a chair or back to bed.
- When bathing the patient.
21
Q
What is an SCD device?
A
Sequential compression device.
22
Q
True or false: The Braden scale is used on every patient regardless of whether they are independent.
A
True
23
Q
The higher the number on the Braden Scale the _____ the risk?
A
Lower
24
Q
The lower the number on the Braden Scale the _____ the risk?
A
Higher
25
If a patient scores a 1 in sensory perception on the Braden scale what would this indicate?
Completely Limited
1.Unresponsive
2. Limited ability to feel pain over most of the body.
26
If a patient scores a 2 in sensory perception on the Braden scale what would this indicate?
Very limited
1. Painful
2. Connot communicate discomfort
3. Sensory impairment over half the body.
27
If a patient scores a 3 in sensory perception on the Braden scale what would this indicate?
Slightly limited
1. verbal commands
2. Cannot always communicate discomfort
3. Sensory Impairment- 1-2 extremities
28
If a patient scores a 4 in sensory perception on the Braden scale what would this indicate?
1. Verbal commands
2. No sensory deficit
29
If a patient scores a 1 in moisture on the Braden scale what would this indicate?
Constantly Moist
1.Perspiration, urine, etc
2. always
30
If a patient scores a 2 in the moisture on the Braden Scale what would this indicate?
Very Moist
1. Often but not always
2. Linen changed at least once per shift
31
If a patient scores a 3 in moisture on the Braden Scale what would this indicate?
Occasionally Moist
1. Extra linen changed qday
32
If a patient scores a 4 in moisture on the Braden Scale what would this indicate?
Rarely Moist
1. usually dry
33
If a patient scores a 1 in activity on the Braden Scale what would this indicate?
Bedfast
1. Never OOB (never out of bed)
34
If a patient scores a 2 in activity on the Braden scale what would this indicate?
Chairfast
1. Ambulation severely limited to non-existent
2. Cannot bear own weight- assisted to chair
35
If a patient scores a 3 in activity on the Braden Scale what would this indicate?
Walks occasionally
1. short distances with or without assistance
2. Majority of time in bed or char
36
If a patient scores a 4 in activity on the Braden Scale what would this indicate?
Walks Frequently
1. Outside room 2x per day
2. Inside room q 2 hours during waking hours
37
If a patient scores a 1 in mobility on the Braden Scale what would this indicate?
Completely immobile
1. Makes no change in body or extremity position
38
If a patient scores a 2 in mobility on the Braden Scale what would this indicate?
Very limited
1. Occasional slight changes in position
2. unable to make frequent/significant changes independently
39
If a patient scores a 3 in mobility on the Braden Scale what would this indicate?
Slightly Limited
1. frequent slight changes independently
40
If a patient scores a 4 in mobility on the Braden Scale what would this indicate?
No limitation
1. Major and frequent changes without assistance
41
If a patient scores a 1 in nutrition on the Braden Scale what would this indicate?
Very Poor
1. Never eats complete meal, very little protein
2. NPO, Clear liquids, IV > 5 days
42
If a patient scores a 2 in nutrition on the Braden scale what would this indicate?
Probably Inadequate
1. Rarely eats complete mean, some protein
2. Occasionally takes dietary supplements
3. Receives less than optimum liquid diet or tube feeding.
43
If a patient score a 3 in nutrition on the Braden Scale what would this indicate?
Adequate
1. Eats over 1/2 of most meals, adequate protein
2. Usually takes a supplement
3. Tube feeding or TPN probably meets nutritional need.
44
If a patient scores a 4 in nutrition on the Braden Scale what would this indicate?
Excellent
1. Eats most of meal, never refuses, plenty of protein
2. Occasionally eats between meals
3. Does not require supplements
45
If a patient scores a 1 in friction and sheer on the Braden Scale what would this indicate?
Problem
1. Moderate to max assistance in moving
2. Frequently slides down in bed or chair.
3. Spasticity, contractures or agitation leads to almost constant friction
46
If a patient scores a 2 in friction and sheer on the Braden Scale what would this indicate?
Potential problem
1. Moves feebly, requires minimum assistance
2. Skin probably slides against sheets
3. Relatively good position in char or bed with occasional sliding
47
If a patient scores a 3 in friction and sheer on the Braden Scale what would this indicate?
No apparent problem
1. Moves in bed and chair independently
2. Sufficient muscle strength to lift up completely during move
3. Good position in bed or char
48
What is the Braden Scale used to assess?
Risk of skin breakdown
49
What score is considered low risk on the Braden scale?
15-18
50
What are things we should implement for a low risk patient according to the Braden Scale? List 4
1. Regular turning schedule
2. Enable as much activity as possible
3. Protect heels
4. Manage moisture, friction and sheer
51
What score is considered moderate risk on the Braden Scale?
13-14
52
What are things we should implement for moderate risk on the Braden Scale? List 5
1. Regular turning schedule
2. Enable as much activity as possible
3. Protect heels
4. Manage moisture, friction and sheer
5. Position patient at 30 degree lateral incline using wedges or pillows.
53
What score is considered a high risk on the Braden Scale?
12 or less
54
What are things we should implement for high risk patients on the Braden Scale? List 7
1. Regular turning schedule
2. Enable as much activity as possible
3. Protect heels
4. Manage moisture, friction and sheer
5. Position patient at 30 degree lateral incline using wedges or pillow
6. Make small shifts in position frequently
7. Pressure redistribution surface
55
What are some tissue integrity interventions? List 4
1. Frequent repositioning
2. Sitting in chair for 2-hour intervals
3. Keeping HOB at 30 degrees
4. Keeping a written schedule of turning and positioning.
56
What is the longest amount of time a patient should remain sitting in a chair for?
No more than 2 hours
57
True or false: Patients sitting in chairs for longer than 2 hours will increase the pressure to sacral tissue?
True
58
What is the magic number when repositioning a patient in bed?
30 degree--- HOB
59
True or False: Keeping a written schedule of turning and repositioning should be something we also teach a patients family to do?
True
60
Name the stages of wound staging
Stage 1 (I): Non blanchable redness
Stage 2 (II): Partial-Thickness
Stage 3 (III): Full- Thickness skin loss
Stage 4 (IV): Full-Thickness tissue loss
--Unstageable/Unclassified full-thickness skin or tissue loss-depth unknown
-- Suspected deep-tissue injury-depth unknown
61
What does the early intervention protocol pneumonic C.H.A.N.T stand for?
C-Cleanse
H- Hydrate (and protect) skin
A- Alleviate pressure
N- Nourish
T- Treat
62
What should you do for a Red/excoriated peri/Rectal area?
1. Cleanse
2. Dry thoroughly
3. Moisture barrier daily and PRN
63
What should you do for redness/excoriation between skin folds?
1. Cleanse
2. Dry thoroughly
3. Place inner dry or dry AG textile in skin folds
64
What should you do for red heels?
1. Position pressure off of heels
2. Elevate on pillows
3. Sage boot
4. Reduce friction
65
What should you do for a red sacral/coccyx area?
1. Change positions q 1-2 horus
2. HOB < 30 degrees unless contraindicated
3. Avoid excess moisture
4. Frequent peri care
5. Wrinkle free linen
66
Why do you want to make sure a patients sheets are wrinkle free?
The wrinkled linens can cause extra pressure to the skin
67
What are the nursing priorities for skin? List 4
1. Assessing & Monitoring skin integrity
2.Identifying risks for skin problems
3. Identifying present skin problems
4. Planning, implementing & evaluating interventions to maintain skin integrity.
68
Inflammation does not always mean ____?
Infection
69
True or false: Inflammation is always present with infection
True
70
What does our inflammatory response system do in response to cell injury? list 3 (hard slide to word reference slide 33 in skin integrity for help)
1. Neutralizes and dilutes inflammatory agent.
2. Removes necrotic materials
3. Establishes an environment suitable for healing and repair.
71
In what conditions can our inflammatory responses be activated? List 4
1. Surgical wounds, other skin injuries
2. Allergies
3. Autoimmune Diseases
4. Skin infections.
72
Define a wound
Any disruption of the integrity & function of tissues in the body
73
True or false: Wound assessment & classification is not important in terms of wound healing?
False- Very important
74
Tissue trauma causes an inflammatory response in the first ___ hours?
24
75
The intensity of our inflammatory response depends on what? List 2
1. Extent and severity of the injury
2. Reactive capacity of the injured person
76
True or false: The inflammatory response mechanism is the same regardless of the injuring agent?
True
77
Within the inflammatory response --- we have the vascular response. What things are happening during the vascular response? List 4.
1. increased capillary permeability, fluid moves into tissue spaces
2. initially serous fluid, but eventually contains albumin pulling more fluid from vessels into tissue.
3. Result: redness, heat and swelling at site of injury and surrounding area
4. Fibrinogen is activated to fibrin, which strengthens the blood clot, prevents spread of bacteria.
78
Within the inflammatory response-- we have the cellular response. What thing are happening during the cellular response?
1. Neutrophils and monocytes move through capillary wall and accumulate at site of injury
2. Bone marrow releases more neutrophils in response to infection, WBC elevated
3. Complement system- Major mediator of inflammatory response.
4. Exudate
-Fluid and leukocytes
-Nature and quantity of exudate
--Type and severity of injury
-- tissue involved
79
What are things you will be able to see (clinical manifestations) when the inflammatory response is activated (locally) list 5
Local response to inflammation
1. redness
2. heat
3. pain
4. swelling
5. Loss of function
80
What clinical manifestations will you see when the inflammation response turns to systemic inflammation?
list 5
1. Increased WBC
2. Malaise
3. Nausea and anorexia
4. Increased pulse and respiratory rate
5. Fever
81
What is the cause for systemic inflammation?
Causes are poorly understood, but likely due to complement activation and release of cytokines.
82
True or false: localized/untreated inflammation can turn into systemic inflammation?
True
83
Why does your pulse and respiratory rate increase when you are having systemic inflammation?
Because you are running a fever the resp. rate and pulse rate increase to try and lower the bodies temp.
84
What are the 3 types of inflammation?
1. Acute
2. Subacute
3. Chronic
85
What are some characteristics of acute inflammation? list 2
1. Healing in 2-3 weeks, no residual damage
2. Neutrophils predominant cell type at site
86
What are some characteristics of subacute inflammation? list 3
1. no residual damage
2. Neutrophil predominant cell type at site.
3. Last longer
87
What are some characteristics of chronic inflammation? List 4
1. May last for years
2. Injurious agent persists or repeats injury to site
3.Predominant cell types are lymphocytes and macrophages
4. May result from changes in the immune system.
88
As nurses when it comes to skin integrity what are some health promotions to consider (poorly worded sorry) reference slide 44.
1. Prevention of injury
2. Adequate nutrition
3. Early recognition of injury/inflammation
4. Immediate treatment
89
Nursing and interprofessional management include observation and recognition. What should we keep in mind for immunosuppressed patients?
Classic manifestations of inflammation may be masked for immunosuppressed patient.
90
What is one early clinical manifestation symptom of inflammation?
General malaise
91
True or false: it is important to note vital signs, especially if infection is present.
True
92
If an infection is present what happens to temperature, pulse and respiration rate?
Increase
93
What are some things to consider with fever management?
Antipyretics may not be necessary, as mild- moderate fever usually does little harm. HOWEVER, very YOUNG or very OLD, uncomfortable or those with significant medical problems benefit.
94
A fever greater than ____ can be damaging to body cells and intervention is ______?
1. 104
2. necessary
95
What is the final phase of the inflammatory process?
Healing
96
What are the two major components in healing?
1. Regeneration-- replacement of lost cells and tissues with cells of the same type
2. Repair-- healing as a result of lost cells being replaced by connective tissue, results in scar formation.
--- more common
--- more complex
--- occurs by primary, secondary or tertiary infection
97
Healing by primary intention includes what 3 phases?
1. Initial
2. Granulation
3. Maturation phase and scar formation.
98
What are some characteristics of the initial phase of healing by primary intention.
Initial phase (3-5 days, acute inflammatory response)
99
What are some characteristics of the granulation phase of healing by primary intention?
1. Fibroblasts secrete collagen,
2. Wound pink & vascular
3. Risk for dehiscence
4. Resistant to infection
100
What are some characteristics of the maturation phase of healing by primary intention?
1. begins 7 days after injury
2. Continues for months/years,
3. Fibroblasts disappear
4. Wound becomes stronger
5. Mature scar forms
101
Healing by secondary intention have wounds caused from?
1. Trauma
102
What are some characteristics of wounds healing by secondary intention. list 3
1. Wounds from trauma, ulceration and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss
2. Edges cannot be approximated
3. Healing process is the same as primary, but inflammatory reaction may be greater, wound may need to be debrided before healing can take place.
---- Healing: Initial phase, granulation phase, maturation phase.
103
What kind of wound would be considered to be healing by tertiary intention?
A wound originally healing by primary intention but something went wrong, and the wound may have had to be reopened to heal.
104
What are some characteristics of healing by tertiary intention?
1. Delayed primary intention due to delayed suturing of wound
2. occurs when a contaminated wound is left open and sutured closed after infection is controlled
105
What are the three components in the healing process of a partial-thickness (regeneration) wound?
1. inflammatory response
2. Epithelial proliferation & migration
3. Reestablishment of the epidermal layers
106
What are the four phases in the healing process of a full-thickness (repair) wound?
1. Hemostasis
2. Inflammatory phase
3. Proliferative phase
4. Maturation
107
True or false: Full-thickness wounds extend into dermis and heal by scar formation?
True
108
The more skin a wound loses the _____ it will take the wound to heal
Longer
109
What are some factors that influence wound healing? List 4
1. Nutrition
2. Tissue perfusion
3. Infection
4. Age
110
True or false: Protein, vitamins (esp. A & C) and trace minerals of zinc & Copper are important factors in nutrition and wound healing?
True
111
Are adequate calories an important factor in wound healing?
Yes
112
Tissue perfusion is a factor that influence wound healing. Why is this?
Oxygen is what fuels cellular functions
113
How can infection be a factor in wound healing?
1. Prolongs the inflammatory stage, delays collagen synthesis, prevents epithelization, increases cytokine production
114
How can age be a factor in wound healing?
1. Decreased function of macrophages leads to delayed inflammatory response in older adults
115
What are some complications of wound healing? List 5
1. Hemorrhage
2. Hematoma
3. Infection
4. Dehiscence--- wound breaks open (example stitches coming out)
5. Evisceration--- something coming out of a wound
116
How can a wound be classified?
1. Surgical or non surgical: acute or chronic
2. Superficial, partial thickness, full thickness
117
What is a skin tear?
1. Wound caused by shear, friction and/or blunt force
118
How can a skin tear be classified?
1. Can be partial thickness or full thickness
119
Who is at most rick for skin tears?
Older adults and those critically/chronically ill
120
When should you assess a patients skin?
On admission and every shift
121
When assessing a wound what should you include in documentation
1. Location size
2. Condition of surrounding tissue
3. Wound base
4. Drainage -- consistency, color and odor
5. Determine if there are factors that could delay healing
122
If we are wanting to describe a particular location of a wound to the doctor how would we do this?
Look and describe the wound in terms of a clock.
example--- a wound could be documented as " full-thickness, red wound 7cm x 5cm x 3cm with a 3cm tunnel at 7 o'clock and a 2cm underming from 3 o'clock to 5 o'clock.
123
True or false: There is a special camera for taking pictures of wounds?
true
124
True or false: Management of wounds, including types of dressings, depends on type, extent and character of wound and the phase of healing?
True
125
What can you do as a nurse to ensure a clean wound is kept? (reference slide 56) list 4
1. May need cleansing and some type of wound closure (adhesive strips, sutures, staples)
2. Various dressing available to keep wound clean and slightly moist
3. Surgical wounds may be covered with sterile dressing, removed in 2-3 days
4. Dryness is enemy of wound healing. Antimicrobial and Anti bactericidal solutions can damage new epithelium and delay healing, should not use in a clean granulating wound.
126
True or False: Healing wounds love dry conditions
False
127
Surgical wounds may have a _____ placed to help remove excess fluid.
Drain
128
What is a type of drain that a patient may have placed on a surgical wound?
Jackson-Pratt drain
129
What are some things you should know when caring for a contaminated wound?
1. Must be converted to a clean wound before healing can occur.
2. Debridement (removal of dead tissue and debris) may be necessary
3. Dressings are available that can absorb exudate & clean wound.
130
What is the purpose of dressings? list 6
1. Protects from microorganisms
2. aids in hemostasis
3. Promotes healing by absorbing drainage or debriding a wound.
4. Supports wound site
5. Promotes thermal insulation
6. Provides a moist environment.
131
What are some types of dressings? list 6
1. Gauze
2. Transparent film
3. Hydrocolloid
4. Hydrogel
5. Foam
6. Composite
132
True or false: A nurse should be familiar and know the type of dressing, placement of drains & equipment needed?
True
133
How do you prepare your patient for a dressing change?
1. Review previous wound assessment
2. Evaluate pain & If indicated, administer analgesics
3. describe procedure
4. gather all supplies
5. Recognize normal signs of healing
6. answer questions about the procedure or wound.
134
What are some dressing change comfort measures to consider?
1. Administer analgesic medications 30-60 mins before
2. Carefully remove tape
3. Gently clean wound edges
4. Carefully manipulate dressings & drains to minimize stress on sensitive tissues
5. turn and position the patient carefully
6. date and time the dressings
7 DOCUMENT.
135
How should you clean skin & drain sites?
1. From least contaminated to the surrounding skin
2. use gentle friction
4. When irrigating, allow the solution to flow from the least to most contaminated area.
136
True or false: it important to know how many sutures went in the patient but not how many came out?
False- You want to know both so that you can assure that all sutures were taken out
137
What information should we inform our patients of when they have steri-strips?
1. Do not pull or create tension
2. Teach to allow them to fall off naturally (about 10 days) may shower
138
True or false: A prophylactic dose of antibiotics can decrease the incidence of infection in certain kinds of surgery?
True
139
When should a prophylactic antibiotic be given?
Prior to surgery and may be re-dosed after if surgery is unusally long
140
When should a prophylactic antibiotic be given?
Prior to surgery and may be re-dosed after if surgery is unusually long
141
Surgical site infection prevention includes
giving prophylactic antibiotics
142
True or false: A patient may be distressed about appearance, fear of scares or permanent disfigument?
True
143
True or false: A caregiver's facial expressions can not cause further alarm or mistrust?
False
144
What should we educate our patient and family over regarding wounds?
Teach patient and family the healing process & normal changes to wound as it heals, as well as home care of wound, infection prevention, signs and symptoms to report and adequate nutrition
145
What is another name for a pressure ulcer?
Pressure injury
146
What is a pressure ulcer?
Localized injury to skin and/ or underlying tissues
147
What are pressure ulcers usually located?
Over bony prominences. Especially the sacrum and heels.
148
How do pressure ulcers happen? List 2
1. Results from prolonged pressure or pressure in combination with shearing forced.
2. Can be injury related to medical or other devices
149
How do pressure ulcers usually heal?
By secondary intention
150
Where are common ulcer sites. List 22
1. occipital bone
2. Scapula
3. Spinous process
4. Elbow
5. Iliac crest
6. Sacrum
7. Ischium
8. Achillies tendon
9. Heel
10. Sole
11. Ear
12. Shoulder
13. Anterior Iliac spine
14. Trochanter
15. Thigh
16. Meidal Knee
17. Lateral knee
18. Lower leg
19. Medial Malleolus
20. Lateral Malleolus
21. Lateral edge of foot
22. Posterior knee
151
What is the pathophysiology of a pressure ulcer.
1. skin under pressure for a prolonged period of time -->
2. Stop capillary flow to tissues -->
3. Deprives tissues of oxygen and nutrients -->
4. Cell death tissue necrosis.
152
What are factors influencing pressure injuries?
1. Pressure intensity (amount of pressure)
2. Pressure duration (length of time pressure is exerted on the skin)
3. Tissue tolerance factors- ability of tissue to tolerate the pressure.
- Nutrition
- Perfusion
-Comorbidities
- Condition of soft tissue.
4. Shearing forces (when skin adheres to a surface and skin layers slide in the directions of body movement)
5. Moisture- Excessive moisture that leads to skin breakdown.
153
If a patient skin integrity is compromised how often should you check/turn the patient.
Every 2 hours
154
What are some risk factors for pressure ulcers?
1. advanced age
2. Anemia
3. Diabetes
4. Elevated body temp
5. Friction
6. Immobility
7. Impaired circulation
8. Incontinence
9. Low Diastolic BP (<60mmHg)
10. Mental deterioration
11. Neurologic disorders
12. Obesity
13. Pain
14. Prolonged surgery
15. Vascular disease
155
What are the clinical manifestations for pressure ulcers?
1. Depends on the extend of tissue involved
2. Staged/categorized based on visible or palpable tissue in the ulcer bed
3. Staging is based on the national pressure ulcer advisory panel guidelines
4. Stage 1 (minor) to stage (severe)
5. Presence of slough or eschar may prevent staging until it is removed
156
What is a deep tissue injury?
Purple or maroon localized area of discolored intact skin or blood-filled blister.
157
What does a deep tissue injury indicate?
Indicates damage of underlying soft tissue from pressure and/or shear.
158
What are characteristics of a deep tissue injury?
1. Purple or maroon localized area of discolored intact skin or blood-filled blister
2. May be preceded by tissue that is painful, firm, mushy, and boggy
3. May be difficult to detect in patients with dark skin tones
159
How do you do a skin assessment for patients with dark skin?
1. Look for areas of skin that are darker than surrounding skin. These may appear purple, brown, or blue.
2. Use your hand to assess skin. An ulceration may feel warm initially, then become cooler with time.
3. Apply gentle pressure to common sites of injury to feel consistency. Boggy or edematous tissue may indicate a stage 1 pressure ulcer.
4. patients may report pain or itchy sensation
160
Describe a stage 1 pressure ulcer?
1. Intact skin that is non-blanchable redness of a localized area
2. Common over bony prominence
3. May be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
4. Darkly pigmented skin may not have visible blanching, but color may differ from the surrounding area.
161
True or false: A stage 1 pressure ulcer has intact skin?
True
162
Stage 1 pressure ulcers are typically found where?
Bony prominence
163
Describe a stage 2 pressure injury?
1. Partial thickness loss of dermis
2. Shallow open ulcer with red/pink wound bed
3. May also present as an intact or ruptured serum-filled blister
4. Can be shiny or dry shallow ulcer without slough or brusing
5. Adipose (fat) is NOT visible and deeper tissues are NOT visible
6. Granulation tissue, slough and eschar are NOT present
164
True or false: You can see bone in stage 2 pressure ulcer
False
165
Describe a stage 3 pressure ulcer
1. Full-Thickness skin loss
2. Subcutaneous tissue MAY be visible, but bone, tendon or muscle are NOT.
3. Presents as deep carter with possible undermining or adjacent tissue
4. Ulcer depth varies by location depending on depth of tissue in that area.
166
Can you see adipose tissue in a stage 3 pressure ulcer?
Yes
167
Describe a stage IV (4) pressure ulcer
1. Full-Thickness loss, extends to muscle, bone or supporting structures.
2. Bone, Tendon, or muscle may be visible or palpable
3. Slough or eschar may be present on some parts of the wound bed.
4. Undermining and tunneling may also occur.
168
What is undermining?
Wound that extends horizontally under the skin.
169
What is tunneling?
When the wound goes down further towards the bone
170
Describe a unstageable ulcer
1. Full-thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed.
2. Slough or eschar must be removed to expose the base of the wound in order to be staged.
3. HOWEVER stable, dry eschar on heels should NOT be removed
171
Describe Slough
May be yellow, tan, green, grey or brown
172
Describe eschar
May be tan, brown, or black in the wound bed
173
What are some complications of pressure ulcers?
1. Infection
2. Cellulitis
3.Recurrence of tissue breakdown/repeat pressure ulcer
174
What are some signs of an infected pressure ulcer?
1. Leukocytosis
2. Fever
3. Increased ulcer size, odor or damage
4. Necrotic tissue
5. indurated, warm and painful
175
True or false: An untreated ulcer may lead to cellulitis with spread of inflammation/infection to subcutaneous tissue, connective tissue, bone (osteomyelitis), can lead to sepsis and death.
True
176
True or false: nurses play a critical role in the prevention and treatment of pressure injuries
True
177
Assess _____ patients for ____ for skin breakdown every 12 hours.
1. ALL
2. Risk
178
True or false: stage III and IV pressure injuries acquired after admission should never happen?
True
179
Is it important to redistribute pressure in order to prevent pressure ulcers?
Yes
180
What are some pressure ulcer techniques?
1. Pressure redistribution
2. Keep skin dry
3. Reposition
4. Turning scheduling
5. Nutrition and fluid intake.
181
What are some repositioning techniques that will help prevent pressure ulcers?
1. Drawsheet or transfer board when moving
2. position patient at 30 -degrees lateral position
3. HOB at 30 -degrees or less
4. Trapeze Bar
182
If a patient is incontinent, what should you clean with to help prevent a pressure ulcer.
Clean with no-rinse perineal cleaner & supply barrier ointment
183
What should a nurse care plan look like?
1. Prevent deterioration
2. Reduce factors that contribute to pressure and skin breakdown
3. Prevent infections
4. Promote healing
5. Prevent recurrence
184
What do you do if your patient has a pressure injury?
1. Document- stage, size, location, exudate, infection, pain and tissue appearance. Take pictures.
2. Wound care specialists- will determine specific cleansing protocol and which types of dressing are appropriate, but general principles:
- Clean with normal saline to avoid damaging cell
- Keep slightly moist to encourage re-epithelialization
3. Surgical treatment may be necessary
-Skin grafts, skin flaps, or musculocutaneous flaps are surgical interventions to aid in healing.
185
What education should we share with the patient and family.
1. Teach prevention techniques to patient and caregivers, including early signs of skin breakdown and tissue injury.
2. Continued nutritional support
3. Pressure ulcer care techniques, wound care at home
4. Turning schedule
186
What are some other types of skin damage? List 3.
1. Moisture- Associated Skin Damage (MASD) or Incontinence associated dermatitis (IAD)
2. Medical Adhesive- related skin injury (MARSI)
3. Skin Tears
187
True or false: Lower Extremity ulcers have different pathophysiology from pressure ulcers
True.
188
What are the typical causes of lower extremity ulcers?
They are related to changes in blood flow to lower extremities due to chronic disease processes.
189
What are the typically causes of Arterial ulcers?
1. Peripheral Artery Disease (PAD) causes problems with blood flow in arteries, becoming narrow or blacked, usually caused by atherosclerosis.
2. Ulcers are caused by ischemia and nutrition deprivation as a result of decreased circulation.
190
What are some characteristics of arterial ulcers
1. Skin will be thin, shiny and dry, with loss of hair on ankles and feet
2. Even wound margins, punched- out appearance, pale, deep wound bed.
3. Extremely painful, with minimal exudate
191
True or false: Those with atherosclerosis, PVD, diabetes, smoking, hypertension, advanced age, obesity, and cardiovascular disease are at decreased risk.
False- They are at an increased risk
192
Where can arterial ulcers be found.
1. May be found between toes or on tips of toes, on phalangeal head, lateral malleolus or areas with rubbing footwear
193
How do you treat arterial ulcers?
Must revascularize with stents to treat ischemia, then topical treatments will help with healing ulcer
194
What is the main cause of venous leg ulcers?
1. Venous insufficiency occurs when blood cannot flow upward from veins in the legs
2. Chronic venous insufficiency occurs when valves are damaged, allowing blood to leak backward, resulting in venous stasis
195
Who is at most risk for developing a venous leg ulcer?
1. Those with obesity,
2. deep vein thrombosis (DVT),
3.pregnancy,
4. incompetent valves,
5. congestive heart failure (CHF),
6.muscle weakness,
7. decreased activity,
8.advanced age
9. family history
196
What are the characteristics of a venous leg ulcer?
1. Found in lower legs, have irregular wound margins and superficial, ruddy granular tissue.
2. Painless to moderately painful
3. surrounding skin may be red, scaly, weepy and thin
197
How can we treat venous leg ulcers?
1. Compression therapy promotes blood return and prevents blood from pooling
198
What is the cause of a diabetic ulcers?
1. Caused by peripheral neuropathy, fissures in skin and decreased ability to fight infection, as well as diabetic foot deformities caused by damage to ligaments and destruction of bone.
199
Where are diabetic ulcers typically located?
Located on plantar aspect of foot, over metatarsal heads, under heels and on toes (bony prominences)
200
What are some characteristics of a diabetic ulcer?
1. Painless, even wound margins, rounded or oblong shape with surrounding callous
201
True or false: A diabetic ulcer can easily turn into cellulitis or osteomyelitis.
True
202
How are diabetic ulcers normally treated?
Treatment includes removing stress/pressure from injured site, debriding wound, antibiotics if infection occurs.
203
What is cellulitis?
2. Deep inflammation of subcutaneous tissue caused by enzymes produced by bacteria
204
True or false: Cellulitis often follows a break in the skin?
True
205
What bacteria is the most common cause of cellulitis?
1. Staph and strep
206
What are the clinical manifestations of cellulitis?
1. Hot, tender, erythematous, edematous area with diffuse borders
2. Chills, malaise and fever
207
How do you treat cellulitis?
1. Moist heat, immobilization, elevation
2. Systemic antibiotic therapy
3. Hospitalization if IV therapy warranted (severe infection)
4. Progression to gangrene if left untreated.
208
What is the most important treatment for infection is _______?
Prevention
209
Skin and soft tissue infection can be treated with? (do not need to memorize just recognize)
1. Cephalosporins
2. Some penicillin (narrow-spectrum PCN)
3. Carbapenems
4. Vancomycin
5. Clindamycin
6. Linezolid
7. Deptomycin
8. Levofloxacin
210
What is psoriasis?
Common, chronic autoimmune inflammatory disorder characterized by plaque formation with varying degrees of severity
211
What does mild psoriasis look like?
1.Red patches covered with silvery scales on scalp, elbows, knees, palms, and soles
212
What does severe psoriasis look like?
May involve entire skin surface and mucous membranes, superficial pustules, high fever, leukocytosis and painful fissuring of the skin.
2. Two Processes:
-Accelerated maturation of epidermal cells
-excessive activity of inflammatory cells
213
What is the treatment goal for psoriasis?
Reduce inflammation, suppress rapid turnover of epidermal cells, no cure
214
What are types of treatments for psoriasis?
1. Topical treatments: Glucocorticoids vitamin D3 analogs, tazarotene, salicylic acid, anthralin, tars
2. Methotrexate, cyclosporine, biologics (adalimumab, etanercept, others)
3. Phototherapy: Coal tar plus UVB irradiation, Photochemotherapy (PUVA therapy) Sunlight
215
What should a patient with psoriasis avoid doing?
1. Scrubbing
2. Long exposure to water
3. Trying to remove scales
