Integumentary and Musculoskeletal Systems 2%

Question 1

Wet to Dry Dressings

Answer 1

• -Wet to dry dressing changes remove healthy granulating tissue required for wound healing
• Mechanical debridement
• Place moist saline gauze onto the wound bed, then allowing it to dry and adhere to the tissue in the wound bed
• Repeated every 4 to 6 hours.

Question 2

Infiltration/Extravasation RX

Answer 2

Phentolamine

• adrenergic blocker that dilates peripheral blood vessels
• prevent necrosis and sloughing
• diluted with normal saline
• injected throughout area of extravasation

Hyaluronidase

• treatment of IV extravasations
• enzyme which temporarily (24-48 hours) breaks down the hyaluronic acid of tissue and promotes more rapid reabsorption of extravasated fluid

Question 3

Dressing Considerations

Answer 3

• Depth of wound
• Amount of exudate
• Degree of contamination

Question 4

Pressure Injury - Stage II

Answer 4

• Definition
  
  • Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough
  • May also present as an intact or open/ruptured serum-filled or sero-sanguineous filled blister
• Description
  
  • Presents as a shiny or dry shallow ulcer without slough or bruising
  • This stage should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation.

Question 5

Pressure Injury - Stage III

Answer 5

• Definition
  
  • Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Some slough may be present.
  • May include undermining and tunneling
• Description
  
  • The depth of a stage III pressure ulcer varies by anatomical location
    
    • Bridge of the nose, ear, occiput, and malleolus do not have “adipose” subcutaneous tissue and stage III ulcers can be shallow
    • In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers
  • Bone/tendon is not visible or directly palpable

Question 6

Pressure Injury - Stage IV

Answer 6

• Definition
  
  • • Full thickness tissue loss with exposed bone, tendon, or muscle . – Slough or eschar may be present.
  • • Often include undermining and tunneling .
• Description
  
  • • The depth of a stage IV pressure ulcer varies by anatomical location .
    
    • The bridge of the nose, ear, occiput, and malleolus do not have “adipose” subcutaneous tissue and stage IV ulcers can be shallow.
  • • Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis or osteitis likely to occur.
  • • Exposed bone/tendon is visible or directly palpable.

Question 7

Systemic Antimicrobials

Answer 7

Preferred when there is a systemic infection.

Do not penetrate necrotic tissue.

Not used for management of chronic wounds

Question 8

Hydrogel Dressing

Answer 8

• Able to absorb large volumes of exudate from wounds.
• Reduces the need for dressing changes.
• Used for wounds with little secretions and infected wounds
• Made with materials that have high water content
• Advantages
  
  • Promotes moist environment
  • Provides autolytic debridement
  • Moderate absorbency
  • Helps reduce pain
  • Some applications provides visual of wound
  • Rehydrates necrotic eschar
• Disadvantages
  
  • Do not use for heavy exudating wounds
  • May cause maceration to surrounding skin
  • May require a secondary dressing

Question 9

IV Placement

Answer 9

• Consider areas that prevent infiltration or extravasation.
• Avoid areas of joint flexion, small/fragile veins, edematous/neurologic areas of impairment

Question 10

Muscle Strength Grades

Answer 10

• Grade 5: Normal power/movement
• Grade 4: full active ROM against gravity and resistance
• Grade 3: full ROM against gravity
• Grade 2: full ROM against some resistance, no gravity
• Grade 1: contraction felt, but no limb movement
• Grade 0: no contractions; paralysis

Question 11

Wound Healing Promotion

Answer 11

Optimized wound healing:

• Hydration
• Glucose control
• Nutritional support

Question 12

Pressure Injury Sites

Answer 12

• Sacral area
• Greater trochanter
• Ischial tuberosity
• Heel
• Lateral malleolus

Question 13

Osteomyelitis Treatment

Answer 13

• Give intravenous antibiotics
• Give intravenous fluids
• Immobilize area if needed
• Give pain medications

Question 14

Braden Scale

Answer 14

Risk for pressure injury

Question 15

Immobility Prevention

Answer 15

• Turn & reposition Q2hr.
• Active & passive ROM Q4 - 8hr.
• HOB > 30while in bed

Question 16

Vitamin Deficiency

Answer 16

• Vitamin D deficiency: common in aging adults and nutritional deficiencies.
  
  • Lead to patient falling and failing to thrive

Question 17

Vascular Access

Answer 17

Central venous access - prevent infiltration or extravasation with the use of vesicants or vasopressors

Question 18

Osteomyelitis S/S

Answer 18

• Pain/tenderness to area
• Redness
• Exudate
• Warmth
• Fever due to infection

Question 19

Infiltration

Answer 19

• Unplanned administration of a medication or nonvesicant solution into the surrounding tissue

Question 20

Extravasation

Answer 20

• Unplanned administration of a medication or vesicant solution into the surrounding tissue
• Vesicant solution: any medication or agent that can cause blistering
  
  • cytotoxic medications such as certain chemotherapy drugs
  • dyopamine
  • phenytoin
  • norepinephrine
  • phenylephrine
• S/S: pain, swelling, redness or blistering at the IV site, lack of blood return, increase in resistance or change in the quality of infusion

Question 21

Pressure Injury Stage I

Answer 21

• Definition
  
  • Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
    
    • Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area
• Description
  
  • Area may be more painful, firm, or soft, or warmer or cooler than adjacent tissue
  • May be difficult to detect in person with dark skin tones

Question 22

Infiltration/Extravasation Grading

Answer 22

Question 23

Infiltration / Extravasation Treatment by Grade

Answer 23

Question 24

Hydrocolloid Dressing

Answer 24

• Occlusive, provide:
  
  • moist healing environment
  • autolytic debridement
  • insulation
• Impermeable to bacteria and other contaminants
• Self-adherent and mold well (adhere to intact skin only)
• Not recommended for wounds with heavy exudate, sinus tracts, or infection
• Made with gel-forming agents
• Advantages
  
  • Promotes a moist environment
  • Provides autolytic debridement
  • Highly absorbent
  • Waterproof
• Disadvantages
  
  • May promote the growth of anaerobic bacteria
  • Not best choice of patients with fragile skin
  • May be difficult to stay in position
  • Sometimes produces odor
• When to use:
  
  • burns
  • noninfected wound with scant to moderate drainage
  • necrotic or granular wound
  • dry wound
  • partial- or full-thickness pressure wounds
  • venous ulcers
  • protection of intact skin or a newly healed wound
• Change Q3-5 days
• Example: allevyn

Question 25

Alginate Dressing

Answer 25

• Used for wounds with high amounts of wound drainage
• Made from seaweed
• Contact dressings
  
  • When alginate comes into contact with exudate, it turns into a gel
• Can absorb up to 20 times its own weight
• Advantages:
  
  • Promotes a moist environment
  • Reduce pain
  • Absorbent
  • Suitable for bleeding wounds
  • Autolytic debridement
• Disadvantages:
  
  • Not for dry wounds
  • Requires secondary dressing
  • Sometimes cause stinging or discomfort
• Example: Aquacel Ag, silver alginate

Question 26

Collagen Dressing

Answer 26

• Stimulate new tissue growth
• Encourage the deposition and organization of newly formed collagen fibers and granulation tissue in the wound bed
• chemically bind to matrix metalloproteinases (MMPs) found in the extracellular fluid of wounds
• Indications
  
  • Partial- and full-thickness wounds
  • Minimal to heavy exudate
  • Skin grafts and skin donation sites
  • Second-degree burns
  • Granulating or necrotic wounds
  • Chronic nonhealing wounds
• Contraindications
  
  • Third-degree burns
  • Patient sensitivity to bovine, porcine, or avian products
  • Wounds covered in dry eschar
• Example: Collagen matrix, fibracol, puracol, collagen gel

Question 27

Dressing Types

Answer 27

Question 28

Pressure Injury - Unstageable

Answer 28

• Definition
  
  • Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
• Description
  
  • Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined but it will be either a Stage III or IV
  • Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

Question 29

Suspected Deep Tissue Injury

Answer 29

• Definition
  
  • Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear
• Description
  
  • The area may be preceded by tissue that is painful, firm, mushy, or boggy, or warmer or cooler than adjacent tissue
  • Deep tissue injury may be difficult to detect in individuals with dark skin tone.
  • Evolution may include a thin blister over dark wound bed. The wound may further evolve and become covered by thin escar
  • Evolution may be rapid, exposing additional layers of tissue even with treatment