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Clinical Instruction (Kass) > Skin Integrity > Flashcards

Skin Integrity Flashcards

1
Q

What are pressure injuries also referred to as?

A

Pressure ulcers
Pressure sores
Bed sores
Decubitus ulcer

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2
Q

What is the definition of a pressure injury?

A

Localized damage to skin or underlying soft tissue usually over a bony prominence typically related to a medical device
The result of intense or prolonged pressure or pressure in combination with shear

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3
Q

How can a pressure injury present?

A

As intact skin
Open ulcer

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4
Q

T/F: pressure injuries do not occur on mucous membranes

A

False. Pressure sores can occur on mucous membranes on the lips, oral mucosa, tongue or inside the nares

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5
Q

What are pressure sores the result of?

A

A combination of pressure, temperature, surface moisture/humidity and airflow

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6
Q

What can affect the tolerance of soft tissue for pressure and shear?

A

Microclimate
Nutrition
Perfusion
Comorbidities
Condition of soft tissue

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7
Q

What is the first stage of pressure injuries?

A

Intact skin with non-blanchable redness
Changes in sensation, temperature or firmness may precede visual changes

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8
Q

What is the second stage of pressure injuries?

A

Partial thickness loss of skin involving epidermis and dermis
Presents as intact or open serum filled blister or crater

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9
Q

Which tissues are especially vulnerable to pressure sores from medical devices?

A

Mucosal medications

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10
Q

T/F: pressure injuries are not usually preventable

A

False. Pressure injuries are frequently avoidable

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10
Q

What is does MDRPI mean?

A

Medical device related pressure injury

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11
Q

What are the risks associated with hospital acquired pressure injuries?

A

Extend length of stay
Decreased health related quality of life
Increased risk of mortality
Increase 30 day readmission rate
Increase cost of patient care

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12
Q

What are medical devices that are frequently responsible for pressure injuries?

A

Nasogastric tubes
Orogastric tubes
Foley catheters
Ostomy tubes
Surgical drainis
Cervical collars
Casts

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13
Q

Where would NIV masks cause pressure sores?

A

Bridge of nose
Bony prominences
Anywhere that mask interface or head gear come in contact with skin

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14
Q

Where would endotracheal tubes cause pressure sores?

A

Lips
Tongue
Corners of mouth
Underneath tape/straps
Under ears
Back of neck

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15
Q

Where do ET tube holders cause pressure sores?

A

Lips
Cheeks
Ears
Back of neck
Skin above lips

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16
Q

Where would bite blocks cause pressure sores?

A

Mouth
Lips
Tongue

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17
Q

Where could tracheostomy tubes cause pressure sores?

A

Skin under the flange

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18
Q

Where could a HHFNC cause pressure sores?

A

Nares
Bony prominences of cheeks
Ears

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19
Q

Where could pulse oximeters cause pressure sores?

A

Under probe site on fingers, toes or ears

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20
Q

Where can a nasal cannula cause pressure sores?

A

Nares
Behind ears
Under chin

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21
Q

Where can facemasks and trach collars cause pressure sores?

A

Under mask straps
Contact points on nose face and neck

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22
Q

Where can CPAP masks cause pressure sores?

A

Circumscribing nose
Bridge of nose
Nares
Chin

23
Q

Who is at the greatest risk for developing pressure sores?

A

Chronically steroid dependent
Patients on vasopressors
Have fragile and edematous skin

24
Q

Why are people who are chronically steroid dependent at greater risk for pressure sores?

A

Steroids slow process of wound healing

25
Q

Why do patients on vasopressors have a greater risk for pressure sores?

A

They will have a lower blood pressure making it easier to cut off blood supply to surrounding tissue

26
Q

What patients are generally chronically steroid dependent?

A

Asthma
Osteoarthritis
Rheumatoid arthritis
Crohn’s disease
IBS

27
Q

Which patients may have fragile or edematous skin?

A

Elderly
Tissue edema
Septic shock

28
Q

What mechanical forces exasperate pressure sore formation?

A

Pressure
Shear
Friction
Moisture

29
Q

What can shearing forces do to the tissue?

A

Stretching, kinking and tearing of vessels in the subcutaneous tissues leading to deeper necrosis

30
Q

How does moisture exacerbate skin breakdown?

A

Moist skin compromises tissue strength and increases risk of breakdown when exposed to pressure and shear

31
Q

What can cause the skin to become moist?

A

Perspiration
Wound drainage

32
Q

How can we reduce skin moisture?

A

Clean skin routinely
Use products that are absorbent and wick moisture away from skin

33
Q

What are protective options to prevent skin breakdown?

A

Gecko gel pad
Sleep comfort nasal pad
Mepilex foam
Ear protector tubing
Skin barrier lotion/topical steroids

34
Q

How long should protective skin barriers be changed?

A

When dirty
Between 3-7 days depending on site conditions

35
Q

T/F: gauze is an acceptable skin protective barrier

A

False. Never use gauze as a skin protective barrier

36
Q

When using a mask for NIV, what can you do to avoid pressure sores?

A

Use skin protective barriers
Rotate mask types

37
Q

How tight should an NIV mask be?

A

Should be able to fit 2 fingers under the strap

38
Q

Why should you avoid lifting 1 side of the mask?

A

Increases risk of injury from shearing forces

39
Q

How do we prevent pressure sores for patients who are intubated?

A

Move position and check lips/mouth every 4 hours

39
Q

Why should you limit the the number of on/off maneuvers performed when patients are wearing masks?

A

Limit risk of injury due to shear and friction

40
Q

What can you do to limit the number of on/off procedures for patients on NIV?

A

Communicate, collaborate and cluster care to minimize on/offs

41
Q

Describe how to remove NIV masks

A

Reverse of application
Remove side clips simultaneously and lift mask from the chin upwards

42
Q

How should the ETT stabilizer strip be positioned?

A

Should not be tough lips

43
Q

How should the commercial tube holder be set up to avoid pressure injuries?

A

Dont let straps compress ears
2 finger tightness
Change straps if wet, soiled and/or bloody

44
Q

How tight should trach tubes be?

A

Fit 1 finger underneath

45
Q

How often should oximetry probes be moved?

A

Every 2 hours

46
Q

Describe the controversy associated with bed angle and pressure sores

A

> 30 degrees reduces chances of VAP
<30 degrees reduces changes of compressive pressure on the sacrum

47
Q

What can result from hospital acquired pressure injuries?

A

Extend length of stay
Increase cost of patient care
Increase risk of mortality
Increase 30 day readmission rate
Decrease heath related quality of life

48
Q

Pressure injuries result from a combination of excess

A

Pressure
Temperature
Surface Moisture

49
Q

T/F: Patients should have a zero leak from their NIV mask

A

False

50
Q

What can happen during shearing to blood vessels?

A

Stretching
Kinked
Torn

51
Q

During a hand-off, what information about skin breakdown should be communicated?

A

patients skin integrity
strategies for prevention
patient risk factors

52
Q

What do secretions or wound drainage on the skin around the tracheostomy site lead to

A

a decrease in skin integrity

53
Q

How can a pressure injury present?

A

As intact skin
As an open ulcer
On the mucus membranes

54
Q

T/F: the ETT stabilizer should not touch the patients lips

A

true

55
Q

What are options for skin protective barriers?

A

Ear protector tubing
gecko gel pads
sleep comfort nasal pads

Clinical Instruction (Kass) (13 decks)

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