Skin Integrity Flashcards
what is primary prevention focusing on in tissue integrity
patient education and prevention… (who can we educate them on how not to get a wound)
what is secondary prevention on tissue integrity
after the wound happens (not good education) what can we do while they have a wound and to get it healed
what is tertiary prevention on tissue integrity
who do we prevent them from coming back to us, more education, teach how to take care of wound and how to clean it at home
what are clinical manifestation of compromised tissue integrity
itching, burning, pain, excessively dry skin, peeling skin, draining wound-something in wound, pressure ulcers, tear in skin, depression, changes in skin color, fluid and lights imbalance
what are wounds classified by
cause and depth of tissue affected
what are the 2 causes of a wound
surgical or nonsurgical, acute or chronic
what are the depths of tissue affected
superficial, partial thickness, full thickness
acute=
less than 6 months
superficial=
epidermis is affected
partial thickness=
through epidermis to dermis
full thickness=
anything from sub Q down to muscle, bone
what are age related changes of tissue integrity
skin becomes fragile delayed wound healing dec in Vit D production susceptible to dry skin dec in sensory percep risk hypo/hyperthermia dec in elasticity dec in perspiration
what are the (primary) healing of a primary intention
initial (inflammatory phase)
granulation phase
maturation phase
incision with blood clot, edges approximated with suture, fine scar
primary intention
irregular large wound with blood clot, granulation tissue fills in wound, large scar
secondary intention
contaminated wound, granulation tissue, delayed closure with suture
tertiary intention
want this to heal from the inside out so it does not leave a big air pocket
secondary intention
delayed primary intension so opened back up to heal
tertiary intention
not going to heal from the inside out because wound not big enough (neatly approximated) surgical incision or paper cut
primary intention
fibrin clots, erythrocytes, neutrophils, cellular debris come to surface
initial inflammatory response
wound is pink and vascular, surface epithelium at the wound edges begin to regenerate,
granulation phase
may start 7 days after injury occurs and can continue for several months or years, collagen fibers are organized and remodeling occurs (scaring)
maturation phase
wounds from trauma, infection, ulceration, can not suture back, more exudate
secondary intention
why are secondary intention more at risk for infection
because have to leave open
how is secondary intention classified as
color (red, yellow, black)
superficial or deep wound that is clean and pink in appearance (serosanguinous drainage)
red wound (stage 2 pressure ulcer, skin tear, second degree burn)
presence of slough or soft necrotic tissue (liquid semi solid ivory to yellow green may be present) slough should be removed and drainage absorbed
yellow wound
why should any form of slough be removed
it is non viable tissue and oxygen can not reach wound bed to help regeneration
necrotic tissue, risk for infection
black wound (full thickness, stage 3&4 pressure ulcer)
what are the signs of shock
rapid pulse, cool clammy skin, pale skin, rapid breathing, pupils dilated, N/V, weakness, fainting
how should you measure a wound
head to toe
side to side
depth
what therapy helps heal from the inside out
negative pressure wound therappy
what does negative pressure wound therapy do
suction removes drainage and speeds up healing process
why would you monitor lytes when pt is on negative pressure wound therapy
pulls off so much fluid and can cause lyte imbalance
allows 02 to diffuse into serum, instead of RBCs delivering the 02
hyperbaric oxygen therapy
what is the foundation for good wound healing
high fluid intake, get high in protein, carbohydrates, vit B and C along with MODERATE fat intake
what lab values do you want high in wound healing
albumin
what are risk factors for pressure ulcers
prolonged pressure, poor hygiene, poor nutrition, incontinence, breaks in the skin
pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement
shearing force
two surfaces rubbing against each other
friction
what are the contribution factors of pressure ulcers
shearing force, friction and moisture
non blanchable reddened area (SKIN IS INTACT)
stage 1 PU
partial thickness loss of dermis, shallow open ulcer with pink wound bed, WILL HAVE LOSS OF SKIN (intact or ruptured serum filled blister)
stage 2 PU
full thickness skin loss or necrosis of sub Q tissueDOES NOT INVOLVE bone, facia, or tendons, will have slough, exudate
stage 3 PU
Full thickness loss can extend to MUSCLE, BONE, or TENDONS, tunneling
stage 4 PU
purple or maroon localized area of discolored intact skin or blood filled blister (looks like bruise)
Deep tissue injury
what is an unstageable ulcer and what should not be removed
full thickness tissue loss with a base covered in slough and or eschar. DO NOT want to remove STABLE ESCHAR because it is protecting it
what are the signs of infection
leukocytosis, fever, increased ulcer size, odor, or drainage, necrotic tissue, pain
what are complications of PU
recurrence (most common)
cellulitis
chronic infection
osteomyelitis
a braden scale of 23 is _______ and a scale of 6 is _______
none; severe
what are good ways for ulcer prevention
teaching, mobilization, skin care, nutrition
inflammation of sub Q tissues and often follows a break in the skin
cellulitis
cellulitis starts ______ is hot, red, painful and can ______ if not treated
locally; spread
what type of pt can not heal cellulitis quickly
diabetic and hypertensive pt
what are the clinical signs of cellulitis
hot, tender, erythematous, edematous, diffuse borders, skin looks SHINY, skin can have red spots, blisters and skin dimpling
flaking, weeping, tears from swelling, fever, pain, altered gait, malaise, and chills are all manifestations of
cellulitis
when a pt has chills, malaise, and fever what are we worried about
sepsis
who should you treat cellulitis
MOIST heat
elevation and immobilization
systemic antibiotic therapy if long term
silvery scaling plaques on reddish colored skin, is BENIGN and NOT contagious
psoriasis
seen on elbows knees, palms, soles and fingernails (is an autoimmune disorder)
psoriasis
what happens when a person scratches their psoriasis spots?
could cause a secondary infection due to a break in skin
clinical manifestations of psoriasis
itching
burning
pain
what type of psoriasis mimics RA
psoriatic arthritis
goal for psoriasis is to reduce _____ and suppress rapid turnover of ______ cells. there is ____ a _____, but _____ is possible
inflammation; epidermal; no cure; control
