Skin Integrity Flashcards by pamela pence

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)

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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

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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

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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

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what are wounds classified by

cause and depth of tissue affected

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what are the 2 causes of a wound

surgical or nonsurgical, acute or chronic

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what are the depths of tissue affected

superficial, partial thickness, full thickness

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acute=

less than 6 months

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superficial=

epidermis is affected

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partial thickness=

through epidermis to dermis

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full thickness=

anything from sub Q down to muscle, bone

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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

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what are the (primary) healing of a primary intention

initial (inflammatory phase)
granulation phase
maturation phase

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incision with blood clot, edges approximated with suture, fine scar

primary intention

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irregular large wound with blood clot, granulation tissue fills in wound, large scar

secondary intention

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contaminated wound, granulation tissue, delayed closure with suture

tertiary intention

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want this to heal from the inside out so it does not leave a big air pocket

secondary intention

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delayed primary intension so opened back up to heal

tertiary intention

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not going to heal from the inside out because wound not big enough (neatly approximated) surgical incision or paper cut

primary intention

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fibrin clots, erythrocytes, neutrophils, cellular debris come to surface

initial inflammatory response

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wound is pink and vascular, surface epithelium at the wound edges begin to regenerate,

granulation phase

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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

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wounds from trauma, infection, ulceration, can not suture back, more exudate

secondary intention

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why are secondary intention more at risk for infection

because have to leave open

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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