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final > skin integrity > Flashcards

skin integrity Flashcards

1
Q

pressure injury

decubitus, ulcer, bedsore

A

area of tissue injury or necrosis due to tissue compression between a bony prominence and an external surface in combination with shear and friction for a prolonged period of time

Dec blood flow leads to dec nutrients and O2 to tissues

staged to classify degree of tissue damage

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2
Q

pressure intensity

A

external pressure exceeds capillary pressure (15 32 mm Hg) causes tissue ischemia

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3
Q

evaluate hyperemia on skin

A

by pressing with finger, if blanches (turns lighter) then erythema returns when you remove finger = ok

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4
Q

if non - blanching erythema

A

deep tissue damage

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5
Q

pressure duration of ulcers

A

low pressure over prolonged time is bad

high intensity pressure over short time is bad

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6
Q

tissue integrity of ulcer (tissue tolerance)

A

how skin can tolerate pressure

factors are shearing, friction, moisture, blood vessels, poor nutrition, aging, hydration, low blood pressure all affect the tolerance of the skin

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7
Q

risk factors of ulcers

A

impaired sensory perception

altered LOC

impaired mobility

friction

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8
Q

impaired sensory perception

A

can not feel pain or pressure on their body

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9
Q

altered LOC

A

they might be able to feel pressure but cant understand how to relieve it or communicate their discomfort

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10
Q

impaired mobility

A

cant independently change positions off of bony prominences

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11
Q

friction

A

when 2 surfaces rub together

affects the epidermis (shallow damage) sheet burn

seen in the restless, spastic conditions

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12
Q

shear

A

when tissue layers move on each other, blood vessels teat and stretch in subcutaneous layer (deep necrosis)

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13
Q

moisture

A

reduces resistance of skin making it more susceptible to damage

wound drainage, excessive perspiration, fecal or urinary incontinence

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14
Q

stage 1 pressure injury

A

intact skin, non blanchable redness

darker pigmentation - has dark purple hue, no blanching

initially warm; then cold; soft and boggy; firm or soft

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15
Q

stage 2 pressure injury

A

partial thickness loss of epidermis, dermis or both

visible pink wound

superficial, blister, or shallow crater

shiny, dry ulcer without slough or bruising (no granulation or eschar present

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16
Q

stage 3 pressure injury

A

full thickness skin loss; damage or necrosis of subcutaneous tissue

bone, tendon, or muscle not exposed

may include tunneling and undermining

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17
Q

stage 4 pressure injury

A

full thickness skin loss with extensive destruction; tissue necrosis; damage to muscle, bone, tendon

eschar and tunneling present

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18
Q

unable to stage

A

full thickness loss; base of ulcer cover in slough, yellow, tan, gray green orby eschar (brown black)

cant see depth so remove dead to see base

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19
Q

deep tissue pressure injury

A

intact or non intact

persistent non-blanchable deep red, maroon, purple discoloration

epidermal separeaationg revealing dark wound bed

results from intense/prolonged pressure/ shear at bone/ muscle interface

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20
Q

wound colors

A

black, yellow, red, multiple colors

21
Q

epithelialization

A

partial thickness wound with healing - pink

22
Q

granulation tissue

A

healing of full thickness; beefy red; fills wound with connective tissue (appears red/bumpy)

23
Q

exudate

A

wound drainage

24
Q

slough

A

stingy yellow substance attached to wound bed

25
Q

eschar

A

necrotic brown or black tissue

26
Q

types of wound healing

A

primary and secondary intention

27
Q

primary intention c

A

clean surgical incision; well-approximated; granulation tissue not visible; infection rate is low

28
Q

secondary intention

A

full thickness tissue loss (laceration, burn, pressure ulcer ) wound is left open until it fills gradually with granulation tissue. Much scarring

29
Q

tertiary intention

A

a delay between injury wound closure

combination of prim and secondary closure

delayed primary closure

wound is not sutured immediately until no sign of infection and then close (heavily contaminated)

30
Q

hemorrhage

A

large blood vessels are severed or patient has poor clotting; suture slip; clot dislodges

can be internal or external

31
Q

hematoma

A

localized collection of blood underneath the skin surface giving a bluish color

small ones are reabsorbed; large ones might need evacuation or surgical removal

32
Q

infection

A

portal of entry for microogranisms

purulent draiage; incisional area; fever; high leukocyte count

extended hospital stay

33
Q

dehiscence

A

total/ partial disruption in edges

underlying subcutaneous tissue together

obesity; poor nutrition; stress on incision; sutures removed too early

do saline dressing

34
Q

evisceration

A

protrusion of viscera through the abdominal wound

abdominal fascia separates and organs protrude

emergency= supine bedrest, moist sterile towels

35
Q

factors affecting wound healing

A

nutrition

circulation - O2 perfusion

infection

age

obesity

smoking

stress/psychosocial

36
Q

wound assessment

A

wound drainage

serous

serosanguineous

sanguineous

purulent

37
Q

wound drainage

A

note amount, color, consistency, odor

38
Q

serous

A

pale, yellow, watery

39
Q

seosanguineous

A

pale, pinkish-red, yelow, watery

40
Q

sanguineous

A

bood bright red

41
Q

purulent

A

white cells and microorganisms thick opaque, yellow, light green, tan

42
Q

nursing diagnosis for skin integrity

A

imparied skin integrity

related to pressure and friction

risk for infection

acute/chronic pain

imbalanced nutrition

impaired physical mobility

ineffective peripheral tissue perfusion

43
Q

skin Bundle (SKIN)

A

S urface

K eep turning

I ncontinence

N utrition

44
Q

wound management

A

does not move through the stages of healing if it is infected; drainage interferes with healing

irrigation of a wound

debridement

45
Q

irrigation of a wound

A

cleansing of wound

46
Q

debridement

A

removal of necrotic tissue mechanical (wet-dry); autolytic (synthetic dressing); chemical (topical enzyme); surgical (scalpel)

47
Q

emptying drain

A

open plug

drain into a container (do not hit inside of container)

press down on container/press bulb while simultaneously wiping off port with alcohol

replace cap

48
Q

evaluation of wound

A

was the etiology of skin impairment addressed? were the pressure, friction, shear and moisture components identified and did the plan of care lower the contribution of each of the components

was the healing supported by providing the wound base with a moist protected environment?

were issues such as nutrition assessed and a plan of care developed that provided the patient with the calories to support healing

final (6 decks)

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