skin integrity

Question 1

pressure injury

decubitus, ulcer, bedsore

Answer 1

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

Question 2

pressure intensity

Answer 2

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

Question 3

evaluate hyperemia on skin

Answer 3

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

Question 4

if non - blanching erythema

Answer 4

deep tissue damage

Question 5

pressure duration of ulcers

Answer 5

low pressure over prolonged time is bad

high intensity pressure over short time is bad

Question 6

tissue integrity of ulcer (tissue tolerance)

Answer 6

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

Question 7

risk factors of ulcers

Answer 7

impaired sensory perception

altered LOC

impaired mobility

friction

Question 8

impaired sensory perception

Answer 8

can not feel pain or pressure on their body

Question 9

altered LOC

Answer 9

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

Question 10

impaired mobility

Answer 10

cant independently change positions off of bony prominences

Question 11

friction

Answer 11

when 2 surfaces rub together

affects the epidermis (shallow damage) sheet burn

seen in the restless, spastic conditions

Question 12

shear

Answer 12

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

Question 13

moisture

Answer 13

reduces resistance of skin making it more susceptible to damage

wound drainage, excessive perspiration, fecal or urinary incontinence

Question 14

stage 1 pressure injury

Answer 14

intact skin, non blanchable redness

darker pigmentation - has dark purple hue, no blanching

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

Question 15

stage 2 pressure injury

Answer 15

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

Question 16

stage 3 pressure injury

Answer 16

full thickness skin loss; damage or necrosis of subcutaneous tissue

bone, tendon, or muscle not exposed

may include tunneling and undermining

Question 17

stage 4 pressure injury

Answer 17

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

eschar and tunneling present

Question 18

unable to stage

Answer 18

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

Question 19

deep tissue pressure injury

Answer 19

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

Question 20

wound colors

Answer 20

black, yellow, red, multiple colors

Question 21

epithelialization

Answer 21

partial thickness wound with healing - pink

Question 22

granulation tissue

Answer 22

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

Question 23

exudate

Answer 23

wound drainage

Question 24

slough

Answer 24

stingy yellow substance attached to wound bed

Question 25

eschar

Answer 25

necrotic brown or black tissue

Question 26

types of wound healing

Answer 26

primary and secondary intention

Question 27

primary intention c

Answer 27

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

Question 28

secondary intention

Answer 28

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

Question 29

tertiary intention

Answer 29

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)

Question 30

hemorrhage

Answer 30

large blood vessels are severed or patient has poor clotting; suture slip; clot dislodges can be internal or external

Question 31

hematoma

Answer 31

localized collection of blood underneath the skin surface giving a bluish color small ones are reabsorbed; large ones might need evacuation or surgical removal

Question 32

infection

Answer 32

portal of entry for microogranisms purulent draiage; incisional area; fever; high leukocyte count extended hospital stay

Question 33

dehiscence

Answer 33

total/ partial disruption in edges underlying subcutaneous tissue together obesity; poor nutrition; stress on incision; sutures removed too early do saline dressing

Question 34

evisceration

Answer 34

protrusion of viscera through the abdominal wound abdominal fascia separates and organs protrude emergency= supine bedrest, moist sterile towels

Question 35

factors affecting wound healing

Answer 35

nutrition circulation - O2 perfusion infection age obesity smoking stress/psychosocial

Question 36

wound assessment

Answer 36

wound drainage serous serosanguineous sanguineous purulent

Question 37

wound drainage

Answer 37

note amount, color, consistency, odor

Question 38

serous

Answer 38

pale, yellow, watery

Question 39

seosanguineous

Answer 39

pale, pinkish-red, yelow, watery

Question 40

sanguineous

Answer 40

bood bright red

Question 41

purulent

Answer 41

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

Question 42

nursing diagnosis for skin integrity

Answer 42

imparied skin integrity related to pressure and friction risk for infection acute/chronic pain imbalanced nutrition impaired physical mobility ineffective peripheral tissue perfusion

Question 43

skin Bundle (SKIN)

Answer 43

S urface K eep turning I ncontinence N utrition

Question 44

wound management

Answer 44

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

Question 45

irrigation of a wound

Answer 45

cleansing of wound

Question 46

debridement

Answer 46

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

Question 47

emptying drain

Answer 47

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

Question 48

evaluation of wound

Answer 48

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