tissue integrity 1 Flashcards
activated form of vitamin D
calcitriol
what is the purpose of the skin?
protection, sensory, vitamin D synthesis, fluid balance, and natural flora
what two sweat glands are found in the dermis layer of the skin?
eccrine sweat gland and apocrine sweat gland
layers of the skin from outer to inner
epidermis, dermis, and subcutaneous tissue
assessment of the skin:
inspect entire body, especially bony prominences, visual and tactile, assess any rashes or lesions, note hair distribution, skin color, and blanch test
skin assessment focus on
level of sensation, movement, and continence
skin dragging against surface is ____, can cause skin tears and blisters
friction
sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary is ___
shear
shear causes stretching and tearing of blood vessels which ____ blood flow, ____ blood pooling and lead to cell damage
reduce, increase
braden scale: low risk points are ____
15-18
braden scale moderate risk is how many points ____
13-14
high risk on braden scale points are ____
12 or less
tissue integrity interventions:
frequent repositioning, sitting in chair for only 2-hour intervals, anything longer may increase pressure to sacral tissue, keeping HOB at 30 degrees (NO HIGHER, unless respiratory issues), keep a written schedule of turning and positioning
stage I of wound staging:
intact skin with a localized are of nonblanchable redness
stage II wound staging
partial-thickness, skin loss with exposed epidermis, presents as an intact or ruptured serum-filmed blister
stage III wound staging:
full-thickness, skin loss, adipose tissue is visible, possible slough or eschar. may have undermining tunnel
stage IV wound staging:
full-thickness, tissue loss with exposed tendon, muscle, fascia, ligament, cartilage or bone in the ulcer
unstageable/unclassified wound staging:
full-thickness, skin or tissue loss, depth unknown because it is obscured by eschar or slough
suspected deep-tissue injury wound staging:
depth unknown
early intervention protocol- CHANT
cleanse, hydrate (& protect) skin, alleviate pressure, nourish, treat
intervention for redness/excoriation between skin folds
cleanse, dry thoroughly, place inter dry or dry AG textile in skin folds
intervention for red heels
position pressure off of heels, elevate on pillows, sage boot, and reduce friction
intervention protocol for red sacral/coccyx area
change position every 1-2 hours, HOB 30 degrees, avoid excess moisture, frequent peri care, and wrinkle free linen
inflammation and infection:
inflammation is always present with infection, but infection is not always present with inflammation
any disruption of the integrity and function of tissues in the body is called a _____
wound
______ causes an inflammatory response in the first ___ hours
tissue trauma, 24 hours
neutrophils are ___
new white blood cells
neutrophils and macrophages remove pathogens by ____
phagocytosis
vascular response is ___
increased capillary permeability, fluid moves into tissue spaces
result of vascular response:
redness, heat, and swelling at site of injury and surrounding area
_____ is activated to fibrin, which strengthens the blood clot, prevents spread of bacteria
fibrinogen
cellular response is ____
neutrophils and monocytes move through capillary wall and accumulate at site of injury
local response to inflammation
redness, heat, pain, swelling, loss of function
serous is
clear, watery plasma
purulent
is thick, yellow, green, tan, or brown- concerning**
serosanguineous
pale, red, watery: mixture of serous and sanguineous
sanguineous
bright red; indicates active bleeding
clinical manifestations for systemic response to inflammation:
increased WBC count, malaise (lethargic), N/V, increased pulse and respiratory rate, fever
types of inflammation: acute
healing in 2-3 weeks, no residual damage; neutrophils predominant cell type at site
types of inflammation: subacute
same features, but lasts longer
types of inflammation: chronic
may last for years, injurious agent persists or repeats injury to site, predominant cell types are lymphocytes and macrophages, may result from changes in immune system
wound healing: regeneration
replacement of lost cells and tissues with cells of the same type
wound healing: repair
healing as a result of lost cells being replaced by connective tissue, results in scar formation - more common, more complex, occurs by primary, secondary, or tertiary intention
healing by primary intention: 3 phases
initial phase (3-5 days), granulation phase, maturation phase and scar is formed (7 days after)
healing by secondary intention:
wounds from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss; edges can be approximated, same healing process but may need debriding
healing by tertiary intention:
delayed primary intention due to delayed suturing of wound, occurs when a contaminated wound is left open and sutured closed after infection is controlled.
factors that would influence wound healing:
protein, vitamins (esp. A & C), trace minerals of zinc & copper, adequate calories, tissue perfusion
hemorrhage
bleeding
hematoma
bleeding under skin
dehiscence
separation or splitting open of layers of a surgical wound
evisceration
extrusion of viscera or intestine through surgical wound
skin tear is usually common in what type of patients?
older adults and those critically/chronically ill
what is the most common drain to help remove excess fluid?
jackson-pratt drain
purposes of dressings:
protect from microorganisms, aids in hemostasis, promotes healing by absorbing drainage, supports wound site, promotes thermal insulation, provides a moist environment
types of dressings:
gauze, transparent film, hydrocolloid, hydrogel, foam, composite
_____ antibiotics can decrease the incidence of infection in certain kinds of surgery
prophylactic
most effective against cells undergoing active growth and division, one of the most widely used antibacterial drugs
cephalosporins
this person said “if patient has a bedsore, it is not the patients fault it is the nurse’s fault”
Florence Nightingale
when do you asses skin of a patient?
initiation of care (beginning of shift), then at least once a shift
what light is the best to assess patient skin
natural light not flourescent
wound approximation:
two edges come together
eschar is
dead tissue
factors that influence wound healing
nutrition, tissue perfusion, infection and age
nutrition for wound healing
protein, vitamins (especially A & C), trace minerals of zinc and cooper, and adequate calories
tissue perfusion:
oxygen fuels cellular functions
how do you clean a wound?
from least contaminated to the surrounding skin
