Tissue Integrity Flashcards
What is the largest organ of the body
Skin
What are the two layers of skin
Epidermis and Dermis
What is the Dermis
Thick, dense, fibroblastic, connective tissue
highly vascularized
Supports and nourishes epidermis
What does the dermis contain
Nerves
Sweat Glands
Sebaceous glands
Hair Follicles
What is the subcutaneous tissue
“fat layer”
Is the body’s energy store and also supports blood vessels and nerves
Acts as a cushion to protect from damage and helps protect from the cold.
Channels nutrients and oxygen to the dermis via capillaries
What is the Fascia
White and shiny in appearance
Sheath covering for muscles, nerves and blood vessels.
Acts as a support so that the muscles can act as a single unit
Muscle tissue appearance
Pink To Dark Red
Firm
Highly Vascular
Striated
What are ligaments
A band of strong fibrous tissue that connects two or more bones/cartilage together
What is the cartilage
Shock absorber
Thin layer of tough tissue that covers the end of bones where they meet in the joint, without causing friction or damage
What is the Tendon and its appearance
Attaches muscle to bone
strong fibrous tissue
Gleaming yellow or white, shiny if healthy
Function of bones
Supports and protects internal organs
206 in the body
What is bone marrow
Soft spongy tissue in the center of many bones, makes and stores blood vessels
What are the functions of the skin
To protect
Hold the body shape
Prevents loss of fluid
Produces sebum/melanin, Vitamin D
Sensation
Elimination, perspire
Maintains Temp
Immunological response(emotions)
Expression of emotions/psychosocial * Absorption
What are the risk factors of wounds
Immobility
Inadequate Nutrition (no proteins, fats, carbs)
Fecal and Urinary Incontinence
Decreased mental status
Diminished sensation
Excessive body heat
Chronic Medical Conditions
Describe moisture in wounds
Continued exposure causes tissue softening
Skin is more susceptible to shear, pressure and, especially, friction
What parts of the body would you asses for wounds
Areas at high risk for skin breakdown:
Those include:
Body folds
Temporal region
Ears
Scapulae
Spinous process * Shoulders
Elbows
Saccrum
Coccyx
Ishial Tuberosities
Femoral Trochanters
Knees
Malleoli
Metatarsals
Heels
Toes
Areas covered by restrictive clothing or equipment
What parts of the body are pressure ulcers more frequent
Sacral/coccyx
Greater trochanter
Ischial Tuberosity
Heel
Lateral Malleolus
What are some ulcer comorbidities in the cardiovascular system
CAD,CHF,PVD,PAD
What are some ulcer co morbidities in the respiratory system
Pneumonia, COPD, Asthma
What are some ulcer co morbidities in the G.I.
GI bleeding, Swallowing problems, diarrhea
What are some ulcer co morbidities in the Genitourinary System
Urinary Incontinence, Kidney failure
What are some ulcer co morbidities in the Musculoskeletal System
CVA, Arthritis
What are some ulcer co morbidities in the Endocrine
Diabetes
What are some ulcer co morbidities in the Hematological
Anemia, Fluid and Electrolyte balances
What are some ulcer co morbidities in cancer
Radiation treatment, Antineoplastic medication
Part of a wound: Describe the wound
Considered the open area only
Diameter is edge to edge
There are 3 parts to the wound: depth, edges aka the rim and base( the bottom)
Parts of a wound: Describe the Periwound
Tissue around the outside of the perimeter of the wound
Minimum of 4cm
Parts of a wound: Describe tunneling
A channel or a pathway that extends in any direction from the wound through subcutaneous tissue or muscle resulting in dead space with potential for abscess formation
What is a fistula
An abnormal passage from an internal organ or vessel to the outside of the body
organ to organ, has a tunnel between both of them
Parts of a wound: Describe undermining
“lip around the wound”
Tissue destruction underlying intact skin along the wound margins
is caused by shearing forces against the wound
How do you measure an ulcer length
Measure from wound edge to wound edge
size is documented in cm
consider the wound as a face of a clock 12 o’clock points to the patient’s head, 6 o’clock points to the patient’s feet
therefore length would be 12 to 6
How do you measure an ulcer width
Measure from wound edge to wound edge
size is documented in cm
3 o’clock to 9 o’clock would be the width of the wound
How do you measure ulcer depth
Distance from the visible surface to the deepest part of the wound
cotton tipped applicator to the deepest part of the wound measure from tip of applicator
If there is no depth, put 0.
Tissue types: Describe granulation tissue
Beefy deep pink or red
Has an irregular surface
puffy or bubbly appearance
seen in the wound bed of healing full thickness wounds
Tissue types: Describe clean non granulating
Deep pink or red
Smooth (nongranular)
Striated (when muscle fibers are exposed
Is not healing, granulation tissue has to be present to heal
Tissue types: Describe Hyper-granulation tissue
Granulation tissue forms above the surface of the surrounding epithelium
Delays healing
Tissue types: Describe Necrotic Tissue-slough
Yellow, Green or grey
Nonviable tissue (dead)
Thin
Wet stringy
Tissue types: Describe Necrotic tissue- eschar
Black brown
Dry nonviable tissue (dead)
Thick
Hard
Leathery
Do not want to wet this, acts as protection!
Tissue types: Describe Epithelial tissue
Deep pink to pearly, light purple or lavender in color
In full thickness wounds, new tissue migrates from the wound edges to gradually cover the granulation tissue
Exudate of a wound
serous, sanguineos, serosanguineoud, purulent
- Serous: thin, watery, clear
- Sanguineos: thin, bright red… bleeding, darker red older bleeding
- Serosanguineous: thin, watery, pale red to pink
- Purulent: thick opaque, tan to yellow,green with offensive
Periwound
edema, induration, erythmia, crepitus
- Edema: abnormal accumulation of fluid beneath the skin, is it swollen?
- Induration: process of the skin “becoming hard”
- Erythema: redness may be from infection, irritation from drainage, urine, feces or trauma
- Crepitus: an accumulation of air or gas in the tissue. “Rice Krispies” feeling in the skin
Describe Pressure in its role in ulcers
Compression or squeezing together a soft tissue caused by weight or tension
These forces cause blood vessels to collapse resulting in oxygen deprivation response
Blocked blood flow
Describe sharing in its role in ulcers
internal opposing motion of tissue layer and bone
Caused by gravity & friction forces, elevation of head of bed and from sliding down in chair
Result in pressure ulcers in the buttocks and lower back that are deep and oval in shape
Tunneling and undermining are caused by shearing
Describe friction in its role in ulcers
Force that opposes the movement of one surface to another
Epidermal layer of skin is worn away
Skin will look like an abrasion or superficial laceration
Stage 1 Pressure Ulcer
blister like,Intact skin, usually over bony prominence
Area is painful, firm, soft warmer or cooler as compared to adjacent tissue
Indicates “at risk” person
Stage 2 Pressure Ulcer
Goes from epidermis to the dermis
Partial thickness, loss of dermis presenting as a shallow open also with the red pink wound bed ( looks like a blister was popped)
Shiny or dry shallow ulcer without slough or bruising
Stage 3 Pressure Ulcer
Full thickness loss of skin, adipose tissue present
They can be shallow in the nose, ear, occipital and malleolus
In other areas, can develop extremely deep ulcers
Bone/tendon is not visible or directly palpable
Rounded, crater like shapes, has regular edges
Stage 4 Pressure Ulcer
Destruction of epidermis, dermis, and subcutaneous or deeper
Now shows exposed bone, tendon or muscle
Slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling
Can extend into muscle or supporting structures and bone/tendon is visible and directly palpable
Unstageable ulcer
Full thickness, stable, has eschar( brown covering that serves as natural cover)
tissue loss in which the base of the ulcer is covered by yellow tan gray green or brown slough
True depth and stage cannot be determined unless enough slough is removed to expose the base of the wound
Describe a suspected Deep Tissue Injury
Purple localized area of discolored intact skin or blood-filled blister due to damage from pressure and/or shear.
May evolve and become covered by thin eschar.
Evolution may be rapid exposing additional layers of tissue even with optimal treatment
Reverse staging
Stage 4 cannot become a stage 3,2 or 1
When a stage 4 heals it should be classified as a HEALED stage 4 pressure ulcer not a stage 0
once a stage 4 always a stage 4
Nonselective Debridement
mechanical; painful
removes viable and non-viable tissue
Includes: Scrubbing, Irrigation (4-15 PSI) and then sharp debridement
Selective Debridement
Removes non-viable tissue only
Autolytic
Enzymatic
Bio-surgical
What does normal healing require
Adaquate Protein, fat, carbs and minerals
Topical wound management
Objective is to heal wound in the shortest amount of time possible with minimal discomfort and scaring
Dressing, cleanser
Pack the wound, has to have some moisture to it
Primary dressing type
Therapeutic or protective covering applied directly to the wound or lession
Secondary dressing type
Materials that serve therapeutic or protective functions and are needed to secure a primary dressing
What are the wound cleansers used
Normal saline is the preferred cleansing agent, doesn’t harm tissue and is cost effective
Tap water
Commercial cleaners
What is the purpose of dressings on ulcers
For comfort, prevent or control infection, absorb drainage, maintain moisture, protect from further damage, and to protect the skin surrounding the wound
How would you write a treatment for an ulcer
Using generic names of dressing so that another product in that category can be used
Include:
Wound location
Cleaning solution
Primary dressing applied
Moisture barrier periwound
secondary dressing
Frequency of dressing change and the expected duration of need
What is a Vesicle
Circular free fluid filled
up to 1 cm
What is a Bulla
Circular free fluid filled
Greater then 1 cm
What is a Macule
A change in color of the skin
Circular flat discoloration
Less then 1 cm
“freckle”
What is a Patch
Same as a macule but larger then 1 cm
What is a Papule
Superficial solid
Less than 1 cm
What is a nodule
Circular and elevated and solid
Greater then 1 cm
What is a pustule
Circular collection of leukocytes
Free fluid filled
Varies in size
What is a denuded
Looks like skin is peeling off
Loss of epidermis caused by exposure to urine, feces, body fluids, affected by some type of moisture
What is the Braden Scale
Scale a person on how likely they are to get an ulcer
Degree of perception
Moisture
Activity
Mobility
Nutrition
Friction
Shear
What are interventions to prevent pressure ulcers
Full change of position every two hours for immobile patients
5 pillow rule
Rule of 30
What is the 5 pillow rule
1 under legs to elevate heels
2 between ankles
3 between knees
4 behind the back
5 under the head
What is the rule of 30
Head of the bed elevated no more than 30 degrees
Above 30 friction and shearing occur
What are acute wounds
Those without underlying defect and usually occur secondarily to surgery or trauma
What are the types of acute wounds
Incision ( paper cut)
Contusion (bruise like)
Abrasion
Puncture (stepped on a nail)
Laceration
Penetrating wound (gunshot)
What are examples of acute wounds
Skin tears
Lacerations
Cat and dog bites
Puncture wounds
Gun shot wound
Allergic reaction
human bites
What are the treatment to acute wounds
Control severe bleeding (pressure, eleviation )
Prevent infection
Controll swelling
Check for rapid, thready pulse and clammy skin of bleeding is severe
Explain the healing of acute wounds
Primary intention
Surgical incision or no tissue loss
Wound edges approximated with staples, sutures, adhesive strips
Secondary intention
Wound edges remain open
Will heal from bottom up
Grossly contaminated wounds
Tertiary intention
Closed with sutures after infection is gone (delayed primary
How long do acute wounds heal
Face: 2-5 days
Trunk and arms and legs and scalp: 7 days
Hands,feet and over joints and on the back: 10-14 days
Chronic wound
Keeps growing and doesn’t heal, after dressings and cleaning no change is noticed.
Have to change what your doing
Full thickness wound
When it gets into the subcutaneous, muscle and the bone
Intentional wound
Anything you do to the wound intentional
Anything that is done, not an accident
What is used in healing acute wounds
Adhesive closure strips: reinforce skin closure
Staples: close large incisions in timely manner
Tissue adhesive: Used in clean, dry linear incisions or lacerations
Pale coloring indicates=
Obstruction of arterial supply
Cyanotic coloring
Failure of vascular supply
