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Tissue Integrity > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

1
Q

Stage 1

A

> Intact skin - non-blanch-able redness of a localized area
•common over bony prominence
•may be painful, soft, warmer, or cooler as compared to adjacent tissue
•Darkly pigmented skin may not have visible blanching, but color may differ from the surrounding area

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2
Q

How many times do you do skin assessments?

A

> On admission
Twice a day (once per shift)

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3
Q

What is the most common complication of pressure ulcers?

A

Recurrence of tissue breakdown/repeat pressure ulcers

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4
Q

What are signs of infections?

A

> Swelling
Redness
Foul odor
Leukocytosis
Fever
Necrotic tissue
Increased injury size, odor, or drainage

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5
Q

Cellulitis

A

Leads to sepsis and death

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6
Q

Pressure ulcer prevention

A

•Keep skin dry (for incontinence- clean with no-rinse perineal cleaner and supply barrier ointment)
•Reposition
•Turning schedule
•Nutrition and fluid intake

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7
Q

C.H.A.N.T

A

Clean, Hydrate skin, Alleviate pressure, Nourish, and Treat

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8
Q

Ostomies can get yeast infections

A
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9
Q

MASD

A

Moisture associated skin damage or IAD

> type of other skin damage

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10
Q

What are other skin damage examples?

A

•MASD
•Incontinence associated dermatitis
•Medical adhesive related skin injury
•Skin tears

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11
Q

Pressure Ulcers

A

AKA - Pressure Injury
•Localized injury to skin/underlying tissues
>Usually over bony prominences
>Most comment on sacrum and heels

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12
Q

How do pressure ulcers occur? How do they heal?

A

•Results for prolonged pressure or pressure combination with shearing forces

•By Secondary intention

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13
Q

How do pressure ulcers occur?

A

Can be injury related or other devices

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14
Q

Arterial Ulcers

A

•Thin and shiny
•Loss of hair
•Peripheral Artery Disease (PAD) causes problems with blood flow in arteries, becoming narrow or blocked, caused by artherosclerosis
•Usually found in the ankles or feet
•Pale
•Deep wound bed
•Even wound margins
•Punched out appearance

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15
Q

Who is at risk for arterial ulcers?

A

•Atherosclerosis patients
•PVD
•DM
•Smoking
•HTN
•Advanced age
•Obesity
•Cardiovascular disease

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16
Q

Venous Leg Ulcers

A

•Red and ruddy
•Painless to moderate pain
•Found in lower legs
•Irregular wound margins and superficial
•Surrounding skin may be red, scaly, weepy, and thin
•Compression therapy promotes blood return and prevents blood from pooling

17
Q

Diabetic Ulcers

A

Caused by peripheral neuropathy
•Fissures in skin
•decreased ability to fight infection
•Diabetic foot deformities caused by damage to ligaments and destruction of bone

18
Q

What does a diabetic ulcer look like?

A

•Even wound margins
•Rounded or oblong shape with surrounding callous

19
Q

Diabetic Ulcers can easily turn into cellulitis or osteomyelitis

A
20
Q

How do you treat diabetic ulcers?

A

•Removing stress/pressure from the injured site
•Debriding wound
•Antibiotics if infection occurs

21
Q

Cellulitis

A

•Inflammation of subcutaneous tissue
•Often following break in skin
•Often caused by Staph and Strep
•Deep inflammation of subcutaneous tissue caused by enzymes produced by bacteria

22
Q

Cellulitis Clinical Manifestations

A

•Hot, tender, erythematous, edematous area with diffuse borders
•Chills, malaise, and fever
•

23
Q

How do you treat Cellulitis?

A

•Moist heat
•Immobilization
•Elevation
•Systemic antibiotic therapy
•Hospitalization if IV therapy warranted (severe infections)
•Progression to gangrene if left untreated

24
Q

What is the most important treatment for infections?

A

PREVENTION!!!

25
Q

What antibiotics can you use to treat skin and soft tissue infections?

A

Slide 38 part 2

26
Q

Psoriasis

A

Most common autoimmune inflammatory disorder
•plaque formation with varying degrees of severity
•Severe- may involve entire skin surface and mucous membranes, superficial pustules, high fever, leukocytes, and painful fissuring of the skin

2 processes
•Accelerated maturation of epidermal cells
•Excessive activity of inflammatory cells

27
Q

What does psoriasis look like?

A

Silver scales

28
Q

Localized

A

Tissue Integrity (1 decks)

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