Tissue Integrity Flashcards
Stage 1
> 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
How many times do you do skin assessments?
> On admission
Twice a day (once per shift)
What is the most common complication of pressure ulcers?
Recurrence of tissue breakdown/repeat pressure ulcers
What are signs of infections?
> Swelling
Redness
Foul odor
Leukocytosis
Fever
Necrotic tissue
Increased injury size, odor, or drainage
Cellulitis
Leads to sepsis and death
Pressure ulcer prevention
•Keep skin dry (for incontinence- clean with no-rinse perineal cleaner and supply barrier ointment)
•Reposition
•Turning schedule
•Nutrition and fluid intake
C.H.A.N.T
Clean, Hydrate skin, Alleviate pressure, Nourish, and Treat
Ostomies can get yeast infections
MASD
Moisture associated skin damage or IAD
> type of other skin damage
What are other skin damage examples?
•MASD
•Incontinence associated dermatitis
•Medical adhesive related skin injury
•Skin tears
Pressure Ulcers
AKA - Pressure Injury
•Localized injury to skin/underlying tissues
>Usually over bony prominences
>Most comment on sacrum and heels
How do pressure ulcers occur? How do they heal?
•Results for prolonged pressure or pressure combination with shearing forces
•By Secondary intention
How do pressure ulcers occur?
Can be injury related or other devices
Arterial Ulcers
•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
Who is at risk for arterial ulcers?
•Atherosclerosis patients
•PVD
•DM
•Smoking
•HTN
•Advanced age
•Obesity
•Cardiovascular disease
Venous Leg Ulcers
•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
Diabetic Ulcers
Caused by peripheral neuropathy
•Fissures in skin
•decreased ability to fight infection
•Diabetic foot deformities caused by damage to ligaments and destruction of bone
What does a diabetic ulcer look like?
•Even wound margins
•Rounded or oblong shape with surrounding callous
Diabetic Ulcers can easily turn into cellulitis or osteomyelitis
How do you treat diabetic ulcers?
•Removing stress/pressure from the injured site
•Debriding wound
•Antibiotics if infection occurs
Cellulitis
•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
Cellulitis Clinical Manifestations
•Hot, tender, erythematous, edematous area with diffuse borders
•Chills, malaise, and fever
•
How do you treat Cellulitis?
•Moist heat
•Immobilization
•Elevation
•Systemic antibiotic therapy
•Hospitalization if IV therapy warranted (severe infections)
•Progression to gangrene if left untreated
What is the most important treatment for infections?
PREVENTION!!!
