Tissue integrity Flashcards
skin is the _____ organ
largest
skin is a ________ barrier
protective
it is the _________ responsibility to assess and monitor skin integrity
nurses
purpose of skin (5)
-protection
-sensory
-vitamin D synthesis
-fluid balance
-natural flora
when assessing the skin, (6)
-look at bony prominences!
-visual and tactile
-assess and rashes or lesions
-note hair distribution
-skin color
-blanch test
skin assessment to do’s (6)
-identify the patient’s risk
-identify the signs and symptoms of impaired skin integrity or poor wound healing
-examine skin for actual impairment
-focus on : level of sensation, movement and continence
-assess skin on initiation of care, then at least once/shift
-high risk patients : assess every 4 hours or more
high risk patients should be assessed every _____ hours
-examples of high risk pts
4 hours
-diabetes, bedridden,
palpate areas of _______ to determine if skin is blanchable, paying attention to ____________, _____________, and _________________
redness
bony prominences
medical devices
areas with adhesive tape
tool used to assess skin - gives number
braden scale
braden scale score risk - low
15-18
braden scale score risk - Mod
13 or 14
braden scale score risk - high
12 or less
sensory perception - #1
completely limited
-unresponsive
-limited ability to feel pain over most of the body
sensory perception - #2
very limited
-Painful stimuli
-Cannot communicate discomfort -Sensory impairment over half the body
sensory perception - #3
slightly limited
-Verbal commands
-Cannot always communicate discomfort
-Sensory impairment – 1-2 extremities
sensory perception - #4
no impairment
-Verbal commands
-No sensory deficit
moisture - #1
constantly moist
moisture - #2
very moist
-change linen once per shift
moisture - #3
occasionally moist
-change linen twice per shift
moisture - #4
rarely moist
activity - #1
bedfast
-never OOB
activity - #2
chair fast
activity - #3
walks occasionally
activity - #4
walks frequently
mobility - #1
completely immobile
-makes no change in body or extremity position
mobility - #2
very limited
-occasional slight changes in position
-unable to make frequent/significant changes independently
mobility - #3
slightly limited
-frequent slight changes independently
mobility - #4
no limitation
-major and frequent changes without assistance
nutrition - #1
very poor
-never eats complete meal, very little protein
-NPO, clear liquids, IV > 6 days
nutrition - #2
probably inadequate
-rarely eats complete meal, some protein
-occasionally takes a dietary supplement
-receives less than optimum liquid diet or tube feeding
nutrition - #3
adequate
-eats over 1/2 of most meals, adequate protein
-usually takes a supplement
-tube feeding or TPN probably meets nutritional need
nutrition - #4
excellent
-eats most of meal, never refuses, plenty of protein
-occasionally eats between meals
-does not require supplements
friction and sheer - #1
problem
-moderate to maximum assistance in moving
-frequently slides down in bed or chair
-spasticity, contractures, or agitation leads to almost constant friction
friction and sheer - #2
potential problem
-moves freely, requires minimum assistance
-skin probably slides against sheets
-relatively good position in char or bed with occasional sliding
friction and sheer - #3
no apparent problem
-moves in bed and chair independently
-sufficient muscles strength to lift up completely during move
-good position in bed or chair
low risk (15-18) - (4)
-regular turning schedule
-enable as much activity as possible
-protect heels
-manage motions, friction and sheer
moderate risk (13-14) - (5)
-Regular turning schedule
-Enable as much activity as possible
-Protect heels
-Manage moisture, friction and sheer
-Position patient at 30 degree lateral incline using wedges or pillows
high risk (12 or less) - (7)
-Regular turning schedule
-Enable as much activity as possible
-Protect heels
-Manage moisture, friction and sheer
-Position patient at 30 degree lateral incline using wedges or pillows
-Make small shifts in position frequently
-Pressure redistribution surface
tissue integrity interventions
frequent repositioning (3)
-sitting in chair for 2 hour intervals
-HOB at 30 degrees
-written schedule of turning and positioning
wound staging
Stage I
nonblanchable redness
wound staging
Stage II
partial-thickness
wound staging
Stage III
full-thickness
skin loss
wound staging
Stage IV
full thickness
tissue loss
wound staging
unstageable/unclassified
full-thickness skin or tissue loss depth unknown
wound staging
suspected
deep-tissue injury-depth unknown
C.H.A.N.T wound protocol
C-cleanse
H-hydrate (and protect) skin
A-alleviate pressure
N-nourish
T-treat
red/excoriated peri/rectal area
early intervention protocol (3)
-cleanse
-dry thoroughly
-moisture barrier daily and prn
red heels
early intervention protocol (4)
-Position pressure off of heels
-Elevate on pillows
-Sage boot
-Reduce friction
redness/excoriation between skin folds
early intervention protocol (3)
-cleanse
-dry thoroughly
-place inner dry or dry AG textile in skin folds
red sacral/coccyx area
early intervention protocol (5)
-change position q 1-2 hours
-HOB <30 degrees unless contradicted
-avoid excess moisture
-frequent peri care
-wrinkle free linen
nursing priorities for skin (4)
-assess and monitor skin integrity
-identifying risks for skin problems
-identifying present skin problems
-planning, implementing, & evaluating interventions to maintain skin integrity
inflammatory response - sequential response to cell injury (3)
-Neutralizes and dilutes inflammatory agent
-Removes necrotic materials
-Establishes an environment suitable for healing and repair
inflammation =/ infection
inflammation is always present with infection, but infection is not always present with inflammation
inflammatory response occurs with multiple conditions like (4)
-surgical wounds, other skin injuries
-allergies
-autoimmune disease
-skin infections
wound def :
any disruption of the integrity and function of the tissues in the body
wound __________ and ___________ is important to wound healing
assessment
classification
tissue trauma causes an _____________ ___________ in the first _____ hours
inflammatory response
24 hours
intensity of inflammatory response depends on (3)
-extent and severity of injury
-reactive capacity of injured person
-immune system
inflammatory response is _______ regardless of __________ agent
same
injuring
local response to inflammation (6)
ONE AREA
- see and feel
-redness
-heat
-swelling
-pain
-loss of function
systemic response so inflammation (6)
WHOLE BODY
- can see in vital signs, bloodwork
-increased WBC count
-malaise
-nausea and anorexia
-increase pulse and RR
-fever
type of inflammation - acute
-healing 2-3 weeks, no residual damage
-neutrophils predominant cell type at site
type of inflammation - subacute
-same features as acute, but longer length
type of inflammation - chronic (4)
-may last for years
-injurious agent persists or repeats injury to site
-predominant cell type : lymphocytes and macrophages
-may result from changes in immune system
nursing & interprofessional management
health promotion (4)
-prevention of injury
-adequate nutrition
-early recognition of injury inflammation
-immediate treatment
nursing & interprofessional management
observation / recognition
-classic manifestations of inflammation may be masked for immunosuppressed patient, early symptom may be general malaise
nursing & interprofessional management
vital signs
-important to note, especially if infection present. temp, pulse, RR may increase
nursing & interprofessional management
fever management
-antipyretics may/not necessary
-fever great than 104 can be damaging
final phase of inflammatory process is ______
healing
healing of wound - 2 components
- regeneration
- repair
regeneration of wound
replacement of lost cells and tissues with cells of the same type
wound 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
initial phase is __ - __ days
_________ inflammatory response
3-5
acute
granulation phase
fibroblasts secrete ___________
wound __________ and _____________
risk for ____________________
resistant to ______________
collagen
pink & vascular
dehiscence
infection
maturation phase beings __ _______ after injury and continues for ________/____________
7 days
months/years
primary intention
- initial phase
- granulation phase
- maturation phase and scar formation
secondary intention
-wounds have _________ margins with extensive tissue loss
-edges __________ be approximated
-healing process is same as ___________, but inflammatory action may be ___________. wound may be need to be ________________
-irregular
-cannot
-primary / greater / debrided
tertiary intention
-delayed ______________ intention due to delayed ___________ of wound
-occurs when ______________________
-primary / suturing
-a contaminated wound is left open and sutured closed after infection is controlled
partial thickness wounds (regeneration)
-_________ components in healing process
-__________________ response
-epithelial _______________ and ________________
-reestablisment of ______________ layers
-three
-inflammatory
-proliferation and migration
-epidermal
full thickness wounds (repair)
-____ phases in healing process
-____________
-_______________ phase
-______________ phase
-___________
-extend into___________, heal by _______ formation
-four
-hemostasis
-inflammatory
-proliferation
-maturation
-dermis / scar
factors that influence wound healing
-nutrition (protein, vitamins, trace minerals of zinc and copper/adequate calories)
-tissue perfusion (O2 fuels cellular functions)
-infection (prolongs inflammatory stage, delays collagen synthesis, prevents epithelialization, increases cytokine production)
-age
hemorrhage - complication
bleeding
hematoma - complication
bleeding under skin
infection - complication
bacteria, virus
dehiscence - complication
wound opens up
(pt doesn’t use pillow to cough-splinting, staples open)
evisceration - complication
wounds open up and things inside begin coming out
wound classification and identification
-
skin tear
-
-
wound classification and identification
classified by ________ and ________
-_________ or non-___________ ; ___________ or ___________
-_____________, _____________ thickness, or _______ thickness
cause and depth
-surgical or non surgical ; acute or chronic
-superficial, partial thickness or full thickness
wound classification and identification
_________ tear ; wound caused by shear __________ and/or blunt _________
-___________ thickness or ______ thickness
-common in ________ and those ___________/___________ ill
skin / friction / force
-partial or full
-older adults / critically or chronically ill
wound assessment
-asses skin on __________ and every ___________
-include : (4)
-any ___________ - __________, __________ & ________
-determine if there are factors that could ________ healing
-admission/shift
-location, size, condition of surrounding tissue, wound base
-drainage - consistency , color, odor
-delay
management of wounds depends on (3)
type, extent, and character of wound and phase of healing
cleaning wounds
-may need ________ and some type of wound ________ closure, ex. 3 )
-various ___________ available to keep wound ______ and slightly ___________
-_____________ wounds may be covered with _________ dressing, removed in ___-___ days
-____________ is enemy of wound _____________
-cleaning / closure / adhesive strips, sutures, staples
-dressings / clean / moist
-surgical / sterile / 2-3 days
-dryness / healing
common drain for wound
purpose?
Jackson-Pratt drain
remove excess fluid
common drain for wound
purpose?
Jackson-Pratt drain
remove excess fluid
contaminated wounds
-must be converted to clean wound before healing can occur
-debridement (removal of dead tissue and debris) may be necessary
-dressings are available that can absorb exudate and clean the wound
purposes of dressings (6)
-protects from microorganisms
-aids in hemostasis
-promotes healing by absorbing drainage or debriding a wound
-supports wound site
-promotes thermal insulation
-provides a moist environment
types of dressings
-gauze
-transparent film
-hydrocolloid
-hydrogel
-foam
-composite
changing dressings - what to know
-know type of dressing, placement of drains, and equipment needed
preparing pt for dressing change (6)
-review previous _________ assessment
-evaluate ___________, if indicated, administer ________
-_____________ procedure
-gather all _________________
-recognize normal signs of ____________
-answer _____________ about the procedure or wound
-wound
-pain / analgesics
-describe
-supplies
-healing
-questions
dressing change comfort measures (7)
-administer analgesic meds 30-60 mins before
-carefully remove tape
-gently clean wound edges
-carefully manipulate dressings and drains to minimize stress on sensitive tissue
-turn and position patient carefully
-date and time dressings
-document
cleaning skin and drain sites
-basic skin cleaning
-clean from least contaminated to the surrounding skin
-use gentle friction
-when irrigating, allow the solution to flow from the least to most contaminated area
suture removal
-review policy (NII) and orders prior to removing sutures
-how many? document
-clip near skin, opposite of knot
steri strips
-don’t pull or crate tension
-teach to allow them to fall off naturally (about 10 days), may shower
prophylactic doses of antibiotics can _____ the ________ ____ ________ in certain kinds of surgery
decrease
incidence of infection
prophylactic use of antibiotics for these types of surgeries
contaminated surgeries -
-cardiac
-peripheral vascular
-ortho
-GI
-OB/GYN
-contaminated surgeries (fractures, perforated abdominal organs) : antibiotics are treatment, not prophylaxis, as infection rates of these is 100%
prophylactic antibiotics should be given _______ surgery and may be __________ if surgery is unusually long
prior to
re-doses
important things to remember :
-Surgical Site Infection prevention - may be given prophylactic antibiotics
-Patient may be distressed about appearance, fear of scars or permanent disfigurement
-Caregivers’ facial expressions can cause further alarm & mistrust
-Teach patient & family healing process & normal changes to wound as it heals, as well as home care of wound, infection prevention (hand washing), s/s to report, adequate nutrition
initial phase is __ - __ days
_________ inflammatory response
3-5
acute
