Tissue Integrity Flashcards
what is the larget organ in the body?
skin
- supports critical life function
the outer layer of the skin with 5 interrelated layers is the ____
epidermis
the layer of skin that contains three types of connective tissue is the _____
dermis
what is the three types of connective tissue of the dermis
collagen, elastic fibers, reticular fibers
the layer of skin with loose connective tissue and fat cells is the ______
subcutaneous tissue
which layer of the skin attaches the skin to muscle and bones?
subcutaneous tissue
the major cells of the epidermis are
keratinocytes
melanocytes
the major cells of the dermis are
fibroblast
list the different skin appendages
hair, nails, glands (sebaceous, sweat)
what are the functions of the integumentary system?
protect the underlying body tissues by serving as a barrier to the external environment
fat in the subcutaneous layer insulates the body and provides protection from trauma. Melanin screens and absorbs UV radiation.
nerve endings and special receptors collects sensory information from environmental stimuli.
controls heat regulation by responding to changes in internal and external temperature with vasoconstriction or vasodilation
True or false:
Infant skin is 40-50% thinner than adults
True
what are common skin alterations in infants
-Mongolian spots
-Nevi
-erythema toxicum
define milia
sebaceous glands on face
what is erythematous
red color at birth – then fades
* skin color is early detector of potential problems
define acrocyanosis
blotchy or mottled colored extremities
how does an increase of estrogen affect the skin?
increase estrogen can lead to an increase of blood flow to the skin
in pregnancy, an increase in melanotropin can cause _________
hyperpigmentation
*can cause melasma and linea nigra
an increase of blood flow to the skin can cause __________
angiomata (vascular spiders) and palmar erythema
mechanical stretching of the skin in pregnancy is also called
striae gravidarum (stretch marks)
What happens to hair and nails during pregnancy?
- accelerated growth
- hirsutism
what are some skin changes that can happen with aging?
- decreased subcutaneous fat, muscle laxity, degeneration of elastic fibers, collagen stiffening (wrinkling, sagging breast and abdomen, redundant flesh around eyes, tenting)
- Decreased extracellular water, surface lipids, and sebaceous gland activity (Decreased extracellular water, surface lipids, and sebaceous gland activity
*Decreased extracellular water, surface lipids, and sebaceous gland activity (Dry skin with minimal to no perspiration, skin color uneven)
*Dry skin with minimal to no perspiration, skin color uneven (Bruising)
*Decreased proliferative capacity (delayed wound healing)
when performing a health history assessment for skin what kind of questions will you ask?
- past medical history
- medications
*surgeries
*self-care habits
*nutrition
*elimination
*activity-exercise - sleep-rest
*cognitive-sensory
while performing a physical exam of the skin it is important for the nurse to ______ and ______
inspect and palpate
list diagnostics that can be done for the skin
- biopsy
- culture
- patch test
- woods lamp
A wound that has not healed within 3 months is considered to be _______
chronic
how do you perform a trauma/injury wound assessment (what kind of things do you want to pay attention to?)
■ Location
■ Size
■ Depth
■ Tunneling
■ Wound margin
■ Wound base
■ Exudate (drainage)
■ Peri-wound area
■ Dressings
loss of perfusion wounds
- a prolonged period of poor perfusion
-ex: chronic ulcers (diabetic or venous), loss of digits
*short period of no perfusion
- pressure ulcers
describe proper wound cleaning
- Clean Wounds
○ Cleansing
○ Dressing change
§ Leave superficial wound closures in place
□ Steri-strips, sutures, Dermabond
§ Schedule varies on wound and dressing type
□ Post-op dressings stay for 48 hours.
○ Maintain moist environment for healing
○ Topical antimicrobials and antibacterials
○ Drains
describe the different type of wound debridements
*Surgical:
* Quick method of debridement to prevent, control, or remove infection
* Used when large amounts of nonviable tissue are present
* Prepares wound bed for healing, skin grafting, or flaps
*Mechanical
* Methods:
* Wet-to-dry dressings, in which open-mesh gauze is moistened with normal saline, lightly packed into wound surface, and outer layer allowed to dry. Wound debris adheres to dressing and then dressing is removed
* Wound irrigation. Make certain bacteria are not accidentally driven into wound with high irrigation pressure
* Noncontact low-frequency ultrasound and ultrasonic mist
*autolytic
* Moisture-retentive semiocclusive or occlusive dressings (e.g., hydrocolloids, transparent films, hydrogels) (Table 11.9) that soften dry eschar by autolysis
* Must assess area around wound for maceration
*enzymatic
* Drug applied topically to dissolve necrotic tissue and then covered with moist dressing (e.g., saline-moistened gauze)
* Process can be slow, and thick eschar may have to be scored with scalpel
*conservative
* Use of scalpels, curettes, scissors to remove nonviable tissue
* Ensure adequate vascular blood supply
*biological
* application of sterile fly larvae to dead tissue
patient teaching on wound care
○ Promote wound healing—adequate nutrition and rest
○ Monitor for symptoms of infection
Redness, swelling, purulent drainage, fever
patient teaching on drain care
○ How to empty
○ What record (color, clarity, output)
○ Cleansing
list other collaborative interventions for wound care
- Negative-Pressure Wound Therapy
- Hyperbaric Oxygen Therapy
- Drug Therapy
- Nutritional Therapy
- Infection Prevention and Control
describe the difference between negative pressure wound therapy (wound vac) and hyperbaric oxygen therapy
Negative-Pressure Wound Therapy (wound vac)
* Treats acute and chronic wounds
* Continuous or intermittent negative pressure in wound bed
○ Removes excess fluid and exudate
○ Reduces bacterial load
○ Encourages blood flow
* Ongoing monitoring
○ Drainage (color, clarity, output)
○ Healing process
○ Serum protein and electrolyte levels
○ Coagulation studies
Hyperbaric Oxygen Therapy
* Delivers 100% oxygen at 1.5-3 times the normal atmospheric pressures
○ Oxygen diffuses into serum tissues (instead of RBCs)
○ Stimulates angiogenesis (production of blood vessels)
○ Kills anerobic bacteria
○ Accelerates granulation of tissue and wound healing
* Topical or systemic delivery
○ Topical: delivered to affected area
Systemic: delivered to entire body
how does becaplermin work?
○ Becaplermin: platelet-derived growth factor gel
§ Stimulates cell proliferation and migration (wound healing)
Used for diabetic foot ulcer
how can nutrition help in wound healing?
- Nutritional therapy
○ Promote fluid intake to replace losses
○ High protein and carbohydrate diet; moderate fats
○ Vitamin A, C & B-complex vitamins
what are pressure injuries?
- localized injury to skin and/or underlying tissue over bony prominence
what causes pressure injuries
pressure or pressure + shear
the most common area of pressure injuries is the ________
sacrum
pressure injury risk factors
- Immobility
- Inadequate nutrition
a. Weight loss
b. Loss of subcutaneous tissue and muscle atrophy - Fecal and urinary incontinence
- Decreased mental status
- Diminished sensation
- Excessive body heat
a. Decreases metabolism
b. Increase tissue need of O2 - Advanced age
a. Subcutaneous tissue decreases
b. Skin gets thinner - Chronic medical conditions
a. Long term diabetes
b. Cardiovascular disease- Other factors: Poor lifting and transferring techniques, incorrect application of pressure-relieving devices
- Inadequate nutrition
stage 1 pressure injury can be described as
a. Partial-thickness skin loss involving dermis
b. Non-blanchable erythema of intact skin
c. Full-thickness skin loss with extensive tissue damage and necrosis. Muscle tendon, & bone exposed and directly palpable (slough or eschar may be present)
d. Skin with purple discoloration or blood-filled blister
b
stage 2 pressure injury can be described as
a. Partial-thickness skin loss involving dermis
b. Full-thickness skin loss involving damage or necrosis of subcutaneous tissue. Bone, tendon, and muscle not exposed
c. Full-thickness skin loss with extensive tissue damage and necrosis. Muscle tendon, & bone exposed and directly palpable (slough or eschar may be present)
d. Eschar present; Unable to assess depth, undermining
a
stage 3 pressure injury can be described as
A. Skin with purple discoloration or blood-filled blister
B. Partial-thickness skin loss involving dermis
C. Non-blanchable erythema of intact skin
D. Full-thickness skin loss involving damage or necrosis of subcutaneous tissue. Bone, tendon, and muscle not exposed
D
Stage 4 pressure injury can be described as
A. Unstageable: Eschar present; Unable to assess depth, undermining
B. Suspected Deep Tissue Injury: Skin with purple discoloration or blood-filled blister
C. Full-thickness skin loss with extensive tissue damage and necrosis. Muscle tendon, & bone exposed and directly palpable (slough or eschar may be present)
D. Non-blanchable erythema of intact skin
C
A pressure injury in which eschar is present, has undermining, and is unable to assess depth is _____
A. stage 3
B. stage 4
c. suspected deep tissue
d. unstageable
unstageable
skin with purple discoloration or blood-filled blister is at which stage of a pressure injury?
A. suspected deep tissue
B. unstageable
C. stage 4
d. stage 1
A
what are possible complications of pressure injuries?
- recurrence - most common
- infection
- cellulitis
- osteomyelitis
- sepsis - death
what are some signs of infection of a pressure injury
*fever
* increase in ulcer size, odor or drainage
* necrotic tissue
* tissue is warm, painful and indurated (raised)
nursing assessment of pressure injuries
- pressure injury risk assessment (Braden scale)
- skin assessment
- document any wound or injury present on admission or transfer
what are the six categories on the Braden scale and their scales
Mild risk: 15-18
Moderate risk: 13-14
High risk: 10-12
Severe risk: less than 9
how can nurses help prevent pressure injuries
- Early identification of high-risk patients
- Mobilize
○ Reposition based on risk and mobility - Skincare
○ Remove excessive moisture
○ Avoid massage over bony prominences (you’re adding more pressure)
○ Use lift sheets and devices
○ Position with pillows or elbow and heel protectors
○ Use specialty beds
○ Cleanse skin if incontinence occurs
□ Use absorbent pads or briefs
nursing interventions: what are some pressure injury treatments?
- Document and describe stage, size, location, exudate, infection, pain, and tissue appearance
○ Measure length and width (cm, at the largest ends)
○ Measure depth - Use pressure injury healing tool to document healing
- Relieve pressure
- Debride
- Cleanse with nontoxic solutions
- Keep wound bed moist
- Cleanse and cover with an appropriate dressing
- Monitor for symptoms of infection
- Promote adequate nutrition
- 2 and above is a contaminated wound
what is the difference between skin grafts, skin flaps, and musculocutaneous flaps?
- Skin grafts: section of transplanted skin
○ Does not include blood vessels (must grown own) - Skin flaps: tissue transplant WITH blood vessels
- Musculocutaneous flap: includes muscles, skin, blood vessels
what are some patients and family teaching on pressure injuries
- Risk factors of pressure ulcers
- Techniques for incontinence
- Correct positioning to decrease risk of breakdown
- Resources for care at home
- Dressing change technique
- Daily skin inspection
- Good nutrition to enhance healing
- High protein diet
