Tissue integrity Flashcards
epiderms contain what types of special cells
keratinocytes
melanocytes
merkel cells - light touch
langerhans cells
what’s a part of the dermis
CT (collagen and elastic fibers) with capillaries, blood vessels, lymph vessels
what’s subcutaneous tissue have and do
have blood vessels and nerves -> thermoregulation, sensation
protec, insulate
maceration
irritation of the epidermis caused by moisture
dermatitis
red skin irritation that develops when skin is exposed to feces, urine, stoma effluent, and wound secretions
skin tears caused by what
loss of top layer of the skin from mechanical forces
most common injuries associated with skin frailty
skin tears
pressure injuries
infections (cellulitis)
cellulitis
infection of the superficial layers of the skin
decreased skin properties in the elderly
less elastic
less subq tissue
less blood supply
less hydrated
changes in skin properties in pts with decreased mobility
changes in thermoregulation
loss of collagen
muscle atrophy
impaired sensation
decreased blood flow
incontinence
changes in skin properties in pts that are obese
decreased moisture
maceration
increased temperature
decreased blood and lymph flow
radiation in cancer pts can change skin how
inflammation
decreased blood supply
skin surface damage
erythema
bony prominences; redness of skin from dilation of blood vessels
blanchable or not
blanchable vs. nonblanchable erythema
blanchable: temporarily becomes white when pressure is applied
nonblanchable: structural damage in the small vessels supplying blood to the underlying tissues
lacerations
tears in the skin; typically from blunt or sharp objects and have an irregular or jagged shape
simple or complicated classification
what type of wounds are considered for surgical ones
intentional acute wounds
surgical wounds are classified into what based on cleaniness
clean: closed at completion
clean-contaminated: closed at completion
contaminated: left open with long term wound management
surgical wound healing time and characteristics
red: 1-4 days
bright pink: 5-14 days
pale pink: 15 days - 1 yr
exudate
fluid consisting of plasma that is secreted by the body during the inflammatory phase of healing; resolve by day 5 post surgery
moisture associated skin damage (MASD)
form of dermatitis; from sweat, increased local skin temp, abnormal skin pH, deep skin folds
cause of chronic wounds
develop over time from disruption of acute wound healing;
conditions that cause alterations to blood flow
3 types of chronic lower extremity wounds
venous, arterial, neuropathic disease wounds;
predispose pts to develop pressure injuries
serous exudate
thin, watery’ straw colored
serosanguineous exudate
thin, watery with blood
sanguineous exudate
bloody
purulent exudate
green or yellow
shearing
forces exerted parallel to the surface of the skin and pulled in opposite directions;
sitting or lying on an incline (high fowler)
what risk factors contribute to pressure injury development
immobility
malnutrition
reduced perfusion
altered sensation
decreased LOC
friction
not direct cause to pressure injuries but increases their risk when force created from rubbing
purpose of braden scale
rates pt risk for alterations in tissue integrity
6 categories of braden scale
sensory perception
moisture
activity
mobility
nutrition
friction & tear
interpretation of Braden scale
each category is 0 - 4
adds up
<18 is risk
how should a nurse stage pressure injuries
nonblanchable erythema
depth and amount of skin and tissue loss
condition, presence of dead tissue
tunneling
undermining
undermining
open area extending under skin along the edge of the wound
benchmarking
comparing results and outcomes to toehr sources of similar data; rate pressure injuries stage 1 - 4
stage 1 pressure injury
non-blanchable erythema
stage 2 pressure injury
partial thickness skin loss
pink or red tissue in wound bed
stage 3 pressure injury
full thickness skin loss
visible adipose tissue, granulation tissue: new skin tissue forming
possible death tissue, edge rolled
undermining/tunneling may be present
granulation tissue
new skin tissue that forms on the surface of the wound
stage 4 pressure injury
full thickness skin and tissue loss
fascia, muscles, tendons, ligaments, cartilage, and or bone visible
possible dead tissue, tunneling, edges rolled
slough
yellow, stringy nonviable tissue found in the base of the wound; unstageable pressure injury
eschar
hard nonviable black/brown tissue; removal shows stage 3 or 4 pressure injury
deep tissue pressure injury (DTPI)
localized, non-blanchable, deep red, marron, or purple discoloration;
cause of intense and or persistent pressure and shearing force
mucosal membrane injury caused by what
insertion or placement of a foreign device such as endotracheal tubes, oxygen tubing, feeding tubes, drainage tubes
correct position of bed to minimize risk of pressure injuries
less than 30 degrees to decrease risk of sliding down
wound healing and tissue strengthening nutrients
protein
omega3 & 6 fatty acids
vitamins A and C
minerals (Zn)
why do steroids prevent wound healing
prevent formation of collagen and fibroblasts required for wound healing
compare primary, secondary, and tertiary wound healing
primary: sutured
secondary: left open
tertiary: left open and then sutured
list the 3 stages of wound healing
hemostatic/inflammatory phase
proliferative phase
remodeling phase
most common cause of surgical site infections and prevention
Staph.aureus
chlorhexidine prevent
rinse wound culture with what before collecting sample
Na Cl cleaning before getting sample
dehiscence
complete or partial separation of the suture line and underlying tissues; wound fails to heal properly due to poor surgical technique, infection, or foreign particles in wound
signs of dehiscence
occurs 7-10 days after surgery;
serosanguineous discharge
evisceration
wound and all layers of tissue under the wound separate resulting in protrusion of intraabdominal organs through the suture line;
sterile saline soaked dressing to cover
hemorrhage
bleeding that is internal or external
hematoma
accumulation of blood when clotting mechanisms fail
could lead to wound ischemia; leading to necrosis
higher risk pts for getting hematoma
anticoagulant medications
obese pts
hydrocolloid dressings
used in pressure injuries
keep moisture, absorb exudate, protect,
what is the PUSH tool
pressure ulcer scale for healing
includes: LxW (in cm^2), exudate amount, and tissue type
