tissue integrity 2 Flashcards
pressure ulcers are usually over ____ and most common on ___ & ____
bony prominences, sacrum & heels
pressure ulcers will generally heal by ____ intention
secondary
influencing factors of pressure ulcers:
pressure intensity, pressure duration, tissue tolerance, shearing forces, and excessive moisture that leads to breakdown
risk factors of pressure ulcers:
advanced age, anemia, diabetes, elevated body temperature, friction, immobility, impaired circulation, incontinence, low diastolic BP (<60 mmHg), mental deterioration, neurologic disorders, obesity, pain, prolonged surgery, shear, vascular disease
skin assessment for patients with dark skin
skin may appear purple, brown, or blue; skin temperature, skin/tissue consistence, and patient sensation (report pain or itchy sensation)
stage 1 for pressure ulcers
intact skin, non-blanchable redness of a localized area, common over bony prominences
_____ is the pressure of body pressing the skin down onto a firm surface
interface pressure
staging is based on the ______ guidelines
national pressure injury advisory panel (NPIAP)
slough
thick, yellow/white/gray, covering
eschar
black, dead tissue/skin
stage II pressure ulcer
partial-thickness loss of dermis, shallow open ulcer with pink/red wound bed, could be also a ruptured serum-filled blister
in what stage is adipose fat, deeper tissues, granulation tissue, slough, and eschar are not present
stage II
full-thickness skin loss, subcutaneous tissue may be visible but bone, tendon, or muscle are not
stage III
full-thickness, extends to muscle, bone, or supporting structures, bone, tendon, or muscle my be visible or palpable
stage IV
full-thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed
unstageable ulcer
purple or maroon localized area of discolored intact skin or blood-filled blister. indicates damage of underlying soft tissue from pressure and/or shear
suspected deep tissue injury
complications of pressure ulcers
infection: leukocytes, fever, increased ulcer size, odor, or drainage, necrotic tissue, indurated, warm, painful. Untreated ulcers may lead to cellulitis
pressure ulcer prevention
pressure-redistribution, keep skin dry, reposition, turning schedule, nutrition and fluid intake
your patient has a pressure injury, what now?
document stage, location, size, exudate, infection, pain, and tissue appearance, pictures if required, wound care specialists will determine cleansing protocol/dressings, surgical treatment if necessary
peripheral arterial disease:
loss of hair, brittle nails, dry, shiny, scaly skin, ulcerations, brutis
arterial ulcers
may be found between toes or on tips of toes, on phalangeal head, lateral malleolus, or areas with rubbing footwear
venous leg ulcers
venous insufficiency occurs when blood cannot flow upward from veins in the legs
who is at increased risk for venous leg ulcers?
those with obesity, deep vein thrombosis (DVT), pregnancy, incompetent valves, congestive heart failure, muscle weakness, decreased activity, advanced age, and family history are at increased risk
venous leg ulcers are found where?
lower legs, have irregular wound margins, and superficial, ruddy granular tissue
diabetic ulcers located where
on plantar aspect of foot, over metatarsal heads, under heels and on toes (bony prominence), can turn into cellulitis or osteomyelitis
cellulitis treatment:
moist heat, immobilization, elevation, systemic antibiotic therapy, hospitalization if IV therapy warranted (severe infections), progression to gangrene if left untreated
what medication is not effective against MRSA infections
penicillin
cephalosporins
bactericidal, beta-lactam antibiotics, similar to penicillin structure
psoriasis
common, chronic autoimmune inflammatory disorder characterized by plaque formation with varying degrees of severity
mild symptoms of psoriasis
red patches covered silvery scales on scalp, elbows, knees, palms, and soles
severe symptoms of psoriasis
may involve entire skin surface and mucous membranes, superficial pustules, high fever, leukocytosis, and painful fissuring of the skin.
two processes of psoriasis:
accelerated maturation of epidermal cells & excessive activity of inflammatory cells
Treatment of psoriasis
Reduce inflammation, topical treatments, systematic treatments, and phototherapy
Most common treatment for infection is ____
Prevention
