tissue integrity 2

Question 1

pressure ulcers are usually over ____ and most common on ___ & ____

Answer 1

bony prominences, sacrum & heels

Question 2

pressure ulcers will generally heal by ____ intention

Answer 2

secondary

Question 3

influencing factors of pressure ulcers:

Answer 3

pressure intensity, pressure duration, tissue tolerance, shearing forces, and excessive moisture that leads to breakdown

Question 4

risk factors of pressure ulcers:

Answer 4

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

Question 5

skin assessment for patients with dark skin

Answer 5

skin may appear purple, brown, or blue; skin temperature, skin/tissue consistence, and patient sensation (report pain or itchy sensation)

Question 6

stage 1 for pressure ulcers

Answer 6

intact skin, non-blanchable redness of a localized area, common over bony prominences

Question 7

_____ is the pressure of body pressing the skin down onto a firm surface

Answer 7

interface pressure

Question 8

staging is based on the ______ guidelines

Answer 8

national pressure injury advisory panel (NPIAP)

Question 9

slough

Answer 9

thick, yellow/white/gray, covering

Question 10

eschar

Answer 10

black, dead tissue/skin

Question 11

stage II pressure ulcer

Answer 11

partial-thickness loss of dermis, shallow open ulcer with pink/red wound bed, could be also a ruptured serum-filled blister

Question 12

in what stage is adipose fat, deeper tissues, granulation tissue, slough, and eschar are not present

Answer 12

stage II

Question 13

full-thickness skin loss, subcutaneous tissue may be visible but bone, tendon, or muscle are not

Answer 13

stage III

Question 14

full-thickness, extends to muscle, bone, or supporting structures, bone, tendon, or muscle my be visible or palpable

Answer 14

stage IV

Question 15

full-thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed

Answer 15

unstageable ulcer

Question 16

purple or maroon localized area of discolored intact skin or blood-filled blister. indicates damage of underlying soft tissue from pressure and/or shear

Answer 16

suspected deep tissue injury

Question 17

complications of pressure ulcers

Answer 17

infection: leukocytes, fever, increased ulcer size, odor, or drainage, necrotic tissue, indurated, warm, painful. Untreated ulcers may lead to cellulitis

Question 18

pressure ulcer prevention

Answer 18

pressure-redistribution, keep skin dry, reposition, turning schedule, nutrition and fluid intake

Question 19

your patient has a pressure injury, what now?

Answer 19

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

Question 20

peripheral arterial disease:

Answer 20

loss of hair, brittle nails, dry, shiny, scaly skin, ulcerations, brutis

Question 21

arterial ulcers

Answer 21

may be found between toes or on tips of toes, on phalangeal head, lateral malleolus, or areas with rubbing footwear

Question 22

venous leg ulcers

Answer 22

venous insufficiency occurs when blood cannot flow upward from veins in the legs

Question 23

who is at increased risk for venous leg ulcers?

Answer 23

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

Question 24

venous leg ulcers are found where?

Answer 24

lower legs, have irregular wound margins, and superficial, ruddy granular tissue

Question 25

diabetic ulcers located where

Answer 25

on plantar aspect of foot, over metatarsal heads, under heels and on toes (bony prominence), can turn into cellulitis or osteomyelitis

Question 26

cellulitis treatment:

Answer 26

moist heat, immobilization, elevation, systemic antibiotic therapy, hospitalization if IV therapy warranted (severe infections), progression to gangrene if left untreated

Question 27

what medication is not effective against MRSA infections

Answer 27

penicillin

Question 28

cephalosporins

Answer 28

bactericidal, beta-lactam antibiotics, similar to penicillin structure

Question 29

psoriasis

Answer 29

common, chronic autoimmune inflammatory disorder characterized by plaque formation with varying degrees of severity

Question 30

mild symptoms of psoriasis

Answer 30

red patches covered silvery scales on scalp, elbows, knees, palms, and soles

Question 31

severe symptoms of psoriasis

Answer 31

may involve entire skin surface and mucous membranes, superficial pustules, high fever, leukocytosis, and painful fissuring of the skin.

Question 32

two processes of psoriasis:

Answer 32

accelerated maturation of epidermal cells & excessive activity of inflammatory cells

Question 33

Treatment of psoriasis

Answer 33

Reduce inflammation, topical treatments, systematic treatments, and phototherapy

Question 34

Most common treatment for infection is ____

Answer 34

Prevention