Tissue Integrity 2 - Exam 4 Flashcards
Also called pressure injury
Pressure ulcers
- localized injury to skin or underlying tissue
- usually over bony prominences
- most common on sacrum and heels
Pressure ulcers
Results from prolonged pressure or pressure in combination with shearing forces
Pressure ulcers
Can be injury related to medical or other devices
Pressure ulcers
Will generally heal by secondary intention
Pressure ulcers
Pressure intensity
Amount of pressure
Pressure duration
Length of time pressure is exerted on the skin
Tissue tolerance factors
Ability of tissue to tolerate the pressure
- nutrition
- perfusion
- co-morbidities
- condition of soft tissue
When skin adheres to a surface and skin layers slide in direction of body movement
Shearing forces
Excessive moisture that leads to skin breakdown
Moisture
Risk factors of pressure ulcers
Advanced age
Anemia
Diabetes
Elevated body temperature
Friction
Immobility
Impaired circulation
Incontinence
low BP
mental disorientation
Neurological disorders
Obesity
Pain
Prolonged surgery
Vascular disease
Purple or maroon, localized area of discolored intact skin or blood filled blister 
Suspected deep tissue injury
Indicates damage of underlying soft tissue from pressure and or sheer
Suspected, deep tissue injury 
May be preceded by tissue that is painful, firm, mushy, and boggy
Suspected deep tissue injury
May be difficult to detect in patients with dark skin tones
Suspected deep tissue injury
Boggy or edematous tissue may indicate what stage of pressure ulcer
Stage I
Intact skin- non blanchable redness of a localized area
STAGE I
common over bony prominence
May be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
STAGE I
darkly pigmented skin may not have visible blanching
STAGE I
Partial thickness loss of dermis
STAGE II
Shallow open ulcer with red/pink wound bed
STAGE II
May also present as an intact or ruptured serum- filled blister
STAGE II
Can be shiny or dry shallow ulcer without slough or bruising
STAGE II
Adipose is NOT visible, and deeper tissues are NOT visible
STAGE II
Full thickness skin loss
STAGE III
Subcutaneous tissue may be visible, but bone, tendon, or muscle are NOT
STAGE III
Presents as deep crater with possible undermining or adjacent tissue
STAGE III
Ulcer depth varies by location, depending on depth of tissue in that area
STAGE III
Full thickness loss, extends to muscle, bone, or supporting structures
STAGE IV
Bone, tendon, or muscle may be visible or palpable
STAGE IV
Slough or Eschar May be present on some parts of the wound bed
STAGE IV
Undermining and tunneling May also occur
STAGE IV
Full-thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed
Unstageable ulcer
Slough may be yellow, tan, green, grey, or brown
Unstageable ulcer
Eschar may be tan, brown, or black in the wound bed
Unstageable ulcer
Slough or Eschar must be removed to expose the base of the wound in order to stage
Unstageable ulcer
Stable, dry Eschar on heels should not be removed - which stage is this
Unstageable ulcer
What are some complications of pressure ulcers - infection wise
- leukocytosis
- fever
- increased ulcer size, odor, or drainage
- necrotic tissue
- infuriated, warm, painful
Untreated ulcers may lead to
Cellulitis
Osteomyelitis can lead to
Sepsis and death
Signs of infection include
Swelling, redness, foul odor
What is a key sign of infection
Foul odor
Nurses play a critical role in the —— & ——
Prevention & treatment
Assess skin of —— patient on admission and every shift
Every
Assess all patients for risk for skin breakdown every —- hours
12
Stage —- & —- pressure injuries acquired after admission. NEVER want to happen
III, IV
Sensory/mental - Braden scale
- Totally limited
- Very limited
- Slightly limited
- No impairment
Moisture - Braden scale
- Constantly moist
- Very moist
- Occasionally moist
- Dry
Activity - Braden scale
- Bedfast
- Chairfast
- Walks with assistance
- Walks without assistance
Mobility - Braden scale
- 100 mobility
- Very limited
- Slightly limited
- Full mobility
Nutrition- Braden scale
- Very poor
- 1/2 daily portion
- Most of portion
- Eats everything
Friction/ shear
- Frequent sliding
- Freebie corrections
- Independent corrections
15-18 is considered mild risk for ?
> 75 years old
15-16
Mild risk
12-14
Moderate risk
<12
High risk
If incontinent
Clean with no rinse perineal cleaner & supply barrier ointment
Reposition patient
- draw sheet or transfer board
- position patient at 30 degrees
- HOB at 30 degrees
- trapeze bar
What schedule helps prevent pressure ulcers
Turning schedule
What to DOCUMENT when your patient has a pressure ulcer
Stage, size, location, exudate, infection, pain and tissue appearance
Who determines specific cleansing protocols and which types of dressing are appropriate
Wound care specialist
Clean with normal —- to avoid damaging cells
Saline
Keep slightly—- to encourage re-epithelialization
Moist
Skin grafts, skin flaps, or muscuocutaneous flaps are all surgical interventions to aid in
Healing
What can we teach patient and caregivers about pressure ulcers
Early signs of skin breakdown and tissue injury
—- — —- causes problems with blood flow in arteries, becoming narrow or blocked, usually caused by _____
peripheral artery disease; atherosclerosis
Artierial Ulcers are caused by
Ischemia
Nutritional deprivation
Arterial ulcers are a result of
Decreased circulation
Are found between toes or on tips of toes, on phalangeal head, lateral malleolus, or areas with rubbing footwear
Arterial ulcers
Even wound margins, punched-out appearance, pale, deep wound bed
Arterial ulcers
Must revascularize with stents to treat ischemia, then topical treatments will help with healing ulcer
Arterial ulcer
Venous insufficiency occurs when blood cannot flow upward from veins in the legs
Venous leg ulcers
Chronic venous insufficiency occurs when valves are damaged, allowing blood to leak backward, resulting in venous stasis
Venous leg ulcers
Patients with obesity, deep vein thrombosis, pregnancy, incompetent valves, CHF, muscle weakness, decreased activity, advanced aged, and family history are at increased risk for
Venous leg ulcers
Found in lower legs, have irregular wound margins and superficial, ruddy granular tissue
Venous leg ulcers
Surrounding skin may be red, scaly, weepy, and thin
Venous leg ulcers
Caused by peripheral neuropathy, fissures in skin and decreased ability to fight infection as well as diabetic foot deformities caused by damage to ligaments and destruction to bone
Diabetic ulcers
Located on plantar aspect of foot over metatarsal heads, under heels and on toes
Diabetic ulcer
Can easily turn into cellulitis or osteomyelitis
Diabetic ulcers
Inflammation of subcutaneous tissue
Often following break in skin
Staph and strep most often cause of infection
Cellulitis
Hot tender, erythematous, edematous area with diffuse borders
Chills, malaise, fever
Cellulitis
Moist heat, immobilization, elevation
Systemic antibiotic therapy
Hospitalization if IVs therapy warranted
Progressions to gangrene if left untreated
Cellulitis treatment
Common, chronic autoimmune inflammatory disorder, characterized by plaque formation with varying degrees of severity 
Psoriasis
Red patches covered with silvery scales on scalp, elbows, knees, palms, and soles
What severity of psoriasis is this?
Mild
May involve entire skin surface and mucous membranes, superficial postures, high fever, leukocytosis, and painful fissuring of the skin
What severity of psoriasis is this
Severe
