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IM 1 > Tissue Integrity 2 - Exam 4 > Flashcards

Tissue Integrity 2 - Exam 4 Flashcards

1
Q

Also called pressure injury

A

Pressure ulcers

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2
Q
  • localized injury to skin or underlying tissue
  • usually over bony prominences
  • most common on sacrum and heels
A

Pressure ulcers

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3
Q

Results from prolonged pressure or pressure in combination with shearing forces

A

Pressure ulcers

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4
Q

Can be injury related to medical or other devices

A

Pressure ulcers

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5
Q

Will generally heal by secondary intention

A

Pressure ulcers

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6
Q

Pressure intensity

A

Amount of pressure

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7
Q

Pressure duration

A

Length of time pressure is exerted on the skin

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8
Q

Tissue tolerance factors

A

Ability of tissue to tolerate the pressure
- nutrition
- perfusion
- co-morbidities
- condition of soft tissue

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9
Q

When skin adheres to a surface and skin layers slide in direction of body movement

A

Shearing forces

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10
Q

Excessive moisture that leads to skin breakdown

A

Moisture

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11
Q

Risk factors of pressure ulcers

A

Advanced age
Anemia
Diabetes
Elevated body temperature
Friction
Immobility
Impaired circulation
Incontinence
low BP
mental disorientation
Neurological disorders
Obesity
Pain
Prolonged surgery
Vascular disease

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12
Q

Purple or maroon, localized area of discolored intact skin or blood filled blister 

A

Suspected deep tissue injury

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13
Q

Indicates damage of underlying soft tissue from pressure and or sheer

A

Suspected, deep tissue injury 

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14
Q

May be preceded by tissue that is painful, firm, mushy, and boggy

A

Suspected deep tissue injury

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15
Q

May be difficult to detect in patients with dark skin tones

A

Suspected deep tissue injury

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16
Q

Boggy or edematous tissue may indicate what stage of pressure ulcer

A

Stage I

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17
Q

Intact skin- non blanchable redness of a localized area

A

STAGE I

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18
Q

common over bony prominence
May be painful, firm, soft, warmer, or cooler as compared to adjacent tissue

A

STAGE I

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19
Q

darkly pigmented skin may not have visible blanching

A

STAGE I

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20
Q

Partial thickness loss of dermis

A

STAGE II

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21
Q

Shallow open ulcer with red/pink wound bed

A

STAGE II

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22
Q

May also present as an intact or ruptured serum- filled blister

A

STAGE II

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23
Q

Can be shiny or dry shallow ulcer without slough or bruising

A

STAGE II

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24
Q

Adipose is NOT visible, and deeper tissues are NOT visible

A

STAGE II

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25
Q

Full thickness skin loss

A

STAGE III

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26
Q

Subcutaneous tissue may be visible, but bone, tendon, or muscle are NOT

A

STAGE III

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27
Q

Presents as deep crater with possible undermining or adjacent tissue

A

STAGE III

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28
Q

Ulcer depth varies by location, depending on depth of tissue in that area

A

STAGE III

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29
Q

Full thickness loss, extends to muscle, bone, or supporting structures

A

STAGE IV

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30
Q

Bone, tendon, or muscle may be visible or palpable

A

STAGE IV

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31
Q

Slough or Eschar May be present on some parts of the wound bed

A

STAGE IV

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32
Q

Undermining and tunneling May also occur

A

STAGE IV

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33
Q

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

A

Unstageable ulcer

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34
Q

Slough may be yellow, tan, green, grey, or brown

A

Unstageable ulcer

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35
Q

Eschar may be tan, brown, or black in the wound bed

A

Unstageable ulcer

36
Q

Slough or Eschar must be removed to expose the base of the wound in order to stage

A

Unstageable ulcer

37
Q

Stable, dry Eschar on heels should not be removed - which stage is this

A

Unstageable ulcer

38
Q

What are some complications of pressure ulcers - infection wise

A
  • leukocytosis
  • fever
  • increased ulcer size, odor, or drainage
  • necrotic tissue
  • infuriated, warm, painful
39
Q

Untreated ulcers may lead to

A

Cellulitis

40
Q

Osteomyelitis can lead to

A

Sepsis and death

41
Q

Signs of infection include

A

Swelling, redness, foul odor

42
Q

What is a key sign of infection

A

Foul odor

43
Q

Nurses play a critical role in the —— & ——

A

Prevention & treatment

44
Q

Assess skin of —— patient on admission and every shift

A

Every

45
Q

Assess all patients for risk for skin breakdown every —- hours

A

12

46
Q

Stage —- & —- pressure injuries acquired after admission. NEVER want to happen

A

III, IV

47
Q

Sensory/mental - Braden scale

A
  1. Totally limited
  2. Very limited
  3. Slightly limited
  4. No impairment
48
Q

Moisture - Braden scale

A
  1. Constantly moist
  2. Very moist
  3. Occasionally moist
  4. Dry
49
Q

Activity - Braden scale

A
  1. Bedfast
  2. Chairfast
  3. Walks with assistance
  4. Walks without assistance
50
Q

Mobility - Braden scale

A
  1. 100 mobility
  2. Very limited
  3. Slightly limited
  4. Full mobility
51
Q

Nutrition- Braden scale

A
  1. Very poor
  2. 1/2 daily portion
  3. Most of portion
  4. Eats everything
52
Q

Friction/ shear

A
  1. Frequent sliding
  2. Freebie corrections
  3. Independent corrections
53
Q

15-18 is considered mild risk for ?

A

> 75 years old

54
Q

15-16

A

Mild risk

55
Q

12-14

A

Moderate risk

56
Q

<12

A

High risk

57
Q

If incontinent

A

Clean with no rinse perineal cleaner & supply barrier ointment

58
Q

Reposition patient

A
  • draw sheet or transfer board
  • position patient at 30 degrees
  • HOB at 30 degrees
  • trapeze bar
59
Q

What schedule helps prevent pressure ulcers

A

Turning schedule

60
Q

What to DOCUMENT when your patient has a pressure ulcer

A

Stage, size, location, exudate, infection, pain and tissue appearance

61
Q

Who determines specific cleansing protocols and which types of dressing are appropriate

A

Wound care specialist

62
Q

Clean with normal —- to avoid damaging cells

A

Saline

63
Q

Keep slightly—- to encourage re-epithelialization

A

Moist

64
Q

Skin grafts, skin flaps, or muscuocutaneous flaps are all surgical interventions to aid in

A

Healing

65
Q

What can we teach patient and caregivers about pressure ulcers

A

Early signs of skin breakdown and tissue injury

66
Q

—- — —- causes problems with blood flow in arteries, becoming narrow or blocked, usually caused by _____

A

peripheral artery disease; atherosclerosis

67
Q

Artierial Ulcers are caused by

A

Ischemia
Nutritional deprivation

68
Q

Arterial ulcers are a result of

A

Decreased circulation

69
Q

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

A

Arterial ulcers

70
Q

Even wound margins, punched-out appearance, pale, deep wound bed

A

Arterial ulcers

71
Q

Must revascularize with stents to treat ischemia, then topical treatments will help with healing ulcer

A

Arterial ulcer

72
Q

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

A

Venous leg ulcers

73
Q

Chronic venous insufficiency occurs when valves are damaged, allowing blood to leak backward, resulting in venous stasis

A

Venous leg ulcers

74
Q

Patients with obesity, deep vein thrombosis, pregnancy, incompetent valves, CHF, muscle weakness, decreased activity, advanced aged, and family history are at increased risk for

A

Venous leg ulcers

75
Q

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

A

Venous leg ulcers

76
Q

Surrounding skin may be red, scaly, weepy, and thin

A

Venous leg ulcers

77
Q

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

A

Diabetic ulcers

78
Q

Located on plantar aspect of foot over metatarsal heads, under heels and on toes

A

Diabetic ulcer

79
Q

Can easily turn into cellulitis or osteomyelitis

A

Diabetic ulcers

80
Q

Inflammation of subcutaneous tissue
Often following break in skin
Staph and strep most often cause of infection

A

Cellulitis

81
Q

Hot tender, erythematous, edematous area with diffuse borders

Chills, malaise, fever

A

Cellulitis

82
Q

Moist heat, immobilization, elevation
Systemic antibiotic therapy
Hospitalization if IVs therapy warranted
Progressions to gangrene if left untreated

A

Cellulitis treatment

83
Q

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

A

Psoriasis

84
Q

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

What severity of psoriasis is this?

A

Mild

85
Q

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

A

Severe

IM 1 (34 decks)

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