Tissue Integrity Flashcards
A skin disorder where bacterial, fungal, viral, or parasitic agents are the cause
Infectious
The three layers of the skin:
Epidermis, dermis, subcutaneous tissue
Epidermis – outermost layer
Dermis – second layer; deeper than epidermis
Subcutaneous tissue – also known as the hypodermis; deepest layer, beneath the dermis
Skin disorder caused by skin cancers
Neoplastic
Skin disorder usually caused by a path allergy such as acne, burn, or dermatitis
Inflammatory
An intentional wound usually occurs during ___________.
Surgery
_____________ wounds occur by accident.
Unintentional
A _________ skin lesion occurs on previously healthy skin.
Primary
What is a secondary skin lesion?
Results from a change in a primary lesion
Wound depth that involves the dermis and epidermis; heals by regeneration (naturally)
Partial thickness
Wound depth that involves the dermis, epidermis, subcutaneous fat, and in some cases, muscle and bone; connective tissue repair is necessary (surgery)
Full thickness
What are the 4 terms used to describe a wound?
- Clean
- Clean-contaminated
- Contaminated
- Dirty or infected
When describing a wound what would classify a wound as a “clean” wound?
No infection present; closed. Nothing open, an example of this would be a hematoma or a bruise.
When describing a wound what would classify it as clean-contaminated?
This would be a surgical incision; no infection present; these are intentional wounds. Only contaminated because of break in the skin.
When describing a wound what would classify it as a contaminated wound?
Can be intentional or unintentional; open; inflammation. An example would be a break in sterile technique during surgery but they continue with procedure. Another example of this would be if you’re walking down the street and cut your foot on glass, until there’s an infection it is just a contaminated wound.
When describing a wound what would classify it as a dirty or infected wound?
Infection is noted; dead tissue is present; may have purulent drainage (pus)
The _______ system and the skin are intricately linked through their roles as the protectors of the body.
Immune
Impaired tissue integrity can lead to immune response. Conversely, immune responses such as allergic reactions and inflammation can lead to issues with tissue integrity.
What are the three phases of wound healing?
Inflammatory phase, proliferative phase, and maturation phase
When a client experiences physical symptoms such as pain, swelling, redness, warm to touch, or possible fever what phase of wound is this?
Inflammatory phase- last 3 to 6 days after injury, bleeding is ceased, fibrin begins to form, scab begins to surface, blood supply increases to area
During _________ phase of wound healing collagen is produced to strengthen wound, capillaries spread wound bed increasing blood supply, granulation tissue forms, scab covers wound bed. (Starts itching)
Proliferation phase (from day 3-4 of injury to up to 21 days)
Maturation phase of wound healing
Also called remodeling phase, healing of the scar: often occurs at day 21 of injury and can last 1 to 2 years, collagen fibers re-organize themselves into a structure, wound is remodeled and contracted, scar strengthens.
A break in the skin that can be superficial or deep; examples are an abrasion, laceration, or puncture
Open wound
Injury with no break in the skin; examples are contusion and ecchymosis; may be caused by a blow or other type of trauma
Closed wound
Steps of wound assessment
- Inspect wound and gently palpate surrounding area regularly
- Note presence and characteristics of wound drainage
- Observe for signs of infection: redness, swelling, increased tenderness, or disruption of wound edges; note body temperature and white blood cell count as other indicators
- Measurements
- Count all sutures or staples
How do you document wound measurements?
Size – length X width X diameter
Depth – using sterile cotton swab
Tunneling/undermining– Using sterile cotton swab, use clock as a frame of reference
COCA is used to document observations of a wound, what does COCA stand for?
C– Color of wound bed and drainage
O– Odor (determine after cleaning! And described as foul or none)
C– Consistency of the drainage (thin or thick-clots)
A– Amount of drainage (scant, small, large, copious)
Complications that affect wound healing
Hemorrhage, infection, dehiscence, evisceration
Noted by redness, swelling, heat, and pain at site; purulent exudate maybe noted
Complications that affect wound healing: Infection
Client may be anorexic, nauseous, febrile, and have chills; healthcare provider will order a wound culture, and antibiotics will be administered after culture is obtained
Accidental reopening of suture line (usually abdominal, but could occur with any wound) with tissue separation under wound
Complications that affect wound healing: Dehiscence
Medical emergency! Results from infected suture line or factors that impede wound healing; clients often “feel something giving way”; place client in bed with head of bed low to eliminate gravity and with knees bent to decrease pool on suture line; cover wound with large, sterile, wet Celine dressings; notify surgeon immediately because repair of surgical site is necessary
When internal organs protrude through incisional edges after dehiscence
Complications that affect wound healing: Evisceration
Medical emergency! Contributing factors include infection, for nutrition, failure of suture material, dehydration, and excessive coughing; treated in a manner similar to dehiscence
Wound dressing that is permeable to air and water vapor so it aids in preventing the growth of anaerobic organisms
Hydrocolloid (duoderm) dressing
What is the purpose of dressing a wound with skin prep?
Helps to strengthen the skin to prevent breakdown
What is the purpose of using a transparent dressing (such as tegaderm)?
Allows oxygen and moisture permeability but prevents moisture and bacteria entry
What is the purpose of using a wet-to-dry gauze dressing?
Aids in debridement of necrotic tissue from wound bed; by allowing necrotic material to soften and adhere to the gauze
What is the purpose of using proteolytic enzymes to treat pressure ulcers?
Aid in debridement for infected wounds with dead tissue
What is vacuum assisted closure (VAC) therapy and how does it work to treat pressure ulcers?
Provides negative pressure environment to help reduce edema, increased blood supply and oxygen to the area, promotes a moist environment, decreases bacterial agents and helps with formation of granulation tissue
An ischemic lesion of the skin and underlying tissue; appears over bony prominences, caused by external pressure.
Pressure ulcer
Necessary for wounds covered with eschar and is sometimes needed for wounds covered with slough (dead) tissue; done by physician or specialized staff
Surgical debridement
A moist dressing used to help trap wound drainage against the eschar to allow the body’s own enzymes to break down the necrosis; can be done by the nurse if ordered
Autolytic debridement
When sterile maggots are applied to wound bed to feed off of the bacteria present; this helps reduce bacteria and increase the surface pH
Larval therapy
When synthetic skin or skin from a healthy area of the client is removed and placed over the nonhealing wound and sutured
Skin grafting
Pressure ulcer with intact skin that is only affecting the epidermis and is non-blanchable, what stage would it be?
Stage I
Use skin prep, hydrocolloid or transparent dressing
A pressure ulcer with partial thickness loss of epidermis and/or dermis. Can present as an intact or ruptured blister. Superficial opening with red/pink wound bed. What stage pressure ulcer?
Stage II
Use hydrocolloid or transparent dressing (unless infected)
A pressure ulcer with full thickness tissue loss, where subcutaneous fat is visible. Slough or eschar is sometimes present. Undermining or tunneling may also be present.
Stage III pressure ulcer
Treat with wet to moist gauze, hydrocolloid or proteolytic enzyme
A pressure ulcer with full thickness tissue loss where tendon, muscle, or bone is visible and/or directly palpable. Most likely slough and/or eschar is present. Tunneling and/or undermining might occur.
Stage IV pressure ulcer
Never use transparent or hydrocolloid dressing. Treat with wet to moist gauze or VAC therapy; sometimes surgery is necessary
A pressure ulcer that includes full thickness tissue loss and has intact eschar and/or slough tissue may cover the whole wound bed.
Unstageable pressure ulcer
Debridement is necessary to promote healing
A pressure ulcer where skin is intact but purpleish or maroon in color. Damage is to underlying soft tissue from pressure or shearing, area will be painful.
Suspected deep tissue injury
Treat with nonadhesive dressing, barrier creams or moisturizers
Clear or straw-colored exudate
Serous
Milky exudate full of cells and necrotic debris; color maybe blue, green, or yellow
Purulent
Bright or dark red exudate containing red blood cells
Sanguineous
When assessing edema if depth of pitting is around 2 mm; no obvious distortion after depression this is _______ _________ and referred to as ______.
Slight pitting 1+
When treating a pressure ulcer which products would you use on a stage I?
Skin prep AND hydrocolloid (Duoderm) or transparent dressing (Tegaderm)
When treating a pressure ulcer what products would you use on a stage II?
Hydrocolloid or transparent dressing
When treating a pressure ulcer what type of product would you use on a stage III?
Wet-to-moist gauze dressing AND hydrocolloid or proteolytic enzyme
When treating a pressure ulcer which products would you use for a stage IV?
Wet-to-moist gauze or VAC therapy; sometimes surgery is necessary
Never use transparent or hydrocolliod dressing!
What products would you use to treat a suspected deep tissue injury?
Non-adhesive dressing, barrier creams or moisturizers
Risk factors for pressure ulcer development
Immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminish sensation, excessive body heat, advanced age, chronic medical conditions such as diabetes and cardiovascular disease
Prevention is key for pressure ulcers! What are some ways to prevent pressure ulcers?
Providing nutrition, maintaining skin hygiene, avoiding skin trauma, providing supportive devices such as an overlay mattress, specialty bed, or Kinetic bed
Used to determine a patients risk for developing a pressure ulcer
The Braden Scale
What are the 6 criteria measured for the Braden scale when determining a patient’s risk for developing pressure ulcers?
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and shear
Some age considerations when dealing with tissue integrity in the elderly include:
Decreased thickness and collagen, thinner with less elasticity, epidermal cell growth slows, decreased subcutaneous fat, decrease sensation, increased healing times, decreased thermoregulation
Risk factors for alterations in tissue integrity:
Poor skin care and maintenance, sharing personal hygiene items, use of irritants or allergens that cause inflammation and irritation, excessive cleaning, improper cleaning, chronic illnesses and some treatments, medications
Assessment of tissue integrity:
- Obtain complete medical history; review all systems
- Do thorough head to toe examination
- inspect and palpate
- Must have good lighting
- Consider cultural differences
General inspection of color or odors Inspect for skin alterations Look closely at skin folds and creases Palpate skin temperature Palpate skin moisture Palpate skin turgor Assess for edema Palpate hair texture Inspect scalp for lesions Inspect now curvature, evenness, thickness
Medication used to relieve inflammation and pruritis
Topical corticosteroids
Medication to help prevent blockage of follicles
Antiacne
Medication used to cause cell death at the DNA
Antibacterials
Medication used to treat infection by interfering with bacterial replication and synthesis
Antibiotics
Medication used to cause cell death specific to the organism present
Antifungals
Medication used to inhibit viral DNA replication
Antivirals
Medication used for decreasing pain with nerve blockage
Anesthetics
Medications used to help moisturize the skin
Creams
Medications used to help lubricate the skin to prevent water loss
Ointments
What are the three types of wound healing?
- Primary intention– Edges are well approximated (closed), typically intentional wounds with minimal tissue damage. Example: surgical incisions closed with sutures or staples
- Secondary intention– Gapping open, need to be packed. Edges are not approximated, typically large open wounds. Example: Burns, pressure ulcers
- Tertiary intention– Wounds that are infected or suspected to be infected. Wounds that are left open several days to allow edema or infection to resolve or exudate to drain; later closed with sutures or staples
We always want primary intention and if it’s not primary intention the goal is to get the wound to the primary intention stage!
