Tissue Integrity Flashcards
How does the nurse recognize when an imbalance is developing or has developed?
- Comprehensive history
- Skin and overall health assessment, risk assessment
Identify risk factors for impaired skin integrity and impaired tissue integrity, the importance of nutrition, mobility, and keeping skin clean and dry to prevent skin/tissue problems. Hygiene and skin care discussed. Safety behaviors to prevent trauma.
Primary Prevention
Providing pain management, repositioning, using barrier creams, checking incontinent patients frequently to keep skin clean and dry, manage hygiene, provide appropriate nutrients to promote healthy skin or for wound healing, administer medications, prevent spread of infections or infestations, use lotions and oatmeal baths to relieve pruitus
Secondary Prevention
Teach patient and care giver about home care concerning pressure relief, wound care, hygiene and incontinence care, pruitus relief with oatmeal bath products or bath oil (such as Keri oil) and lotion, nutrition, and safety behaviors to prevent trauma, general skin care
Tertiary Prevention
Minimal inflammation and respiratory, GI, urinary, genital tracts are not entered
Clean wound
A wound that is exposed is always __________ but not always infected. Inflammation may be present. It’s the presence of organisms without any manifestations of infection.
Contaminated
Wound infection is contamination with pathogenic organisms to the degree that growth and spread cannot be controlled by the body’s immune defenses. May contain necrotic tissue, purulent drainage and obvious infection
Infected Wound
Involve damage to the epidermis and upper layers of the dermis
Heal by re-epithelialization within 5 to 7 days
Skin injury immediately followed by local inflammation
-heals by regeneration
Partial thickness wound
- damage extends into lower layers of the dermis and underlying subcutaneous tissue
- removal of the damaged tissue results in a defect that must be filled to heal
- requires connective tissue repair
Full thickness wound
When the tissue surfaces are approximated
Primary intention
Tissue loss and edges cannot or should not approximate- granulation and contraction
Secondary intention
Delayed closure, left open to decrease edema and drain exudate and closed later with sutures, staples, or adhesives
Third intention wound healing
3 Phases of Wound Healing
1) Inflammatory phase
2) Fibroblastic or connective tissue repair phase
3) Maturation or remodeling phase
- caused by staphylococcus bacteria
- most common in children
- occurs when a break in the skin allows bacteria to enter causing inflammation and infection
- reddened macule that becomes vesicular
- blisters that itch
- filled with yellow to honey colored fluid
Impetigo Contagiosa
- red area of skin that tends to expand
- skin dimpling, swelling, tenderness, blisters
- can spread rapidly to other parts of the body
Cellulitis
