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
- Herpes zoster
- starts as small blisters and a red base, with new blisters continuing to form for 3-5 days. The blisters follow the path of individual nerves that come out of the spinal cord in a specific “Ray-like” distribution
Shingles
Pedis-athletes foot
Corpora- ring worm on body
Cruris- jock itch
Capitis- ring worn on head/scalp
Tinea
The ability of body tissues to regenerate and/or repair to maintain normal physiological processes
Tissue Integrity
Fungal infection commonly called athletes foot.
Lesions may be scaly patches with raised boarders
Pruitus is a common symptom
Treated with anti fungal sprays and cream
Tinea pedis
Treated with griseofulvin-weeks to months and take with high fat foods
Oral Ketoconazole
Selenium shampoo
Topical antifungals
Treatment for Tinea
- fungal infection commonly called a yeast infection
- occurs on skin, orally or vaginally
- due to prolonged wetness (skin); due to use of antibiotics and destruction of normal flora (orally and vaginally)
- red and scaly on skin or inflamed with exudate and peeling
Candida
•the oral form is known as thrush-the tongue will have a white coating that cannot be removed
•common in immune suppressed
•treated with medicated powders or creams (skin form); medicated mouthwash (oral form)
Nystatin (Mycosatin), amphotericin B ( Fungizone)
Candidiasis
- head lice
- transmitted by children and pets
- itching
Pediculosis capitus
- body lice
- eggs laid in seams of clothing
- itching and excoriation on trunk and extremities
Pediculosis corpitus
