Tissue Integrity Exam 4 Flashcards
What is the largest organ of the body?
skin
The skin is the ____ protective barrier.
first
Who’s responsibility to assess and monitor skin integrity?
Nurse
Purposes of the skin
Protection
Sensory
Vitamin D synthesis
fluid balance
natural flora
What is the order of skin from top to bottom
Epidermis
Dermis
Subcutaneous
A young male patient with paraplegia has a stage II pressure injury and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family?
-Change the patient’s bedding frequently.
-Apply a dressing over the injury.
-Change the patient’s position every 1 to 2 hours.
-Record the size and appearance of the injury weekly.
Change the patient’s position every 1-2 hours
During the skin assessment, what are the 6 major things inspected on the skin?
bony prominences
visual and tactile
rashes/lesions?
hair distribution
skin color
blanch test
In pediatrics, what is a common bony prominence on an infant?
back of the head
What does the dermis contain in the skin?
Sebaceous and sweat glands
hair follicles, nerves, collagen fibers
connective tissue
What does the subcutaneous layer of the skin contain?
adiose tissue, nerves
The student nurse is assessing a patient with Peripheral Artery Disease (PAD). Upon assessment of the patient’s lower extremities, the student nurse identifies an ulcer. The skin surrounding the ulcer is shiny and dry. The appearance of the wound bed is pale and deep with even margins. How would the student nurse categorize this ulcer?
Arterial Ulcer
Cellulitis
deep inflammation of subcutaneous tissue caused by enzymes produced by bacteria
following break in skin
staph and strep most often cause infection
Osteromyelitis
Inflammation of bone caused by infection, generally in the legs, arm, or spine
Diabetic people need to look at what every night? and why?
Feet, prevent diabetic ulcers
Cellulitis S/S
hot, tender, erythematous, edematous area with diffuse borders (sharpie)
chills, malaise, and fever
Cellulitis Treatment
moist heat, immobilization, elevation
systemic antibiotic therapy
hospitalization if IV therapy warranted (severe)
progression to gangrene if left untreated
The most important treatment for infection is
prevention
What are the antibiotics used to treat skin and soft tissue infections?
slide 38
When do you reassess the patient for tissue risk? (Normally)
admission
once every shift (twice - day and night shift)
What is the blanch test?
if redness, then when touched turns white and back to red = good
if red and when touched still red = skin breakdown
When inspecting the skin, what should you look for?
signs and symptoms of impaired skin integrity
actual impairment
levels of sensations, movement, and continence
visual and tactile of ALL skin
palpate redness for blanch
bony prominences
med devices
areas with adhesive tape
Should you turn the patient when inspecting the skin? When should you?
yes
checking for skin breakdown, when transferring or bathing
Braden Scale Scoring uses what categories? (6)
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
Braden Scale: Sensory Perception Levels
1) Completely limited = unresponsive, can’t feel pain
2) Very limited = painful stimuli, can’t communicate discomfort, can’t feel 1/2 of body
3) Slightly limited = verbal commands, can’t always communicate discomfort, sensory impaired in 1-2 extremitites
4) No impairment = verbal commands, no sensory deficit
On the Braden Scale, the lower (12 or less) the score -
the higher the risk
On the Braden Scale, the higher (15-18) the score -
the lower the risk
Is there ever not a risk on the Braden Scale?
no, there is always a risk.
Braden Scale: Moisture Levels
1)Constantly moist= always; perspiration, urine, etc.
2) Very moist= often but not always; linen changed at least once per shift
3)Occasionally moist= extra linen changed every day
4)Rarely moist= usually dry
Braden Scale: Activity Levels
1) Bedfast= never out of bed, complete bed bath
2)Chairfast= ambulation severely limited to non-existent; no bear of weight; assist to chair with devices
3) Walks occasonally= short distance daily with or without assistance; a majority of time in bed or chair
4)Walks frequently= outside room at least 2 times per day; inside room every 2 hours during waking hours
Braden Scale: Mobility Levels
1) Completely immobile: no change in positioning
2)Very limited: occasional slight change; can’t make significant changes independently
3)Slightly Limited: frequent change independently
4)No limitation: major and frequent change without assistance
Braden Scale: Nutrition Levels
1) Very poor: never eats a complete meal, almost no protein; NPO, clear liquids, IV more than 5 days
2) Probably inadequate: rarely eats completely, some protein, occasional dietary supplements; less than optimum liquid diet or tube feeding
3) Adequate: eats over 1/2 of most meals; adequate protein; usual supplement; tube feeding meets nutritional needs
4)Excellent: eats most of the meal, never refuses, plenty of protein; occasional snacks between meals; no required supplements
Braden Scale: Friction and Shear Levels
1)Problem: moderate to max assist in moving; frequently slides down in bed or chair; spasticity and contractures lead to constant friction
2)Potential Problem: moves feebly, minimum assistance; skin slides against sheets; few slides down
3)No Apparent Problem: moves independently; sufficient muscle strength to lift up completely; good position in bed/chair
What should you do when patient is a low (15-18) risk?
regular turning schedule
activity as much as possible
protect heels
manage moisture, friction and shear
What should you do when a patient is high risk?
regular turning schedule
activity as much as possible
protect heels
manage moisture, friction and shear
Position pt at 30 degree lateral incline with pillows
small shifts in frequent positioning
pressure redistribution
What should you do when patient is at moderate risk?
regular turning schedule
activity as much as possible
protect heels
manage moisture, friction and shear
Position pt at 30 degree lateral incline with pillows
What can a nurse do to maintain tissue integrity?
Frequent repositioning
sitting in chair for 2 hour intervals (if not contraindicated)
HOB at 30 degrees
Written schedule of turning and positioning
Sitting in a chair longer than 2 hours may increase
pressure to sacral tissue
What is the number one thing a nurse can do to prevent pressure ulcers?
Repositioning
What is the order of wound staging?
Stage 1: Nonblanchable Redness
Stage 2: Partial Thickness
Stage 3: Full Thickness Skin Loss
Stage 4: Full Thickness Tissue Loss
Unstageable: Full Thickness skin/Tissue Loss Depth Unknown
Suspected Deep Tissue Injury-Depth Unknown
CHANT (Early Intervention Protocol)
Cleanse
Hydrate (and protect skin)
Alleviate pressure
Nourish
Treat
Early Intervention for red/excoriated peri/ rectal area
Cleanse
Dry thoroughly
Moisture barrier daily and prn
Early Intervention for redness/excoriation between skin folds
Cleanse
Dry thoroughly
Place inner dry or dry AG textile in folds
Early Intervention for red heels
Position pressure off of heels
Elevate on pillows
sage boot (snowboard boot)
reduce friction
Early Intervention for red sacral/coccyx area
change positions every 1-2 hours
HOB less than 30 degrees unless contraindicated
avoid excess moisture
frequent peri care
wrinkle free linens
What are the nursing priorities for the skin?
assess and monitor skin integrity
identify risks for skin problems
identify present skin problems
planning, implementing, and evaluating to maintain intact skin
Inflammatory response to cell injury
-neutralizes and dilutes inflammatory agent
-removes necrotic for a suitable environment for healing
Does inflammation = infection?
No
Inflammation is always present with infection, but infection does not always present with inflammation
What can initiate an inflammatory response?
surgical wounds or injuries
allergies
autoimmune diseases
skin infections
Wound definition
any disruption of the integrity and function of tissues in the body (intentional or pressure)
Wound ________ and ___________ is important to wound healing.
assessment; classification
Tissue trauma causes an inflammatory response in the first ________
24 hours
_________ __________ is the same regardless of the injuring agent.
Inflammatory mechanism
The intensity of the response depends on
extent and severity of the injury
the reactive capacity of the injured person
How does the body react during inflammation? Pathophysiologically steps
Bacteria enters wound
platelets from clotting
mast cells cause vasodilation - blood and needed cells increase
neutrophils and monocytes kill pathogens
macrophages make cytokines to repair tissue
continues until pathogens are eliminated and tissue is repaired
Vascular response is the
increase of capillary permeability when fluid moves into tissue
-serous fluid to albumin
Results of vascular response (symptoms shown)
redness, heat, and swelling at sit of injury and surrounding areas
What does fibrinogen make which strengthens blood clot and prevent the spread of bacteria?
fibrin
The bone marrow releases more neutrophils to the infection site, increasing what?
WBC
Complement system
major mediator of inflammatory reponse
Exudate (examples for infection)
fluid and leukocytes
What are the symptoms and signs of infection?
redness
heat
pain
swelling
loss of function???
If a local infection goes untreated, it can lead to
systemic infection
Malaise
general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify
Systemic response to inflammation
increased WBC
malaise
nausea and anorexia
increased pulse and respirations
fever
The causes of systemic responses to inflammation are poorly understood but are most likely due to
complement activation
release of cytokines
Acute Inflammation
healing in 2-3 weeks, no residual damage
neutrophils predominant cell type at site
Subacute Inflammation
same as acute, but lasts longer
Chronic Inflammation
may last for years
injurious agent persists or repeats injury to the site
predominant cell types are lymphocytes and macrophages
may result from change in immune system (autoimmune)
How do nurses manage inflammation?
Observe for signs of inflammation and at-risk patients
VS monitor
Antipyretics if necessary
Fever greater than ____ degrees is an emergency and damage to body cells.
104.4
What is the final phase of inflammatory response?
healing
Healing includes what 2 major components and their definitions?
-Regeneration - replacement of lost cells and tissues with cells of the same type
-Repair - healing as a result of lost cells being replaced by ct, resulting in scar formation: more common and complex; occurs primary, secondary, or tertiary intention
Healing by Primary Intention
Initial phase (3-5 days with acute inflammatory response)
Granulation (wound turns pink and rebuilds)
Scar forms
Healing by Secondary Intention
wounds from trauma, ulceration and infection with large amounts of exudate
-wide with irregular margins with extensive tissue loss
-same process with greater inflammation
Healing by tertiary intention
delayed primary intention due to delayed suturing of the wound
-the contaminated wound is left open after closed after infection is controlled
Partial-thickness wounds (regeneration) components
inflammatory response
epithelial proliferation and migration
reestablishment of epidermal layers
Partial-thickness wounds need what component of healing?
regeneration
Full-thickness wounds need what component of healing?
repair
Full-thickness wounds (repair) healing phases
Hemostasis
Inflame phase
Proliferative phase
Maturation
-extend to dermis heal by scar formation
Factors of wound healing
Nutrition (protein, vitamins and cals)
Tissue perfusion
Infection
Age
Hemorrhage
bleeding
Hematoma
collection of blood under skin (slows process)
Dehiscence
wound breaks open, staples out
Evisceration
something comes out of the wound, the inside is now outside
Wounds are classified by
cause and depth
-surgical, nonsurgical, acute, chronic
-superficial to full-thickness
Skin tear
wound caused by shear, friction, and/or blunt force
common in older adults and chronically ill
When assessing a wound, what do you report when documenting?
time - on admission and every shift (2 times a day)
location
size
condition of surrounding tissue
wound base
any drainage - consistency, color, odor
factors delayed healing
How should you report undermining and tunneling on a report?
watch or clock
Management of wounds include
types of dressings
depending on type
extent
character of wound
phase of healing
Clean wounds
need cleansing and type of wound closure (tape, sutures)
wound clean and slightly moist
surgical dressings need sterile dressing removed in 2-3 days
What is an enemy of wound healing?
dryness
What should not be used on a healing wound when cleaning a granulating wound?
Antimicrobial and antibacterial solutions
can damage epithelium and delay healing
What is a common drain used with surgical wounds to remove excess fluids?
Jackson-Pratt
Debridement
removal of dead tissue and debris
Purposes of dressings
protect from microorganisms
aids in hemostasis
promotes healing by absorbing drainage or debriding wound
supports wound site
promotes thermal insulation
provides a moist environment
Types of dressings
gauze
transparent film
hydrocolloid
hydrogel
foam
composite
How to prepare the pt for a dressing change?
review previous wound assessment
evaluate pain and if needed analgesics
describe procedure
all supplies
recognize normal signs of healing
answer questions
Dressing change comfort measures
administer pain killers 30-60 mins before
carefully remove dressings and tape
gentle clean surrounding skin, least contaminated to most
use gentle friction
minimize stress on sensitive tissues
turn and position pt carefully
date and time dressings were changed
Suture removal
remove NII
Document the number of sutures before and after
clip near skin, opposite of knot
Steri-strips
don’t pull or create tension
allow them to fall off naturally (10 days) may shower
What is usually given for surgical prophylaxis? When is it given?
antibiotics and cephalosporins, prior
Pressure Ulcers/Injury is localized where?
usually over bony prominences but not always
most commonly sacrum and coccyx
Pressure Ulcers are caused by
prolonged pressure or pressure in combination with shearing forces
-can be related to medical devices
Pressure Ulcers will generally heal by
secondary intention
Explain the pathophysiology of pressure ulcers.
surface pressure for a prolonged period of time
stop the capillary flow to the tissues
deprives tissues of oxygen and nutrients
cell death and necrosis
Influencing factors of pressure ulcers
Pressure Intensity
Pressure Duration
Tissue Tolerance (nutrition, perfusion, co-morbidities, autoimmune or soft tissue diseases)
Shearing forces
Moisture
Pressure Ulcers Risk Factors
advanced age
anemia
diabetes
elevated body temp
friction
immobility
impaired circulation
incontinence
low diastolic BP (less than 60) - lack of perfusion
mental deterioration - restraints, bed alarm, confusion
neurologic disorders
obesity
pain
prolonged surgery
vascular disease
SCD
Sequential Compression device
NPUAP
National Pressure Ulcer Advisory Panel
Can a pressure ulcer ever be “downstaged”?
No
Slough
yellow/white in color
mass of necrotic tissue
Eschar
black necrotizing
The presence of slough or eschar may prevent what?
staging until removed
Deep Tissue Injury looks like
purple/maroon localized area of discolored intact skin or blood-filled blister
Deep Tissue Injury indicates
damage of underlying soft tissue from pressure and/or shear
Deep Tissue Injury is preceded by
painful, firm, mushy and boggy feeling skin
Skin assessment for patients with dark skin
darker skin than the surrounding (appear purple, brown, blue)
Different temperatures (warm/cold
Skin/Tissue consistency on common sites
Patient pain or numbness in area
What is the main difference between Stages 1 and 2?
Intact skin in stage 1
nonintact skin in stage 2
What is the main difference between stages 2 and 3
loss of the epidermis in stage 2
loss of the dermis in stage 3
What is the main difference between stages 3 and 4?
stage 3 has full-thickness lodd
stage 4 shows bone, CT, and tendons
Stage 1
intact skin, non-branch able redness in a localized area
common over bony prominences
different compared to adjacent skin (same as darkly pigmented skin
Stage 2
partial-thickness loss of dermis
shallow open ulcer with red/pink wound bed
present as intact or ruptured serum-filled blister bc no dermis
-shiny/dry shallow ulcer w/o slough or bruising
-adipose tissue and deeper tissue not visible
Stage 3
full-thickness skin loss
subq tissue visible but no bone, tendon, or muscle present
DEEP CRATER w/ possible undermining
depth varies by location
Stage 4
full-thickness loss showing bone, tendon, or supporting structures
Slough or eschar may be present on wound bed
Undermining and tunneling
Undermining
wound extends sideways under the skin flaps
-yellow, tan, green, gray, or brown
Tunneling
gown deeper toward bone
-tan, brown, or black
Unstageable Ulcer
full-thickness loss but slough or eschar obscure the wound bed
If there is stable and dry eschar on the heel of a pt should it be removed? What do you do?
don’t remove it
wait to fall off
Complications of Pressure Ulcers
Infection leading to leukocytosis, fever, increased size, odor, or drainage, necrotic tissue, indurated, warm, painful
Untreated ulcers may lead to _________ with the spread of inflammation to subq tissue, CT, and osteomyelitis.
cellulitis
Cellulitis leads to
sepsis and death
most common complication of pressure ulcers is
recurrence of tissue breakdown or repeated ulcers
Nursing Assessment and Management
Prevention and treatment
assess the skin of every pt on admission and each shift
assess all pt for risk of skin breakdown every 12 hours
stage 3-4 pressure injuries after admission - should never happen
Pressure Ulcer Prevention
Pressure redistribution
keep skin dry
Reposition with turning schedule
nutrition and fluid intake
Care Plan
-Prevent deterioration
-Reduce factors contributing to pressure and skin breakdown
-Prevent infection
-Promote healing
-Prevent repeat injury
What do you do when your pt has a pressure injury?
-Document stage, size, local, exudate, infection, pain, and tissue appearance
-Pictures from EMR if needed
-Wound care specialist cleansing protocol and dressing type (normal saline, keep slightly moist)
-Surgical treatment if necessary
MASD means what?
Moisture-Associated Skin Damage
- looks like inflammation of the skin w/ or w/o erosion caused by moisture
IAD means what?
Incontinence Associated Dermatitis
- skin breakdown do to urine or fecal matter in the sacral and coccyx area
MARSI means what?
Medical adhesive-related skin injury
-the presence of erythema with cutaneous abnormality over 30 minutes + after removal of device secured
With an ostomy, what is the first sign of skin breakdown in that area?
redness around the ostomy
Lower extremity ulcers are related to
changes in blood flow to lower extremities due to chronic disease processes
Arterial Ulcers
PAD means? What does it cause?
Peripheral Artery Disease
-narrowing or blocking of blood flow in arteries caused atherosclerosis, ischemia, and nutrition deprivation bc of decreased circulation
-look shiny and dry with loss of hair around the ankles, feet
Venous Ulcers
occurs when blood can not flow upward from veins in the leg
What pts might have an increased risk of Arterial Ulcers?
atherosclerosis
PVD
diabetes
smoking
hypertension
advanced age
obersity
cardiovascular disease
Arterial Ulcers S/S
-found between and tops of toes, lateral ankle or top of feet
-even wound margins, punched out appearance, pale, deep bed, extremely painful with minimal exudate
Arterial Ulcers treatments
Revascualrize with stents to treat ischemia
Topical cream for ulcer
Chronic venous insufficenecy
valves are damaged, allowing blood to leak backwards
results in venous stasis
What pts might have an increased risk of Venous Leg Ulcers?
obesity
deep vein thrombosis
pregnancy
incompetent valves
congestive heart failure
muscle weakness
decreased activity
advanced age
family history
Venous Leg Ulcers S/S
irregular wound margins and superficial, ruddy granular tissue
-painless to moderate
-surrounding skin is red, scaly, weepy, and thin
Venous Leg Ulcers treatment
compression therapy promotes blood return and prevents blood from pooling and low circulation
Diabetic Ulcers causes
peripheral neuropathy
fissures in skin
decreased ability to fight infection
diabetic foot deformities due to damage to ligaments and destruction of bone
Diabetic Ulcer S/S
located on the sole of foot on bony prominences of the toes
-painless
-even wound margins
-rounded or oblong shape with callous
-easily turn into cellulitis or osteomyelitis
Diabetic Ulcer treatment
removing stress/pressure from the injured site
debriding wound
antibiotics if infected
Cellulitis pathology
deep inflammation of subq tissue produced by bacteria
follows skin breakdown
staph and strep cause infection
Cellulitis S/S
hot, tender, erythematous, edematous area with diffuse borders
chills, malaise, and fever
Cellulitis treatment
moist heat
immobilization
elevation
systemic antibiotic therapy
hospitalization if IV therapy for severe infections
progression to gangrene if untreated
The most important treatment for infection is
prevention!!
Skin and soft tissue infections can be treated with
Cephalosporins
Penicillins
Carbapenems
Vancomycin
Clindamycin
Linezolid
Daptomycin
Levofloxacin
Penecillins
-may be given PO, IM, or IV
-not effective against MRSA infections
-never mixed in same IV solution with aminoglycosides
-least toxic of all antibiotics, very safe clinically
-metabolized and excreted by kidneys
-avoid intra-arterial injections: gangrene, necrosis, slough
Adverse effects of Penicillins
allergies
pain at IM injection site
neurotoxicity
Cephalosporins
Bactericidal, beta-lactam antibiotics, similar to penicillin structure
-Third Generation: Ceftriaxone
Used for surgical prophylaxis, bone and joint infections, skin, and soft tissue infections
-Fourth Generation: Cefepime
Active against pseudomonas and other resistant organisms
-Fifth Generation: Ceftaroline
Only cephalosporin effective against MRSA
Used for skin and soft tissue infections
Carbapenems
-Beta-lactam antibiotics, IV administration
-Very broad-spectrum, not effective against MRSA
-Imipenem, meropenem, ertapenem, doripenem
-Effective for treating mixed infections, intra-abdominal infections, and complicated skin and soft tissue infections
-Elimination primarily renal
-Adverse effects:
—-N/V/D
—-Superinfections
—-Rash, pruitis, seizures
-Interaction with Valproate – Imipenem reduces blood levels of valproate, can lead to breakthrough seizures
Vancomycin
-Only active against gram-positive bacteria
-Used in the treatment of c-diff, MRSA, and other serious infections, especially active against staph aureus and staph epidermidis
-IV administration, eliminated unchanged by the kidneys
Vancomycin adverse effects
=Renal failure, especially if used concurrently with aminoglycosides, cyclosporine, and NSAIDs, must obtain peak and trough serum levels
=Ototoxicity, is rare, usually reversible
=“Red Man Syndrome” – flushing, rash, pruritus, urticaria, tachycardia, and hypotension, usually due to rapid infusion, admin over 60 minutes or more
=Thrombophlebitis is common
=Thrombocytopenia, rare
What is the most common antibiotic to treat bacteria?
Vancomycin
Clindamycin
-Used as alternative to penicillin, drug of choice for severe group A streptococcal infections and gas gangrene, covers most anaerobic bacteria (+/-) and most gram-positive anerobes
-May be administered orally, IM, or IV
-Undergoes hepatic metabolism, excreted by urine and bile
==Adverse effects: c-diff, abdominal pain, fever, leukocytosis, hepatotoxicity
Linezolid
-Oxazolidinone antibiotic (new)
-Effective against multi-drug resistant gram-positive pathogens, including MRSA, but should be reserved for specific infections to prevent the development of resistance
=Adverse effects: N/V/D, headache, dizziness
-Should not be used with SSRIs, ephedrine, pseudoephedrine, cocaine
Daptomycin
-Cyclic lipopeptide (new)
-Can kill all clinically-relevant gram-positive bacteria, including MRSA
-Approved for use with bloodstream infections and complicated skin and soft tissue infections
-Administered IV
=Adverse effects: N/V/D, constipation, headache, insomnia, rash, muscle injury
-May cause eosinophilic pneumonia (fever, cough, SOB), can lead to respiratory failure and death (rare)
Fluroquinolones (levofloxacin, ciprofloxacin)
-Variety of infections, including skin infections
-Metabolized by liver, excreted in urine
=Adverse effects: tendon rupture, N/V, headache, muscle weakness, phototoxicity
What is a major concern about antibiotics?
emergence of resistance
Psoriasis
common, chronic autoimmune inflammatory disorder by plaque formation
-Mild: red patches with silvery scales on usual dry patches of skin
-Severe: entire skin surface and mucous membranes, pustules, high fever, leukocytosis, and painful fissuring of the skin
Psoriasis involves 2 processes
accelerated maturation of epidermal cells
excessive activity of inflamed cells
Psoriasis treatments
NO CURE
reduce inflammation
topical treatments
systemic treatments
phototherapy - tar and safe sunlight with sunscreen
What do you tell your pt about the tar used on psoriasis?
can stain skin and hair
unpleasant odor, irritation, stinging and burning
cover for 8-10 hours
What do you avoid when treating psoriasis?
scrubbing (worse and painful)
long exposure to water
trying to remove scales
A patient who has severe psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which of the following actions should the nurse take first?
A. Discuss the possibility of participating in an online support group.
B. Encourage the patient to volunteer to work on community projects.
C. Suggest that the patient use cosmetics to cover the psoriatic lesions.
D. Ask the patient to describe the impact of psoriasis on quality of life.
D. Ask the patient to describe the impact of psoriasis on quality of life.
