Tissue Integrity - Exam 4 Flashcards
- largest organ
- protective barrier
- nursing responsibility to assess and monitor skin integrity
Skin
What is the purpose of the skin?
- protection
- sensory
- vitamin D synthesis
- Fluid balance
- natural flora
What to assess on the skin?
- bony prominences **
- visual and tactile
- assess any rashes or lesions
- note hair distribution
- skin color
- blanch test
How often do you assess high risk patients ?
Assess every 4 hours or more often
During the skin assessment identify signs and symptoms of?
Impaired skin integrity
Poor wound healing
Assess skin when
- on admission
- at least once/shift
We palpate areas of redness to determine if skin in
Blanchable
Sensory perception
Ability to respond meaningfully to pressure related discomfort
Moisture
Degree to which skin is exposed to moisture
Activity
Degree of physical activity
Mobility
Ability to change and control body position
Nutrition
Usual food intake pattern
Sensory Perception:
completely limited
-unresponsive
- limited ability to feel pain over most of the body
Sensory Perception:
- Very limited
- painful stimuli
- cannot communicate discomfort
- sensory impairment over half the body
Sensory Perception:
- slightly limited
- verbal commands
- cannot always communicate discomfort
- sensory impairment 1-2 extremities
Sensory Perception
- no impairment
- verbal commands
- no sensory deficit
Sensory Perception
- completely limited
- very limited
- slightly limited
- no impairment
Moisture
- constantly moist
- perspiration, urine, ect
- always
Moisture
- very moist
- often but not always
- linen changed at least once per shift
Moisture
- occasionally Moist
- extra linen changed qday
Moisture
- rarely moist
- usually dry
Moisture
- constantly moist
- very moist
- occasionally moist
- rarely moist
Activity
- bedfast
Never out of bed
Activity
- chairfast
- ambulation severely limited to non-existent
- cannot bear own weight (assisted to chair)
Activity
- walks occasionally
- short distances daily with or without assistance
- majority of time in bed or chair
Activity
- walks frequently
- outside room 2x per day
- inside room q2 hours during walking hours
Mobility
- completely immobile
makes no change in body or extremity position
Mobility
- very limited
- occasional slight changes in position
- unable to make frequent/significant changes independently
Mobility
- slightly limited
frequent slight changes independently
Mobility
- no limitation
- major and frequent changes without assistance
Nutrition
- very poor
- never ears complete meal, very little protein
- NPO, clear liquids, IV > 5 days
Nutrition
- probably inadequate
- barely eats complete meal, some protein
- occasionally takes dietary supplement
- Receives less than optimum liquid diet or two feeding
Nutrition
- adequate
- eats over half of most meals, adequate protein
- usually takes a supplement
- Tube feeding or TPN probably meets nutritional need 
Nutrition
- excellent
- eats most of meal, never refuses, plenty of proteins
- occasionally eat between meals
- Does not require supplements 
Friction and Sheer
- problem
- moderate to maximum assistance in moving
- frequently slides down in bed or chair
- Spasticity, contractures or agitation leads to almost constant friction
Friction and sheer
- potential problem
- moves feebly, requires minimum assistance
- skin probably slides against sheets
- relatively good position in chair or bed with occasional sliding
Friction and sheer
- no apparent problem
- moves in bed and chair independently
- Sufficient muscle strength to lift up completely during move
- Good position in bed or chair
Low risk (Braden scale)
15-18
- regular turning schedule
- enable as much activity as possible
- protect heels
- manage moisture, friction and sheer
Low risk 15-18
Moderate risk (Braden scale)
13-14
- regular turning schedule
- enable as much activity as possible
- protect heels
- manage moisture, friction and sheer
- position patient at 30 degree lateral incline using wedges or pillows
Moderate risk
High risk (Braden scale)
12 or less
- regular turning schedule
- enable as much activity as possible
- protects heels
- manage moisture, friction, and sheer
- position patient at 30 degree lateral incline using wedges or pillows
- make small shrifts in position frequently
- pressure redistribution surface
High risk 12 or less
Stage 1 (wound staging)
Nonblanchable redness
Stage II (wound staging)
Partial- thickness
Stage III
Full thickness skin loss
Stage IV - wound staging
Full-thickness tissue loss
Unstageable/unclassified
Full thickness skin or tissue loss-depth unknown
Suspected deep
Tissue injury depth unknown
What does the C in “chant” mean
Cleanse
What does the H mean in Chant
Hydrate and protect the skin
What does the “A” mean in CHANT
Alleviate pressure
What does the “N” in CHANT mean?
Nourish
What does the “T” in CHANT mean?
Treat
What are the 4 nursing priorities for skin?
-Assessing and monitoring skin integrity
-Identifying risks
-Identifying present skin problems
-Planning, implementing, and evaluating interventions to maintain skin integrity
Sequential response to cell injury
-Neutralizes and dilutes inflammatory agent
- removes necrotic materials
- establishes an environment suitable for healing and repair
Inflammation is always present with ______, but infection is not always present with ______.
Infection; inflammation
Tissue trauma causes an ___ ____ in the first 24hours
Inflammatory response
Vascular response result
Redness, heat, and swelling at site of injury and surrounding area
—— and —— move through capillary wall and accumulate at site if injury
Neutrophils / monocytes
Bone Morrow releases more —- in response to infection, WBC elevated
Neutrophils
Local response to inflammation
Redness
Heat
Pain
Swelling
Loss of function
Systemic response to inflammation
Increased WBC count
Malaise
Nausea
Anorexia
Increased pulse and RR
Fever
Acute inflammation
- healing in 2-3 weeks, no residual damage
- neutrophils predominant cell type at site
Subacute
Last longer then acute
Chronic inflammation
- May last for years
- injurious agent persists or repeats injury to site
- predominant cell types are lymphocytes and macrophages
- May result from changes in immune system
Health promotion
- prevention of injury
- adequate nutrition
- early recognition of injury/inflammation
- immediate treatment
Classic manifestations of inflammation may be masked for _____ patient, early symptom may be general malaise
Immunosuppressed
Vitals signs change how when infection is present?
Temperature
Pulse
Respiratory rate may increase
Fever greater than ___ can be damaging to body cells
104
Finale phase of inflammatory process is ?
Healing
What are the two major components of healing?
Regeneration & repair
Replacement of lost cells and tissues with cells of the same type
Regeneration
Healing as a result of lost cells being replaced by connective tissue, results in scar formation
Repair
What are the three phases of healing by primary intention
- Initial phase
- Granulation
- Maturation phase
Initial phase
3-5 days
Acute inflammatory response
Granulation phase
- fibroblast secrete collagen
- wound pink & vascular
- risk for dehiscence
- resistant to infection
Maturation phase
- scar formation
- begins 7 days after injury
- fibroblast disappear
- wound becomes stronger
- mature scar forms
Healing by ——- intention, where the wound may need to be debriefed before healing can take place
Secondary
- irregular, large wound with blood clot
- granulation tissue filled in wound
- large scar
Healing by secondary intention
Occurs when a contaminated wound is left open and sutured closed after infection is controlled
Healing by tertiary intention
- contaminated wound
- granulation tissue
- delayed closure with suture
Healing by tertiary intention
What are the three components of wound healing for partial- thickness wounds?
- inflammatory response
- epithelial proliferation and migration
- reestablishment of epidermal layers
What are the four phases in full thickness wound healing?
- Hemostasis
- inflammatory phase
- proliferative phase
- maturation phase
- full thickness wounds extend into dermis, they heal by scar formation
Factors that influence wound healing
Nutrition, tissue perfusion, infection, and age
Nutrition- wound healing
-Protein, vitamins, and trace minerals of zinc & copper
- adequate calories
Tissue perfusion - wound healing
Oxygen fuels cellular functions
Age - wound healing
Decreased function of macrophages leads to delayed inflammatory response in older adults
Hemorrhage
Bleeding
Hematoma
Bleeding under skin
Infection
Bacteria, virus
Dehiscence
Wound opens up
Evisceration
Wound falling out
Wounds are classified by
Cause and depth
- surgical/ non surgical
- acute or chronic
Superficial, partial thickness , full thickness
Wound cause by shear, friction, and blunt force
Skin tear
- can be partial thickness or full thickness
Wound assessment should happen when?
On admission and every shift
Wound assessments include
Location, size, condition of surrounding tissue, and wound base
Tunneling
Looking at a wound and goes deeper than what we can see
Undermining
Wound expanding under skin
Management of wounds includes
- types of dressings
- depends on type
- extent
- character of wound
- phase of healing
What can we use on wounds for closure ?
Adhesive strips
Sutures
Staples
What is the enemy of wound healing?
Dryness
Antimicrobial and antibactericidal solutions can damage new epithelium and delay healing, should not use in a clean ____ ____
Granulating wound
Surgical wounds may be covered with ____ ___, removed in _____ days
Sterile dressing. 2-3 days
What is the most conning drain type for wounds
Jackson-Pratt
Debridement
Removal of dead tissue and debris
Purposes of dressings
Protects
Aids in hemostasis
Promotes healing
Supports wound site
Promotes thermal insulation
Provides a moist environment
Types of dressings
- gauze
- transparent film
- hydrocolloid
- hydrogel
- foam
- composite
Prepare the patient for a dressing change
- review previous wound assessment
- evaluate pain ~pain meds needed?
- describe procedure
- gather all supplies
Recognize normal signs of healing - answer questions about procedure or wound
Cleaning skin and drain sites
- clean from least contaminated to the surrounding skin
- gentle friction
- when irrigating, allow the solution to flow from the least to most contaminated area
Suture removal
How many to remove- document
Clip near skin, opposite of knot
Steri-strips
Don’t pull or create tension
Teach to allow them to fall off naturally
(About 10 days)
——- doses of antibiotics can decrease the incidence of infection in certain kinds of surgery
Prophylactic
Prophylactic antibiotics should be given when
Prior to surgery
Cephalosporins are widely used, especially —- and —- generations
First; seconds
Most effective against cells undergoing active growth and division. One of the most widely used antibacterial drugs
Cephalosporins
Surgical site infection prevention
May be given prophylactic antibiotics
