Tissue Integrity & Nutrition; tissue Flashcards

Question

what affects proliferative stage in healing

Answer 1

**3-24 days** nutrition is key to the phase - impacts the development of new granulation tissue and new capillary growth. Malnutrition makes healed wound weak - protein!!!! systemic factors: age anemia protein-mia (low protein) zinc deficiency

Answer 2

debridement - mechanical: NSWOC or surgery - chemical: wound care products induction of granulation tissue - firm, red, pebbly debridement/ induction of granulation tissue = wound bed preparation epithelialization - repaired surface

Answer 3

increasing pain, bleeding,increased risk of infection, impacts epithelialization pink to dark red and shiny VAC therapy is a vacuum attached to a sponge (the sponge is the dressing) that is use to promote healing - causes suction to the wound and is only used on healthy wounds

Answer 4

**up to 2 years** same as previous, increased risk for PI. Does not regain pre-injury strength Remodeling or maturation is for full-thickness wounds note: if it is a partial-thickness wound this phase is simply migration - cells migrate across the wound bed

Answer 5

partial-thicness and full-thickness

Answer 6

heals quicker; typically has a much quicker healing time as it is suerficial and only needs epithelial regrowth epidermis and maybe into dermis regeneration occurs through: 1) hemostasis 2) inflammation 3) epithelial proliferation 4) migration (epidermal re-establishment) e.g. superficial skin tear, stage 2 PI, abrasions (road rash), IAD OTA (open to air) can heal in 6-7 days, and with moisture can heal in 4 days.  Full-thickness involves granulation, wound contraction and epithelialization.

Answer 7

takes longer regneration occurs thorugh: 1) hemostasis 2) inflammation 3) proliferation 4) remodeling (up to 2 years) e.g. stage 3 and 4 PI

Answer 8

Vascular response: vasodilation= heat, increased permeability= swelling and redness. Leukocytes can cause pain (Leukocytes= immunity, T and B cells, neuts, basophils and eosinophils, lymphocytes) Made in the bone marrow! Help with phagocytosis. The bleeding phase is within the Inflammation phase as the body attempts to maintain hemostasis, but the bleeding starts first!

Answer 9

AKA pressure ulcers/ sore, decubitus ulcer and bed sore a change in or a break in the skin caused by an injury or trauma related to pressured localized to skin and underlying tissue usually over a body prominence result of pressure, shear, or friction or all 3 affectd by moisture, perfusion and comorbidities

Answer 10

when looking at severity we stage it - can never be back-staged if a PI is bad enough to be a stage 3 then it is always a stage 3. even as it is healing and getting smaller we never change it to stage 2 or 1 as it heals. it gives us an idea of how bad it was.

Answer 11

low pressure over a long period or high pressure over a short period * occludes blood flow * occludes nutrients * cell death

Answer 12

age related changes we have discussed related to integumentary system, mobility and nutrition are all going to affect risk for pI impaired sensory perception imparied mobility alteration of LOC tissue perfusion infection age psychosocial impact of wounds (stress on the system) shearing friction moisture pain nutrition

Answer 13

1) suspected deep tissue injury * discoloured (usually purple or marron) * intact skin * may also be a blood filled blister 2) unstageable * like stage 4 (full-thickness tissue loss) * base of the ulcer is covered by slough or eschar in the wound bed

Answer 14

intact skin darker pigment to area non-blanchable

Answer 15

partial tickness skin loss presenting as a shallow open ulcer with a red/ pink open wound bed

Answer 16

full thickness tissue loss subcutaneous fat may be visible, but bone, tendon and muscle are NOT exposed may have undermining or unneling

Answer 17

full thickness tissue loss with exposed bone muscle or tendon slough may be present

Answer 18

dermatitis = skin inflammation redness with/ withouth blistering, erosion, or loss of the barrier function result of chronic or repeated exposure of the skin to urine or fecal matter

Answer 19

Exposure to urine and feces ↑pH alkaline which allows micro-organisms to thrive and ↑ risk of infection. Feces contain lipid- and protein- digesting enzymes capable of damaging the SC This can be painful (burning, stinging) and embarrassing and is a risk factor for PIs

Answer 20

**YES** IAD confused with stage 1 or 2 PIS both ahve common risk factors IAD = high risk for PI; ↑ risk of infection & morbidity Different etiologies: IAD "top down" injury while PIs are believed to be "bottom up" injuries incontinence is a risk factor for both... IAD can occur in the absence of any PI associated risk factors and vice versa

Answer 21

the challenge for HCP is that these lesions can occur int he same location or in very close proximity, making classification problematic both have common risk factors e.g. incontinence, poor health, immobility the risk of developing PIs has also have been found to increase as the severity score for IAD increases

Answer 22

IAD and PI have different etiologies but may coexist: IAD is a "top down" injury.... damage is initiated on the surface of the skin PI are believed to be a "bottom up" injury, where damage is initiated by changes within the soft tissues below and within the skin. - can occur top down - when medical devices pushing on skin from outside

Answer 23

cause IAD: urinary and/ or fecal incontinence PI: exposure to pressure/ shear location IAD: affects perineum/ genital area PI: bony prominence or associatation with a medical device subjective IAD: pain, burning, itching, tingling PI: may be pain objective IAD: area is diffuse with poorly defined edges intact skin with erythema, with/ wihtout superficial, partial thickness skin loss, secondary superficial skin infection may be present PI: varies from intact skin with non-blanchable erythema to full thickness skin loss, distinct edges or margins, secondary soft tissue infection may be present

Answer 24

highlights: 67 year old/ post-op-thoracotomy/ carcinoma (a skin cancer)/ air leaks - CT/ occasional Tylenol & HM Concerns: - Infection risk- Tube into chest, lung surgery- remember the risks of HAIs Nutrition- needs more protein for healing, Vitamin D (cannot get outdoors), pain or medications might affect nutrition Mobility- independent but how much are they moving? This was a patient I had who was independent but not mobilizing. When I asked if his bottom was sore it was and he had a stage 1 PI. Needed to provide education about prevention and the importance of mobility. Acute: under 6 weeks. Primary intention to heal: It is still open now but once CT is removed it will heal over and be closed.

Answer 25

highlights: 83 year old/ HF/ Edema, SOB and crackles, orthopnea/ O2/ Fluid restrict NP (nasal prongs) and less mobility- risks for PI Arterial and venous ulcer risk due to edema and vascular/arterial insufficiency (will be discussed more in cardiovascular week). This leg wound ie is venous (irregular shape, drainage) Oxygenation- may impact nutrition and intake Fluid restriction- common orders with conditions like heart failure (HF) and renal failure.

Answer 26

1) nutritional screening: pinpoint individuals who are malnourished or at nutritional risk 2) integument screening: pinpoint individuals who are immbile, incontinent, malnourished or at risk due to medical devices malnutrition and integumentary challenges are associated with increased length of stay, costs and morbidity/ mortality

Answer 27

BMI (body mass index)- Weight and body composition change with age Weight peaks in 60’s and decreases beyond 70’s Proportion of body fat increases with age BMI is not perfect- patient may have Normal BMI but poor nutrition, and Not great for persons with ++ muscle mass = high BMI

Answer 28

measurement system for size and make up of body **too much nutrition:** increases stress on the body increases risk for CVS disease, diabetes, sleep apnea, gall bladder disease and some cancers morbid obesity can lead to serious breathing and mobility challenges **too little nutrition:** integ: integumentary issues - PI, IAD, ulcers, infection in wound or invasive device

Answer 29

chronic: vascular ulcer, over 6 weeks, vause of wound is not removed (HF, atherosclerosis) heal: it may not but otherwise would be considered tertiary prevention: checking skin under NP, elevating feet/ patient education on medications and fluids keep wound protected - prevent infection. ensure nutrition. consult if necessary

Answer 30

impaired swallowing - SLP/ upright for meals, up for 30 min post - follow SLP orders/ assist with positioning - risks for PI - skin care and nutrition/ OT and PT/ T&P Q2H - assist with meals/ T&P

Answer 31

basal meatbolic rate - determine the minimum. this is impacted by expenditures and needs - increased by exercise, infection, disease process increasing or decreasing metabolism and ability to digest foods

Answer 32

BMR + energy needed for sustaining life (breathing, circulation, HR, temp) REE (resting energy expenditure) - BMR plus what is needed to digest meals and perform activities

Answer 33

Client who cannot eat: patient cannot swallow or is too high risk of aspiration to safely eat **total parenteral nutrition (TPN)** patient cannot digest/ absorb appropriately or TF is not an option

Answer 34

- can be a permanent intervention - required placement of PEF or PEG as NG or NJ are only temporary PEG and PEJ - inserted in the abdomen into the stomach or small intestine P= percutaneous (through the skin) E= endoscopic (how it is placed) G = gastrostomy (there the end of the feeding tube is placed J- jejunostomy (there the end of the feeding tube is placed) NG or NJ- inserted into the nose. The N is for Naso and the G and the J are the same as above. TPN- is not a permanent option, typically uses an advanced line (typically) inserted by an IV specialist, increased risk of infection. Can use regular IV in some circumstances.

Answer 35

as always is based on the plan and implementation may include: * weights * calorie counts * evaluation of healing * monitoring lab values (fluids, electrolytes, proteins) * evaluating vital signs * assessing sympotms of diagnosis