Tissue Integrity Part 1 Flashcards
what is epithelium
tissue that lines the cavities and structure surfaces throughout the body
what is debridement
removal of dead, damaged or infected tissue
what is granulation
connective tissue that forms on the surface of a healing wound
what is tugor
elastic state of skin and tissue
what is emollient
agents that soften skin or treat dry skin
what is loss of tissue integrity
when skin and underlying soft tissue are compressed btwn a bony prominance and external surface
can occur on any body surface
what is the initial sign of loss of tissue integrity
erythema if pressure removed should resolve in less than 1 hour
what are characteristics of a stage 1 pressure injury
intact skin w/ localized area of non-blanchable erythema
may be preceded by changes in sensation, temp, or firmness
what are characterisitics of a stage 2 pressure injury
partial thickness loss of skin w/ exposed dermis (top layer eroded)
wound bed is viable, pink or red, and moist
may look like intact or ruptured serum-filled blister
adipose tissue and deep tissue not visible
commonly result from shear in the skin over pelvis and shear in heel
what are characteristics of a stage 3 pressure injury
full thickness skin loss w/ adipose fat visible in ulcer
granulation tissue and rolled wound edges are often present
slough and or eschar may be present
fascia, muscle bone tendon, ligament, cartilage, and or bone are not exposed
undermining and tunneling may be present
subcutaneous tissue may be damaged or necrotic
what color is slough
yellow
what are characteristics of a stage 4 pressure injury
full-thickness skin loss w/ exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone
may have slough or eschar
rolled edges, undermining, or tunneling may be present
what are characteristics of an unstageable deep tissue injury
full thickness skin and tissue loss
extent of damage cannot be confirmed bc it is obscured by eschar or slough
what are characterisitcs of a suspected deep tissue injury
intact or non-intact skin
may look like stage 1
localized area of persistent non-blanchable, deep red, maroon, or purple discoloration
epidermal separation reveals dark would bed or blood-filled blister
what are risks for pressure injuries
immobility
impaired sensory perception or cognition
decreased tissue perfusion
nutritional status
friction or shear
increased moisture
age
obesity
how do you promote pressure injury healing
pressure on the area must be eliminated
pt must not lie or sit on the pressure injury
written plan of care w/ turning and positioning schedule
correct nutritional, fluid, and electrolyte imbalances
increased protein intake to promote healing
increase carbs for energy and to spare protein
vit c and trace elements (zinc) for collagen production and wound healing
what are some contributing factors to pressure injuries
bedrest, immobility
incontinence
diabetes and or pvd
malnutrition
decreased sensory perception or cognitive problems
how do you recognize cues of pressure injuries
physical assessment/signs and symptoms
inspect entire body, especially bony prominances
wound assessments
stage
what do you document for pressure injuries
location
size- record length, width, depth using mm or cm
color
extent of tissue involvement
cell types in wound base and margin
exudate
condition of surrounding tissue
what psychosocial assessments should be done
body image
refer to social service or case worker if financial barrier is noted
refer to home care nurse if pt or caregiver can’t safely carry out plan of care
what laboratory assessments should be done
wound culture if purulent drainage is present
wound culture needs to be obtained prior to 1st dose of antibiotic
what are some other diagnostic assessments done
arterial blood flow studies if arterial occlusion is suspected
duplex ultrasound imaging
blood tests for nutritional deficiencies (albumin)
how would you analyze the cues and prioritize hypotheses for pressure injuries
look for compromised tissue integrity due to vascular insufficiency and trauma (continuous pressure, shear, friction)
identify potential for infection associated w/ immobility, decreased nutritional status, friction and shear forces, and excessive moisture or advanced age
how would you plan and implement- generate solutions and take action for pressure injuries to heal
improving tissue integrity
dressings- debridement w/ wet to dry dressing change
mechanical flushing or necrotic and infective exudate
drug therapy- prescribed enzyme preparations that dissolve necrotic tissue
nutrition therapy
surgical management- removal of eschar
objective evaluation
every 4-6 weeks
measurements of size and depth
inspect for granulation tissue
monitor for signs and symptoms of infection
photograph at weekly intervals- monitors healing process
report changes to primary health care provider
maintain safe environment
how do you evaluate outcomes of pressure injuries
experience progress toward wound healing by 2nd intention as evidenced by granulation, epitheliazation, contraction, and reduction or resolution of wound size
reestablis skin tissue integrity and restore skin barrier function
remain free from local or systemic infections
what is health promotion and maintenance for pressure injuries
recognized risk and implement interventions to prevent injury
begin interventions early for any existing injury
key health members can assist
