Tissue Integrity Part 1

Question 1

what is epithelium

Answer 1

tissue that lines the cavities and structure surfaces throughout the body

Question 2

what is debridement

Answer 2

removal of dead, damaged or infected tissue

Question 3

what is granulation

Answer 3

connective tissue that forms on the surface of a healing wound

Question 4

what is tugor

Answer 4

elastic state of skin and tissue

Question 5

what is emollient

Answer 5

agents that soften skin or treat dry skin

Question 6

what is loss of tissue integrity

Answer 6

when skin and underlying soft tissue are compressed btwn a bony prominance and external surface
can occur on any body surface

Question 7

what is the initial sign of loss of tissue integrity

Answer 7

erythema if pressure removed should resolve in less than 1 hour

Question 8

what are characteristics of a stage 1 pressure injury

Answer 8

intact skin w/ localized area of non-blanchable erythema
may be preceded by changes in sensation, temp, or firmness

Question 9

what are characterisitics of a stage 2 pressure injury

Answer 9

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

Question 10

what are characteristics of a stage 3 pressure injury

Answer 10

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

Question 11

what color is slough

Answer 11

yellow

Question 12

what are characteristics of a stage 4 pressure injury

Answer 12

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

Question 13

what are characteristics of an unstageable deep tissue injury

Answer 13

full thickness skin and tissue loss
extent of damage cannot be confirmed bc it is obscured by eschar or slough

Question 14

what are characterisitcs of a suspected deep tissue injury

Answer 14

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

Question 15

what are risks for pressure injuries

Answer 15

immobility
impaired sensory perception or cognition
decreased tissue perfusion
nutritional status
friction or shear
increased moisture
age
obesity

Question 16

how do you promote pressure injury healing

Answer 16

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

Question 17

what are some contributing factors to pressure injuries

Answer 17

bedrest, immobility
incontinence
diabetes and or pvd
malnutrition
decreased sensory perception or cognitive problems

Question 18

how do you recognize cues of pressure injuries

Answer 18

physical assessment/signs and symptoms
inspect entire body, especially bony prominances
wound assessments
stage

Question 19

what do you document for pressure injuries

Answer 19

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

Question 20

what psychosocial assessments should be done

Answer 20

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

Question 21

what laboratory assessments should be done

Answer 21

wound culture if purulent drainage is present
wound culture needs to be obtained prior to 1st dose of antibiotic

Question 22

what are some other diagnostic assessments done

Answer 22

arterial blood flow studies if arterial occlusion is suspected
duplex ultrasound imaging
blood tests for nutritional deficiencies (albumin)

Question 23

how would you analyze the cues and prioritize hypotheses for pressure injuries

Answer 23

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

Question 24

how would you plan and implement- generate solutions and take action for pressure injuries to heal

Answer 24

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

Question 25

how do you evaluate outcomes of pressure injuries

Answer 25

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

Question 26

what is health promotion and maintenance for pressure injuries

Answer 26

recognized risk and implement interventions to prevent injury
begin interventions early for any existing injury
key health members can assist