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Module 1 Exam 4 > Tissue Integrity Part 1 > Flashcards

Tissue Integrity Part 1 Flashcards

1
Q

Where are pressure injuries most common?

A

Bony Prominences, more specifically, the sacrum and heels

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2
Q

What are the 2 causes of pressure ulcers?

A

Pressure and shearing force (insides rubbing against skin)

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3
Q

What Pressure ulcers generally heal by?

A

Second intention healing

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4
Q

Influencing factors of pressure ulcers

A

Pressure intensity
Pressure duration
Tissue tolerence (4 Factors)
- Nutrition
- Perfusion
- Co Morbidities
- Condition of soft tissure
Shearing force
Moisture

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5
Q

How to assess skin

A

Look for darker ares
Temp
Skin Constitute/Consistency
Patient Sensations

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6
Q

Main identifier for Stage I pressure ulcer?

A

Non Blanchable Redness
Different Temp
Different Color
Skin Fully intact

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7
Q

Main Identifiers for Stage II pressure ulcers?

A

Partial Thickness Loss/Slightly Open Skin
Fat and inner tissue/Muscle are NOT visible
No slough or eschar

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8
Q

Main Identifiers for Stage III pressure ulcers?

A

Full thickness loss(Dermis and Epider.)
Fat may be visible but bone, tendons, or muscle are not
Possible undermining or tunneling

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9
Q

Main identifiers for Stage IV pressure ulcers?

A

Full thickness loss as well as muscle bone and supporting structures are visible
Slough/Eschar present

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10
Q

What causes an Unstageable Ulcer?

A

Too much Slough or Eschar

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11
Q

Possible Slough and Eschar Colors

A

Slough:
- Yellow
- Tan
- Green
- Grey
- Brown

Eschar
- Tan
- Brown
- Black

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12
Q

How to notice a Suspected Deep Tissue Injury?

A

Purple or maroon area or Bloodfilled blister

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13
Q

What can untreated ulcers lead to?

A

Cellulitis (Systemic)

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14
Q

How often should you assess patient for RISKS of skin breakdown?

A

q 12 hours

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15
Q

6 categories on Braden scale

A

Sensory
Moisture
Activity
Mobility
Nutrition
Friction/Shear

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16
Q

T/F: On braden Cale higher number is better

A

T

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17
Q

Risk Categories from Braden scale

A

15-16 is Mild
13-14 Moderate
12 or less High

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18
Q

Difference between HOB levels for SKIN and for Oxygen purposes

A

Skin: 30 or less
Oxygen: 30 or more

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19
Q

If pt is incontinent, how can you help prevent ulcers?

A

Clean with no rinse care and use barrier ointment

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20
Q

Care plan steps

A

Prevent deterioration
Reduse factors
Prevent Infection
Promote healing
Prevent recurrence

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21
Q

What can we not doc for ulcers?

A

If there’s an infection or not

22
Q

Who determines how to clean ulcers

A

Wound care specialists

23
Q

What to teach pt’s families for prevention?

A

Early signs
Nutritional support
Care techniques
Turn Schedule

24
Q

3 other types of skin damage

A

Moisture associated
Incontinece Associated
Med adhesive related

25
Q

How do lower extremitiy ulcers differ from pressure ulcers? Common Cause?

A

Cause by blood flow issues usually due to chronic disease
Peripheral Artery Disease (PAD) Blood is stuck or cannot get to LE

26
Q

Signs of PAD

A

Hair loss
Brittle Nails
Dry, Shiny, Scaly Skin
Ulcers
Bruits

27
Q

What causes venous leg ulcers?

A

Poor blood flow to heart from legs

28
Q

Where can you find venous ulcers?

A

Lower legs

29
Q

Venous Ulcers characteristics?

A

Irregular margins, superficial

30
Q

Surrounding skin of venous ulcers

A

Red
Scaly
Thin
Much Darker

31
Q

What usually causes diabetic ulcers?

A

Neuropathy (Lack of sensation)

32
Q

Where are diabetic ulcers usually found?

A

Bottom of foot (plantar)

33
Q

Why are diabetic ulcers dangerous?

A

Can easily turn into cellulitis

34
Q

How to treat cellulitis?

A

Moist heat
Immobilization
Elevation
Systemic antibiotics therapy
IV hospitalization if severe infection

35
Q

What is the best way to help skin and wound infection?

A

PREVENTION

36
Q

What meds can treat skin and soft tissue infections?

A

Cephalosporins
Some penicillins(Narrow spectrum)
Carbapenems
Vancomycin
Clindamycin
Linezolids
Daptomycin
Levofloxacin

37
Q

What are the narrow spectrum penicillins>

A

Pen. G V Nafcillin Oxavillin Dicloxacillin

38
Q

How can you give Penicillin’s?

A

PO IM IV

39
Q

What should never be mixed in same IV solution?

A

Penicillins and aminoglycosides

40
Q

What is penicillin not effective against?

A

MRSA

41
Q

Why is penicillin great?

A

Least toxic, it is very safe clinically

42
Q

Where is pen. metabolized and eliminated?

A

Kidneys

43
Q

Pen. adverse reactions

A

Allergies, pain at injection site, neurotoxicity

44
Q

What are cephalosporins?

A

Bactericidal

45
Q

Examples of Cephalosporins>

A

Ceftriaxone: Surgery, Bone/Joint infection, Skin Infection
Cefepime: Pseudomonas
Ceftaroline: MRSA

46
Q

Psoriasis

A

Chronic Autoimmune Inflammatory Disorder causing plaque formation of varying levels

47
Q

Mild Psoriasis

A

Red Patches with SILVERY SCALES on scalp, elbows, knees, palms and soles

48
Q

Severe Psoriasis

A

Entire Skin Surface affected as well as mucous membranes
High Fever
Leukocytes
Painful Skin Fissures

49
Q

How to treat Psoriasis:

A

Goal is to reduce inflammation
Topical and systemic treatments
Phototherapy, SUNLIGHT

50
Q

What to avoid when treating psoriasis?

A

Scrubbing/Scratching
Long exposure to water
Removing scales

Module 1 Exam 4 (5 decks)

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