Tissue Integrity Part 1 Flashcards
Where are pressure injuries most common?
Bony Prominences, more specifically, the sacrum and heels
What are the 2 causes of pressure ulcers?
Pressure and shearing force (insides rubbing against skin)
What Pressure ulcers generally heal by?
Second intention healing
Influencing factors of pressure ulcers
Pressure intensity
Pressure duration
Tissue tolerence (4 Factors)
- Nutrition
- Perfusion
- Co Morbidities
- Condition of soft tissure
Shearing force
Moisture
How to assess skin
Look for darker ares
Temp
Skin Constitute/Consistency
Patient Sensations
Main identifier for Stage I pressure ulcer?
Non Blanchable Redness
Different Temp
Different Color
Skin Fully intact
Main Identifiers for Stage II pressure ulcers?
Partial Thickness Loss/Slightly Open Skin
Fat and inner tissue/Muscle are NOT visible
No slough or eschar
Main Identifiers for Stage III pressure ulcers?
Full thickness loss(Dermis and Epider.)
Fat may be visible but bone, tendons, or muscle are not
Possible undermining or tunneling
Main identifiers for Stage IV pressure ulcers?
Full thickness loss as well as muscle bone and supporting structures are visible
Slough/Eschar present
What causes an Unstageable Ulcer?
Too much Slough or Eschar
Possible Slough and Eschar Colors
Slough:
- Yellow
- Tan
- Green
- Grey
- Brown
Eschar
- Tan
- Brown
- Black
How to notice a Suspected Deep Tissue Injury?
Purple or maroon area or Bloodfilled blister
What can untreated ulcers lead to?
Cellulitis (Systemic)
How often should you assess patient for RISKS of skin breakdown?
q 12 hours
6 categories on Braden scale
Sensory
Moisture
Activity
Mobility
Nutrition
Friction/Shear
T/F: On braden Cale higher number is better
T
Risk Categories from Braden scale
15-16 is Mild
13-14 Moderate
12 or less High
Difference between HOB levels for SKIN and for Oxygen purposes
Skin: 30 or less
Oxygen: 30 or more
If pt is incontinent, how can you help prevent ulcers?
Clean with no rinse care and use barrier ointment
Care plan steps
Prevent deterioration
Reduse factors
Prevent Infection
Promote healing
Prevent recurrence
What can we not doc for ulcers?
If there’s an infection or not
Who determines how to clean ulcers
Wound care specialists
What to teach pt’s families for prevention?
Early signs
Nutritional support
Care techniques
Turn Schedule
3 other types of skin damage
Moisture associated
Incontinece Associated
Med adhesive related
How do lower extremitiy ulcers differ from pressure ulcers? Common Cause?
Cause by blood flow issues usually due to chronic disease
Peripheral Artery Disease (PAD) Blood is stuck or cannot get to LE
Signs of PAD
Hair loss
Brittle Nails
Dry, Shiny, Scaly Skin
Ulcers
Bruits
What causes venous leg ulcers?
Poor blood flow to heart from legs
Where can you find venous ulcers?
Lower legs
Venous Ulcers characteristics?
Irregular margins, superficial
Surrounding skin of venous ulcers
Red
Scaly
Thin
Much Darker
What usually causes diabetic ulcers?
Neuropathy (Lack of sensation)
Where are diabetic ulcers usually found?
Bottom of foot (plantar)
Why are diabetic ulcers dangerous?
Can easily turn into cellulitis
How to treat cellulitis?
Moist heat
Immobilization
Elevation
Systemic antibiotics therapy
IV hospitalization if severe infection
What is the best way to help skin and wound infection?
PREVENTION
What meds can treat skin and soft tissue infections?
Cephalosporins
Some penicillins(Narrow spectrum)
Carbapenems
Vancomycin
Clindamycin
Linezolids
Daptomycin
Levofloxacin
What are the narrow spectrum penicillins>
Pen. G V Nafcillin Oxavillin Dicloxacillin
How can you give Penicillin’s?
PO IM IV
What should never be mixed in same IV solution?
Penicillins and aminoglycosides
What is penicillin not effective against?
MRSA
Why is penicillin great?
Least toxic, it is very safe clinically
Where is pen. metabolized and eliminated?
Kidneys
Pen. adverse reactions
Allergies, pain at injection site, neurotoxicity
What are cephalosporins?
Bactericidal
Examples of Cephalosporins>
Ceftriaxone: Surgery, Bone/Joint infection, Skin Infection
Cefepime: Pseudomonas
Ceftaroline: MRSA
Psoriasis
Chronic Autoimmune Inflammatory Disorder causing plaque formation of varying levels
Mild Psoriasis
Red Patches with SILVERY SCALES on scalp, elbows, knees, palms and soles
Severe Psoriasis
Entire Skin Surface affected as well as mucous membranes
High Fever
Leukocytes
Painful Skin Fissures
How to treat Psoriasis:
Goal is to reduce inflammation
Topical and systemic treatments
Phototherapy, SUNLIGHT
What to avoid when treating psoriasis?
Scrubbing/Scratching
Long exposure to water
Removing scales
