Tissue Integrity pt. 1 Flashcards
The skin is what
largest organ
the protective barrier
the nurses responsibility to assess and monitor skin integrity
What is the function of the integumentary system?
protect
sensory
vitamin D synthesis ( sun exposure )
Fluid Balance ( how you stay hydrated )
Natural Flora ( good bacteria in our body )
how to inspect what the skin. Select all that apply
- bony prominences
- visual and tactile
- assess any rashes or lesions
- skin color
- blanch test
- capillary refill
bony prominences
visual and tactile
assess any rashes or lesions
skin color
blanch test
Skin assessment
identify the patients risk
identify signs and symptoms of impaired skin integrity or poor wound healing
Examine skin for actual impairment
Focus on: level of sensation, movement, and continence
Assess skin on initiation of care, then at least once/ shift
How many times does the nurse assess a high risk patient?
every 4 hours or more
visual and tactile inspection of ALL the skin
T/F
TRUE
Skin assessment pt 2
palpate areas of redness to determine if the skin is blanchable, paying attention to bony prominences, medical devices, areas with adhesive tape
turning the patient to inspect the skin, assess when patient returns to bed from chair, when bathing, etc.
What is the Braden Scale Tool used form
Used for
Sensory perception
Moisture
Activity
Mobillity
Nutrition
Friction and Shear
Braden Scale Scoring
The lower the number, the higher the risk for decreased tissue integrity
The higher the number, the lower the risk for decreased tissue integrity
Sensory Perception Scales include
- 0
- 1
- 2
- 3
- 4
- 5
- 6
1 - completely limited
- unresponsive
- limited ability to feel pain over most of the body
2 - very limited
- painful stimuli
- cannot communicate discomfort
- sensory impairment over half the body
3 - slightly limited
- verbal commands
- cannot always communicate discomfort
- sensory impairment : 1-2 extremities
4 - no impairment
- verbal commands
- no sensory deficit
Moisture Scale includes
- 0
- 1
- 2
- 3
- 4
- 5
- 6
1 - constantly moist
- perspiration, urine, etc
- always
2 - very moist
- often but not always
- linen changed at least once per shift
3 - occasionally moist
- extra linen changed per day
4 - rarely moist
- usually dry
Activity Scale includes
- 0
- 1
- 2
- 3
- 4
- 5
- 6
1 - bedfast
- never OOB
2 - chairfast
- ambulation severely limited to non-existent
- cannot bear own weight - assisted to chair
3 - walks occasionally
- short distances daily with or without assistance
- majority of times in bed or chair
4 - walks frequently
- outside room 2 x per day
- inside room q 2 hrs during waking hours
Mobility Scale Includes
- 0
- 1
- 2
- 3
- 4
- 5
- 6
1 - completely immobile
- makes no change in body or extremity position
2 - very limited
- occasional slight changes in position
- unable to make frequent/ significant changes independently
3 - slightly limited
- frequent slight changes independently
4 - no limitation
- major and frequent changes without assistance
Nutrition Scale Includes
1 - very poor
- never eats complete meals, very little protein
- NPO, clear liquids, IV > 5 days
2 - probably inadequate
- rarely eats complete meal, some protein
- occasionally takes dietary supplement
- receives less than optimum liquid diet or tube feeding
3 - adequate
- eats over 1/2 of most meals, adequate protein
- usually takes supplement
- tube feeding or TPN probably meets nutritional need
4 - excellent
- eats most of meal, never refuses, plenty of protein
- occasionally eats between meals
- does not require supplements
Friction and Shear Scale
- 0
- 1
- 2
- 3
- 4
- 5
- 6
1 - problem
- moderate to maximum assistance in moving
- frequently slides down in bed or chair
- spasticity, contractures or agitation leads to almost constant friction
2 - potential problem
- moves feebly, requires minimum assistance
- skin probably slides against sheets
- relatively good in position in chair or bed with occasional sliding
3 - no apparent problem
- moves in bed and chair independently
- sufficient muscle strength to lift up completely during move
- good position in bed or chair
What is a LOW risk scale number?
15 - 18
- regular turning schedule
- enable as much activity as possible
- protect heels
- manage moisture, friction and sheet
What is a moderate risk scale number?
13 - 14
- regular turning schedule
- enable as much activity as possible
- protect heels
- manage moisture, friction and sheer
- position patient at 30 degrees lateral incline using wedges or pillows
What is a HIGH risk scale number?
12 or less
- regular turning schedule
- enable as much activity as possible
- protect heels
- manage moisture, friction, and sheer
- position patient at 30-degree lateral incline using wedges or pillows
- make small shifts in position frequently
- pressure redistribution surface
what are some tissue integrity interventions?
FREQUENT REPOSITIONING
SITTING IN CHAIR FOR 2 HR INTERVALS
(if not contraindicated -> longer than 2 hrs may cause pressure to sacral tissue)
KEEPING HOB AT 30 DEGREES NO HIGH THAN THAT
Keeping a written schedule of turning and positioning
What are the pressure injury stages?
Stage 1: Nonblanchable redness
Stage 2: Partial-Thickness
Stage 3: Full-Thickness Skin Loss
Stage 4: Full-Thickness Tissue Loss
Unstageable/ Unclassified: Full-Thickness Skin or Tissue Loss-Depth Unknown
Suspected Deep Tissue Injury-Depth Unknown
What is the early intervention protocol called?
C - cleanse
H - hydrate ( and protect skin )
A - alleviate pressure
N - nourish
T - treat
Redness/ excoriation between skin folds
Cleanse
Dry thoroughly
Place inner dry or dry AG textile in skin folds
- cleanse
- dry thoroughly
- place inner dry or dry AG textile in skin folds
Red heels
- position pressure off of heels
- elevate on pillows
- sage boot
- reduce friction
Red/ excoriated peri/ rectal area
- cleanse
- dry thoroughly
- moisture barrierdaily and prn
red sacral/ coccyx area
- change positions q 1-2 hrs
- HOB <30 degree unless contraindicated
- avoid excess moisture
- frequent peri care
- wrinkle free linen
Nursing priorities for skin?
Assessing and monitoring skin integrity
Identify risks for skin problems
Identifying present skin problems
Planning implementing and evaluating interventions to maintain skin integrity
- assessing and monitoring skin integrity
- identifying risks for skin problems
- identifying present skin problems
- planning, implementing, and evaluating interventions to maintain skin integrity
Sequential response to cell injury
- neutralizes and dilutes inflammatory agent
- removes necrotic materials
- establishes an environment suitable for healing and repair
Any disruption in the skin is still called a what
a wound
any time there’s a break in the skin there will always be what
inflammation
the inflammatory response is always the same response system even if its a small or big wound
T/F
TRUE
Infection is always present with inflammation, but inflammation is not always present with infection
T/F
TRUE
Inflammatory response occurs with which multiple conditions
- surgical wounds, other skin injuries
- allergies
- autoimmune disease
- skin infections
- skin integrity
- surgical wounds, other skin injuries
- allergies
- autoimmune disease
- skin infections
Wound assessment and classification is important to wound healing
T/F
TRUE
Tissue trauma causes an inflammatory response in the first 24 hrs
T/F
TRUE
Inflammatory response mechanism is the same regardless of the injuring agent
T/F
TRUE
Intensity of the inflammatory response depends on
- extent and severity of the injury
- reactive capacity of the injured person
- extent and severity of the injury
- reactive capacity of the injured person
Vascular response to inflammation
- increased capillary permeability, fluid moves into tissue spaces
- initially serous fluid, but eventually contains albumin, pulling more fluid from vessels into tissue
- results: redness, heat, and swelling at site of injury and surrounding area
- fibrinogen is activated to fibrin, which strengthens the blood clot, prevents spread of bacteria
T/F
TRUE
Cellular response to inflammation
- neutrophils and monocytes move through capillary wall and accumulate at site of injury
- bone marrow releases more neutrophils in response to infection, WBC elevated
- complement system - major mediator of inflammatory response
- exudates
( fluid and leukocytes, type and severity of injury, and tissues involved )
T/F
TRUE
Which of these are local responses to inflammation?
- redness
- heat
- pain
- swelling
- loss of function
- HGTW
redness
heat
pain
swelling
loss of function
Which of these are systemic responses to inflammation?
- increased WBC count
- malaise
- nausea and anorexia
- increased pulse and respiratory rate
- fever
- cardinal gaze
increased WBC count
malaise
nausea and anorexia
increased pulse and respiratory rate
fever
causes are poorly understood, but likely due to complement activation and release of cytokines
types of inflammation
acute
subacute
chronic
acute inflammation
healing in 2-3 weeks, no residual damage
neutrophils predominant cell type at site
subacute inflammation
same features as acute but longer
chronic inflammation
may last for years
injurious agent persists or repeats injury to site
predominant cell types are lymphocytes and macrophages
may result from change in immune system
Health Promotions include
- prevention of injury
- adequate nutrition
- early recognition of injury/ inflammation
- immediate treatment
- healing in 2 - 3 weeks, no residual damage
prevention of injury
adequate nutrition
early recognition of injury/ inflammation
immediate treatment
Observation/ Recognition
- classic manifestations of inflammation may be masked for immunosuppressed patient, early symptoms may be general malaise
T/F
TRUE
Vital signs for inflammation
- temperature, pulse, and respiration rates may be increased, especially if infection is increased
T/F
TRUE
Fever Management
- Fevers greater than 104 F can be damaging to body cells. Intervention is necessary
- Antipyretics may not be necessary, as mild, moderate fever usually does little harm. However, very young or very old, uncomfortable, or those with significant medical problems may benefit
T/F
TRUE
What is the final phase of inflammatory process
wound healing
What are the two major components of wound healing
Regeneration
- replacement of lost cells and tissues with cells of the same type
Repair
- healing as a result of lost cells being replaced by connective tissue, results in scar formation
( more complex, more common, occurs by primary, secondary, or tertiary intention )
Primary Intention has 3 phases
- initial phase
- granulation phase
- maturation phase and scar formation
what happens during each of these phases?
Initial Phase
- 3-5 days, acute inflammatory response
Granulation Phase
- fibroblasts secrete collagen, wound pink and vascular, risk for dehiscence, resistant to infection
Maturation Phase and Scar Formation
- begins 7 days after injury, continues for months/ years, fibroblasts disappear, wound becomes stronger, mature scar forms
Healing by secondary intention
- wounds from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss
- edges cannot be approximated
- healing process is same as primary but inflammatory reaction may be greater, wound may need to be debrided before healing can take place
healing by tertiary intention includes
- delayed primary intention due to delayed suturing of wound
- a primary intention healing but got infected and now needs to stitched to be controlled
T/F
TRUE
Partial-Thickness Wound Regeneration Includes
- 3 components in healing process
- inflammatory response
- epithelial proliferation and migration
- reestablishment of epidermal layers
T/F
TRUE
Full-Thickness Wound Repair Includes which of the following phases
- hemostasis
- inflammatory phase
- proliferation phase
- maturation
hemostasis
inflammatory phase
proliferation phase
maturation
full-thickness wounds extend into dermis, they heal by scar formation
What does hemorrhage mean?
bleeding
what does hematoma mean?
bleeding under the skin
what does dehiscence mean
when the wound opens up
what does evisceration mean
when the wound opens up and whatever was supposed to stay inside starts to spill out
Wound ID and classification
classified by cause and depth
- surgical or non-surgical; acute or chronic
- superficial, partial thickness, full thickness
skin tear: wound caused by shear, friction, and/ or blunt force
- can be partial thickness or full thickness
- common in older adults and those critically/ chronically ill
- Payne - martin classification system
- STAR skin classification system
- ISTAP skin tear system
When to assess the wounds?
- assess skin on admission and every shift
- includes: location, size, condition of surrounding tissue, and wound base
- any drainage - consistency, color, odor
- determine if there are factors that could delay healing
Clean wounds include
- may need cleansing and some type of wound closure ( adhesive strips, sutures, staples )
- various dressings available to keep the wound clean and slightly moist
- surgical wounds may be covered with sterile dressin, removed in 2-3 days
- dryness is enemy of wound healing, antimicrobial and antibacterial solutions can damage new epithelium and delay healing, shouldn’t use in a clean granulating wound
T/F
TRUE
surgical wounds may have a drain placed to help remove excess fluid, IE: Jackson-Pratt drain
T/F
TRUE
Contaminated wounds:
- must be converted to clean wounds before healing ca occur
- debridement ( removal of dead tissue and debris ) may be necessary
- dressings are available that can absorb exudate & clean the wound
T/F
TRUE
Purposes of dressings includes
- protects from microorganisms
- aids in hemostasis
- promotes healing by absorbing drainage or debriding a wound
- supports wound site
- promotes thermal insulation
- provides a moist environment
protects from microorganisms
aids in hemostasis
promotes healing by absorbing drainage or debriding a wound
supports wound site
promotes thermal insulation
provides a moist environment
what are the different types of dressings
A. Gauze
B. Transparent Film
C. Hydrocolloid
D. Hydrogel
E. Foam
F. Composite
G. All of the above
G. All of the above
Preparing the patient for a dressing change includes
- reviewing previous wound assessment
- evaluating pain and if indicated, administer analgesics
- describe procedure
- gather all supplies
- recognize normal signs of healing
- answer questions about the procedure or wound
reviewing previous wound assessment
evaluating pain and if indicated, administer analgesics
describe procedure
gather all supplies
recognize normal signs of healing
answer questions about the procedure or wound
Which are the dressing change comfort measures
- administer analgesic medications 30 to 60 minutes before
- carefully clean wound edges
- carefully manipulate dressings & drains to minimize stress on sensitive tissues
- bananana
- turn & position patient carefully
- date and time dressings
- DOCUMENT
administer analgesic medications 30 to 60 minutes before
carefully clean wound edges
carefully manipulate dressings and drains to minimize stress on sensitive tissues
turn and position patient carefully
date and time dressings
DOCUMENT. MAKE SURE TO ALWAYS DOCUMENT.
When cleaning a wound a nurse would do which of these?
- basic skin cleaning ( clean skin and drain )
- clean from least contaminated to the surrounding skin
- use gentle friction
- when irrigating, allow the solution to flow from the least to most contaminated area
- filler
basic skin cleaning ( clean skin and drain )
clean from least contaminated to the surrounding skin
use gentle friction
when irrigating, allow the solution to flow from the least to most contaminated area
- cleaning skin & drain sites
- suture care
- staple removal
are all parts of nursing and interprofessional management?
T/F
TRUE
How to remove sutures
Review policy (NII) & orders prior to removing sutures
How many? DOCUMENT
Clip near skin, opposite of knot
How to remove Steri-strips?
DONT PULL OR CREATE TENSION
Teach to allow them to fall naturally ( about 10 days ), may be shorter
Surgical site infection prevention - may be given prophylactic antibiotics
T/F
TRUE
Patient may be distressed about appearance, fear of scars or permanent
&
Caregivers’ facial expressions can cause further alarm and mistrust ( nurse face )
T/F
TRUE
important point
Teach patient & family healing process & normal changes to wound as it heals, as well as home care of wound, infection prevention ( hand washing ), signs and symptoms to report, adequate nutrition
REMEMBER PATIENT EDUCATION
Cephalosporins are widely used, especially 1st and 2nd generations
- most effective against cells undergoing active growth and division, one of most widely used antibacterial drug
- 1st generation: Cefezolin, Cephalexin
- 2nd generation: Cefotetan
- 3rd generation: Ceftriaxone ( used for active infections, penetrates CSF )
just remember this slide
