tissue integrity pt 2 Flashcards
pressure ulcers/injury
localized injury to skin and/or underlying tissue
-usually over bony prominences
-most common on sacrum and heels
-prolonged pressure or pressure in combo with shearing forces
-can be injury related to medical or other devices
-will generally heal by secondary intention
how many pressure ulcer sites
22
influencing factors
pressure intensity
amount of pressure
influencing factors
pressure duration
length of Time pressure is exerted on skin
influencing factors
tissue tolerance factors
ability of tissue to tolerate pressure
-nutrition
-perfusion
-co-morbidities
-condition of soft tissue
influencing factors
shearing forces
when skin adheres to a surface and skin layers slide in direction of body movement
influencing factors
moisture
excessive moisture leads to skin breakdown
risk factors (15)
-advanced age
-anemia
-diabetes
-elevated body temp
-friction
-immobility
-impaired circulation
-incontinence
-low diastolic BP, <60
-mental deterioration
-neurologic disorders
-obesity
-pain
-prolonged surgery
-vascular disease
clinical manifestations
-Depends on the extent of tissue involved
-Staged/categorized based on visible or palpable tissue in the ulcer bed
-Staging is based on the National Pressure Ulcer Advisory Panel (NPUAP) guidelines
-Stage I (minor) to stage IV (severe)
-Presence of slough or eschar may prevent staging until it is removed
suspected deep tissue injury
-Purple or maroon localized area of discolored intact skin or blood-filled blister
-Indicates damage of underlying soft tissue from pressure and/or shear
-May be preceded by tissue that is painful, firm, mushy, and boggy
-May be difficult to detect in patients with dark skin tones
skin assessment for pts with dark skin
darker areas of skin
look for areas of skin that are darker than surrounding skin. these may appear purple, brown or blue
skin assessment for pts with dark skin
skin temp
use your hand to assess skin. an ulceration may feel warm initially, then become cooler with time
skin assessment for pts with dark skin
skin/tissue consistence
apply gentle pressure to common sites of injury to feel consistency. boggy or edematous tissue may indicate a stage 1 pressure ulcer
skin assessment for pts with dark skin
patient sensation
pts may report pain or itchy sensation
stage 1
-intact skin : non-blanch able redness, localized
-bony prominence areas common
-painful, firm , soft, warmer, or cooler as compared to adjacent tissue
-darkly pigmented skin may not have blanch able skin, but color may differ
stage 2
-Partial-thickness loss of dermis
-Shallow open ulcer with red/pink wound bed
-May also present as an intact or ruptured serum-filled blister
-Can be a shiny or dry shallow ulcer without slough or bruising
-Adipose (fat) is not visible, and deeper tissues are not visible
-Granulation tissue, slough, and eschar are not present
stage 3
-Full-thickness skin loss
-Subcutaneous tissue may be visible, but bone, tendon, or muscle are not
-Presents as deep crater with possible undermining or adjacent tissue
-Ulcer depth varies by location, depending on depth of tissue in that area
stage 4
-Full-thickness loss, extends to muscle, bone, or supporting structures
-Bone, tendon, or muscle may be visible or palpable
-Slough or eschar may be present on some parts of the wound bed
-Undermining and tunneling may also occur
unstageable ulcer
-Full-thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed
-Slough may be yellow, tan, green, grey, or brown
-Eschar may be tan, brown, or black in the wound bed
-Slough or eschar must be removed to expose the base of the wound in order to stage
-Note: Stable, dry eschar on heels should not be removed
complications of pressure ulcers
infection
-leukocytosis
-fever
-increased ulcer size, odor, or drainage
-necrotic tissue
-indurated, warm, painful
complications of pressure ulcers
untreated ulcers may lead to _________
can lead to ________ and __________
cellulitis
sepsis
death
most common complication is ________
recurrence of tissue breakdown/repeat pressure ulcers
nursing assessment and management
-nurses play critical role in prevention and treatment
-assess skin of every pt, every shift
-assess all pts for breakdown ever 12 hours
-stage 3 and 4 pressure injuries acquired after admission - never want to happen
pressure ulcer prevention
-redistribution of pressure
-keep dry skin
-reposition
-turning schedule
-nutrition and fluid intake
repositioning
-drawsheet or transfer board
-position pt at 30 degrees lateral position
-HOB at 30 degrees or less
-trapeze bar
care planning (PRPPP)
-prevent : deterioration
-reduce : factors that contribute to pressure and skin breakdown
-prevent : infection
-promote : healing
-prevent : reoccurrence
what to do if pt has pressure injury
-document : stage, size, location, exudate, infection, pain and tissue appearance
(picture, if needed)
-wound care specialists
-surgical treatment
wound care specialists
-general principles
-determine if specific cleansing protocol and which type of dressings are appropriate
-clean with normal saline to avoid damaging cells
-keep slightly moist to encourage re-epithelialization
surgical treatments
-may be necessary
-skin grafts, skin flaps, musculoskeletal flaps
pt and family teaching
-Teach prevention techniques to patient and caregivers, including early signs of skin breakdown and tissue injury
-Continued nutritional support
-Pressure ulcer care techniques, wound care at home
-Turning Schedule
MASD
moisture associated skin damage
IAD
incontinence associated dermatitis
MARSI
medical adhesive related skin injury
lower extremity ulcers
-different pathophysiology from pressure ulcers
-related to changes in blood flow to lower extremities due to chronic disease processes
PAD ___(full name)_________ causes problems with ________ in arteries, becoming ________ or ________, usually caused by atherosclerosis
peripheral artery diseases
blood flow
narrow
blocked
ulcers caused by ________ and nutrition ________ as a result of ________ circulation
ischemia
deprivation
decreased
material ulcers
skin will be ___________________
thin, shiny and dry with loss of hair on ankles, feet
diseases that cause people to be at risk for arterial ulcers (8)
-atherosclerosis
-PVD
-diabetes
-smoking
-hypertension
-advanced age
-obesity
-cardiovascular disease
arterial ulcers can be found (5)
between toes
tips of toes
phalangeal head
lateral malleolus
areas with rubbing footwear
arterial ulcer wound margins will be (4)
even
punched out appearance
pale
deep wound bed
must revascularize arterial ulcers with ______ to treat ________, then topical treatment will help with _________ ulcer
stents
ischemia
healing
venous leg ulcers happen when
venous insufficiency occurs when blood flow cannot flow toward from veins in the legs
chronic venous insufficiency occurs when
valves are damaged, allowing blood to leak backward, resulting in venous stasis
people at risk for venous leg ulcers (9)
-obesity
-DVT (deep vein thrombosis)
-pregnancy
-incompetent valves
-congestive heart failure (CHF)
-muscle weakness
-decreased activity
-advanced age
-family history
venous leg ulcer margins and tissue
irregular wound margins and superficial, ruddy granular tissue
venous leg ulcers are found where?
Lower legs
are venous leg ulcers painful?
painless to moderately painful
surrounding skin of venous leg ulcers
red, scaly, weepy, thin
_________ therapy promotes blood return and prevents blood from pooling
compression
diabetic ulcers are caused by
-peripheral neuropathy
-fissures in skin and decreased ability to fight infection
-diabetic foot deformities caused by damage to ligaments and destruction of bone
diabetic ulcers can be found
plantar aspect of foot, over metatarsal heads, under heels and on toes
diabetic ulcer wound margins
even, rounded or oblong shape with surrounding callus
are diabetic ulcers painful?
painless
diabetic ulcers can easily turn into
cellulitis or osteomyelitis
treatment of diabetic ulcers
removing stress/pressure from injured site, debriding wound, antibiotics if infection occurs
cellulitis
-inflammation of subq tissue
-often following break in skin
-staph and strep most often cause of infection
treatment of cellulitis
-Moist heat, immobilization, elevation
-Systemic antibiotic therapy
-Hospitalization if IV therapy warranted (severe infections)
-Progression to gangrene if left untreated
treatment of skin and wound infections
-Cephalosporins
-Some penicillins (narrow-spectrum pcn)
-Carbapenems
-Vancomycin
-Clindamycin
-Linezolid
-Daptomycin
-Levofloxacin
antibiotic resistance
emergence of resistance to antibiotics is a major concern
bacteria acquire resistance through ____________, where DNA coding for drug resistance is transferred from one bacterium to another
conjugation
antibiotics do _____ cause ________ changes, but they promote __________ or drug-resistant organisms by creating selection pressures that favor them
not
genetic
emergence
________ - __________ antibiotics promote ______ resistance than _________-________ antibiotics
broad spectrum
narrow spectrum
psoriasis
common, chronic autoimmune inflammatory disorder characterized by plaque formation with varying degrees of severity
mild psoriasis
red patches covered with silver scales on scalp, elbows, knees, palms and soles
severe psoriasis
may involve entire skin surface and mucous membranes, superficial pustules, high fever, leukocytosis, painful fissuring of the skin
two processes of psoriasis
-accelerated maturation of epidermal cells
-excessive activity of inflammatory cells
treatments of psoriasis
-topical (glucocorticoids, vitamin D3 analogs, tars)
-systemic (methotrexate, biologic agents)
-safe sun exposure
-phototherapy
-photochemotherapy (PUVA therapy)
avoid these psoriasis treatments
-scrubbing
-long exposure to water
-trying to remove scales
1 sign of psoriasis
silver scales of skin
