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Module 1 > tissue integrity pt 2 > Flashcards

tissue integrity pt 2 Flashcards

1
Q

pressure ulcers/injury

A

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

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2
Q

how many pressure ulcer sites

A

22

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3
Q

influencing factors
pressure intensity

A

amount of pressure

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4
Q

influencing factors
pressure duration

A

length of Time pressure is exerted on skin

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5
Q

influencing factors
tissue tolerance factors

A

ability of tissue to tolerate pressure
-nutrition
-perfusion
-co-morbidities
-condition of soft tissue

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6
Q

influencing factors
shearing forces

A

when skin adheres to a surface and skin layers slide in direction of body movement

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7
Q

influencing factors
moisture

A

excessive moisture leads to skin breakdown

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8
Q

risk factors (15)

A

-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

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9
Q

clinical manifestations

A

-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

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10
Q

suspected deep tissue injury

A

-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

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11
Q

skin assessment for pts with dark skin
darker areas of skin

A

look for areas of skin that are darker than surrounding skin. these may appear purple, brown or blue

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12
Q

skin assessment for pts with dark skin
skin temp

A

use your hand to assess skin. an ulceration may feel warm initially, then become cooler with time

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13
Q

skin assessment for pts with dark skin
skin/tissue consistence

A

apply gentle pressure to common sites of injury to feel consistency. boggy or edematous tissue may indicate a stage 1 pressure ulcer

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14
Q

skin assessment for pts with dark skin
patient sensation

A

pts may report pain or itchy sensation

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15
Q

stage 1

A

-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

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16
Q

stage 2

A

-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

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17
Q

stage 3

A

-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

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18
Q

stage 4

A

-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

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19
Q

unstageable ulcer

A

-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

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20
Q

complications of pressure ulcers
infection

A

-leukocytosis
-fever
-increased ulcer size, odor, or drainage
-necrotic tissue
-indurated, warm, painful

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21
Q

complications of pressure ulcers
untreated ulcers may lead to _________
can lead to ________ and __________

A

cellulitis
sepsis
death

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22
Q

most common complication is ________

A

recurrence of tissue breakdown/repeat pressure ulcers

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23
Q

nursing assessment and management

A

-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

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24
Q

pressure ulcer prevention

A

-redistribution of pressure
-keep dry skin
-reposition
-turning schedule
-nutrition and fluid intake

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25
Q

repositioning

A

-drawsheet or transfer board
-position pt at 30 degrees lateral position
-HOB at 30 degrees or less
-trapeze bar

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26
Q

care planning (PRPPP)

A

-prevent : deterioration
-reduce : factors that contribute to pressure and skin breakdown
-prevent : infection
-promote : healing
-prevent : reoccurrence

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27
Q

what to do if pt has pressure injury

A

-document : stage, size, location, exudate, infection, pain and tissue appearance
(picture, if needed)
-wound care specialists
-surgical treatment

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28
Q

wound care specialists
-general principles

A

-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

29
Q

surgical treatments

A

-may be necessary
-skin grafts, skin flaps, musculoskeletal flaps

30
Q

pt and family teaching

A

-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

31
Q

MASD

A

moisture associated skin damage

32
Q

IAD

A

incontinence associated dermatitis

33
Q

MARSI

A

medical adhesive related skin injury

34
Q

lower extremity ulcers

A

-different pathophysiology from pressure ulcers
-related to changes in blood flow to lower extremities due to chronic disease processes

35
Q

PAD ___(full name)_________ causes problems with ________ in arteries, becoming ________ or ________, usually caused by atherosclerosis

A

peripheral artery diseases
blood flow
narrow
blocked

36
Q

ulcers caused by ________ and nutrition ________ as a result of ________ circulation

A

ischemia
deprivation
decreased

37
Q

material ulcers
skin will be ___________________

A

thin, shiny and dry with loss of hair on ankles, feet

38
Q

diseases that cause people to be at risk for arterial ulcers (8)

A

-atherosclerosis
-PVD
-diabetes
-smoking
-hypertension
-advanced age
-obesity
-cardiovascular disease

39
Q

arterial ulcers can be found (5)

A

between toes
tips of toes
phalangeal head
lateral malleolus
areas with rubbing footwear

40
Q

arterial ulcer wound margins will be (4)

A

even
punched out appearance
pale
deep wound bed

41
Q

must revascularize arterial ulcers with ______ to treat ________, then topical treatment will help with _________ ulcer

A

stents
ischemia
healing

42
Q

venous leg ulcers happen when

A

venous insufficiency occurs when blood flow cannot flow toward from veins in the legs

43
Q

chronic venous insufficiency occurs when

A

valves are damaged, allowing blood to leak backward, resulting in venous stasis

44
Q

people at risk for venous leg ulcers (9)

A

-obesity
-DVT (deep vein thrombosis)
-pregnancy
-incompetent valves
-congestive heart failure (CHF)
-muscle weakness
-decreased activity
-advanced age
-family history

45
Q

venous leg ulcer margins and tissue

A

irregular wound margins and superficial, ruddy granular tissue

46
Q

venous leg ulcers are found where?

A

Lower legs

47
Q

are venous leg ulcers painful?

A

painless to moderately painful

48
Q

surrounding skin of venous leg ulcers

A

red, scaly, weepy, thin

49
Q

_________ therapy promotes blood return and prevents blood from pooling

A

compression

50
Q

diabetic ulcers are caused by

A

-peripheral neuropathy
-fissures in skin and decreased ability to fight infection
-diabetic foot deformities caused by damage to ligaments and destruction of bone

51
Q

diabetic ulcers can be found

A

plantar aspect of foot, over metatarsal heads, under heels and on toes

52
Q

diabetic ulcer wound margins

A

even, rounded or oblong shape with surrounding callus

53
Q

are diabetic ulcers painful?

A

painless

54
Q

diabetic ulcers can easily turn into

A

cellulitis or osteomyelitis

55
Q

treatment of diabetic ulcers

A

removing stress/pressure from injured site, debriding wound, antibiotics if infection occurs

56
Q

cellulitis

A

-inflammation of subq tissue
-often following break in skin
-staph and strep most often cause of infection

57
Q

treatment of cellulitis

A

-Moist heat, immobilization, elevation
-Systemic antibiotic therapy
-Hospitalization if IV therapy warranted (severe infections)
-Progression to gangrene if left untreated

58
Q

treatment of skin and wound infections

A

-Cephalosporins
-Some penicillins (narrow-spectrum pcn)
-Carbapenems
-Vancomycin
-Clindamycin
-Linezolid
-Daptomycin
-Levofloxacin

59
Q

antibiotic resistance

A

emergence of resistance to antibiotics is a major concern

60
Q

bacteria acquire resistance through ____________, where DNA coding for drug resistance is transferred from one bacterium to another

A

conjugation

61
Q

antibiotics do _____ cause ________ changes, but they promote __________ or drug-resistant organisms by creating selection pressures that favor them

A

not
genetic
emergence

62
Q

________ - __________ antibiotics promote ______ resistance than _________-________ antibiotics

A

broad spectrum
narrow spectrum

63
Q

psoriasis

A

common, chronic autoimmune inflammatory disorder characterized by plaque formation with varying degrees of severity

64
Q

mild psoriasis

A

red patches covered with silver scales on scalp, elbows, knees, palms and soles

65
Q

severe psoriasis

A

may involve entire skin surface and mucous membranes, superficial pustules, high fever, leukocytosis, painful fissuring of the skin

66
Q

two processes of psoriasis

A

-accelerated maturation of epidermal cells
-excessive activity of inflammatory cells

67
Q

treatments of psoriasis

A

-topical (glucocorticoids, vitamin D3 analogs, tars)
-systemic (methotrexate, biologic agents)
-safe sun exposure
-phototherapy
-photochemotherapy (PUVA therapy)

68
Q

avoid these psoriasis treatments

A

-scrubbing
-long exposure to water
-trying to remove scales

69
Q

1 sign of psoriasis

A

silver scales of skin

Module 1 (13 decks)

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