Tissue Integrity pt 2 Flashcards
Influencing factors to pressure injury
- pressure intensity: amount of pressure
- pressure duration: length of time pressure is exerted on the skin
- tissue tolerance factors: ability to tolerate the pressure
- shearing forces: when skin adheres to a surface and skin layers slide in direction of body movement
- moisture: excessive moisture that leads to skin breakdown
just read it
Stage 1 pressure injury
- intact skin - non-blanchable redness of a localized area
- common over bony prominence
- may be painful firm, soft, warmer, or cooler, as compared to adjacent tissue
- darkly pigmented skin may not have visible blanching, but color may differ from the surrounding area
- Nuuh by THAMA
intact skin - non-blanchable redness of a localized area
common over bony prominence
may be pailful firm soft warmer or coolor as compared to adjacent tissue
darkly pigmented skin may not have visible blanching but color may differ from the surrounding area
Stage 2 pressure ulcer
- 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 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
- headache by Millennio
partial thickness loss of dermis
shallow open ulcer with red/ pink wound bed
may present as an intact or ruptured serum- filled blister
can be 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 pressure injury
- full thickness skin loss
- subQ 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
- Iffy by Sik-k, pH-1
full thickness skin loss
subQ tissue may be visible but BONE TENDON OR MUSCLE ARE NOT
presents a deep crater with possible undermining or adjacent tissue
ulcer depth varies by location, depending on depth of tissue in that area
Stage 4 pressure ulcer
- 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
- too much by loco ft dean
full thickness loss EXTENDS TO MUSCLE BONE OR SUPPORTING STRUCTURES
bone tendon or muscle may be visible or palpable
sloud or eschar may be present on some parts of the wound bed
undermining and tunneling may also occur
Unstageable Ulcer/ Injury
- 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 base
- slough or eschar must be removed to expose the base of the wound in order to stage
- NOTE: STABLE DRY ESCHAR ON HEELS SHOULDN’T BE REMOVED
- No makeup by Zion. T
full thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed
sloud may be yellow tan green grey or brown
eschar may be tan brown or black in the wound base
slough and eschar must be removed to expose the base of the wound in order to stage
NOTE: STABLE DRY ESCHAR ON HEELS SHOULDN’T BE 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 patient with darker skin tones
- Bittersweet by Wonwoo and Mingyu
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 diffiicult to detect in patient with darker skin tones
Which of these are other skin damage
- moisture associated skin damage ( MASD )
- medical adhesive related skin injury ( MARSI )
- skin tears
- ostomy skin care
- MASD
- MARSI
- skin tears
Arterial ulcers are caused by what
A. problems with blood flow in arteries, becoming narrow or blocked, usually caused by atherosclerosis
B. blood cannot flow upward from veins in the legs
C. peripheral neuropathy, fissures in skin and decreased ability to fight infection
D. damage to ligaments and destruction of bone
problems with blood flow in arteries, becoming narrow or blocked, usually caused by atherosclerosis
Skin will be thin, shiny, and dry, with loss of hair on ankles and feet
those with atherosclerosis, PVD, diabetes, smoking, hypertension, advanced age, obesity, and CVD are at increased risk for arterial ulcers
Where can a nurse find arterial ulcers
between toes or on tips of toes, on phalangeal head, lateral malleolus, or areas with rubbing footwear
even wound margins, punched out appearance, pale, deep wound bed
How to treat arterial ulcers
must revascularize with stents to treat ischemia, then topical treatments will help with healing ulcer
