WEEK 2-ATI Flashcards
alterations in tissue integrity
layers in the skin
epidermis
dermis
hypodermis
epidermis layers
made of up of four or five layers depending on the area of your body (soles of the feet require 5 since it’s thicker skin in that area)
what does the epidermis serve as
the outermost layer of the skin and provides the waterproof nature of the skin and influences skin color
contains natural flora, which is not pathogenic in the body’s normal state
common skin bacteria
Staphylococcus epidermitis, aureus, and cutibacterium acnes
dermis
directly beneath the epidermis
dermis layer
contains 2 layers
The sweat glands, hair, hair follicles, muscle, sensory neurons, and blood and lymphatic vessels are in the dermis.
hypodermis
deepest layer and is also referred to as the subcutaneous fascia
what does the hypodermis contain
This layer contains adipose lobules and connective tissue, as well as hair follicles, sensory neurons, and blood vessels.
who has thinner skin
children and people after the fifth decade
causes of skin pathologies
Allergens, injury, irritants, diseases, immune responses, and genetics
define skin wound
disruption in the epidermal layer that can go deeper into the dermis or subcutaneous tissue.
what happens during the first stage of wound healing
clotting is initiated
vasoconstriction occurs
fibrin mesh is established
vasodilation occurs
causing hyperemia and edema
neutrophils are recruited to kill bacteria and debride necrotic tissue
proliferation
starts from day 3-day 10 and takes weeks to complete
It is characterized by granulation tissue and repair of vascular structures. The new vascular network brings nutrients to help heal the wound. Epithelialization begins. Fibroblasts proliferate to the wound, and granulation tissue develops.
tissue remodeling
occurs from day 21 up to a year
During the remodeling phase, the balance of synthesis of new cells and degradation of tissue is no longer needed. Collagen strengthens the wound.
clients at risk for skin injuries
advanced in age, multiple health problems, physical limitations, poor nutrition, incontinence, poor circulation and oxygenation, decreased sensation, altered cognition, and taking multiple medications.
alterations in skin integrity can occur for a variety of reasons, including…?
moisture, friction, shearing, pressure, burns, and trauma.
friction
Mechanical force of dragging skin across surface.
shearing
The force of body structures upon the skin, moving in opposite direction.
a common cause of moisture-related skin conditions
incontinence
incontinence-associated dermatitis (IAD)
caused by prolonged exposure to moisture from urine and stool.
intertrigo
inflammation of the skin on surfaces that have folds, such as between the fingers, axilla, and under breasts.
example of shearing
An example is the shearing force of the coccyx on the subcutaneous tissues and the friction of the skin surface as the body slides down or is pulled up in bed
friction vs. shearing
Friction affects the superficial layers, whereas shearing affects the deeper tissues.
who is at the highest risk for skin tears
clients older than 65 because aging and fragile skin is more susceptible to separating and tearing
nutrients needed for healing
proteins
carbs
fats
vitamins and growth factors
perfusion
Blood supply to the area.
vitamin A
supports fibroplasia and epithelialization, which are keys to wound healing.
vitamin B
important for enzymatic functions to support wound healing
vitamin C
collagen synthesis, antioxidant response, and angiogenesis.
vitamin D
key for structural integrity and movement across epithelial layers
vitamin E
may have a negative effect on wound healing by negatively affecting collagen synthesis and the inflammatory process.
zinc
. Zinc supports the immune response and decreases the likelihood of infection.
proteins are?
often lost in excretion of wound exudate
amino acids help?
stimulate growth hormone and facilitate inflammation process to help with immunity
vitamins are?
important micronutrients for the healing process
carbohydrates help?
fuel the body and increase hormone growth factor secretion
fats are?
important for normal cell function and are precursors to prostaglandins
conditions that can affect wound healing
vasoconstriction
medications like corticosteroids
taking anti-inflammatory medication the first few days of injury
receiving chemo
diabetes
stress
what medications could impact wound healing
immunosuppressors
like corticosteroids
chronic wounds
open for more than one month or do not progress through the stages of normal wound healing.
chronic nonhealing wounds can be caused by
metabolic disorders, such as diabetes; vascular deficits, such as arterial or venous insufficiency; or mechanical reasons, such as pressure on the skin
who is higher risk for chronic wounds
obese or diabetic clients
who is most prevalent with chronic wounds
clients older than 65
common chronic wound
diabetic foot ulcers
because diabetes impacts blood flow to the wound as well as the body’s ability to fight off infection, so wounds will heal more slowly or fail to heal.
what can poorly treated chronic wounds lead to
necrotic tissue, infection, amputation, sepsis, or death
physical findings in client with chronic wounds
pain, difficulty sleeping, and a reduction in functional status, including completing activities of daily living.
acute wounds
Heals within four weeks.
any break in the skin may have manifestations of what?
pain, warmth, redness, bleeding, or oozing.
examples of common acute wounds
Skin incisions
Skin tears
Abrasions
Moisture-associated skin damage
chronic wounds
Does not heal within four weeks.
examine for chronic wound
wound for…
size
location
depth
drainage
systemic causes of chronic wounds
diabetes, malnutrition, and connective tissue diseases, such as rheumatoid arthritis.
regional causes of chronic wounds
neuropathy, arterial or venous insufficiency, or lymphatic problems.
local causes of chronic wounds
continued pressure, such as from immobility, infection, and autoimmune conditions.
venous ulcer
Located on the medial area of lower extremity. Shallow depth.
arterial ulcer
Punched out appearance with smooth, well-demarcated wound edges
diabetic ulcer
Located on the weight-bearing areas of the feet. Range from superficial to deep
ABI (ankle-brachial index)
An ABI of less than 0.8 may indicate an arterial perfusion problem.
Doppler ultrasound
may be helpful in diagnosing venous problems.
what may not be present in chronic wounds
Acute infection manifestations such as erythema, pain, edema, and fever may not be present in chronic wounds.
biopsy with culture
may be needed, and the presence of greater than 100,000 colony-forming units is indicative of infection
Levine technique for wound culture
swabbing area of 1cm on the wound
laboratory tests that may be helpful in diagnosing chronic wounds
complete blood count (CBC) to assess white blood cells, identify anemia, and count platelets.
BMP can be helpful in evaluating electrolytes and renal status.
infection can be evaluated with what?
STONEES
Size becoming larger
Temperature increasing
Os (bone exposed)
New breakdown
Erythema
Exudate
Smell
Which of the following is an example of a regional cause for chronic wound development?
Malnutrition
Neuropathy
Immobility
Diabetes
Neuropathy
common locations for pressure injuries
the sacrum, hip, buttock, heel, back of the head, shoulder, and elbow.
stages of pressure injuries
4 stages
unstageable
deep tissue injuryy
stage 1 PI
nonblanchable erythema, skin intact
stage 2 PI
Partial thickness loss of skin and may have blisters, wound bed pink and moist
stage 3 PI
Full thickness loss of skin exposed adipose tissue, undermining or tunneling may occur
stage 4 PI
Full thickness loss of skin; fascia, muscle, tendon, ligament, or bone will be exposed. Undermining or tunneling often occur.
unstageable stage of PI
Full thickness loss of skin and tissue but the extent of the wound is obscured by slough or eschar
deep tissue injury stage of PI
Intact or nonintact skin where the area below is persistent nonblanchable deep red, maroon, or purple. A blood-filled blister may be present. Discoloration may appear different on dark skin.
medications helpful for pressure injuries
non-opiate (Tylenol)
NSAIDs (ibuprofen or Motrin)
more severe pain can be treated with morphine or oxycodone (Vicodin)
infections and PIs
PIs do not typically require antibiotics but watch for manifestations of infection.
Superficial skin infections may be treated with topical antibiotics, and deeper infected wounds may require oral or IV antibiotics
A nurse is admitting a client who has a stage 4 sacral pressure injury that is draining yellow exudate. The client has a history of COPD, diabetes, and cerebrovascular accident and a temperature of 38.9° C (102° F). Which of the following diagnostic tests should the nurse plan to request?
Select all that apply.
White blood cell (WBC) count
b
Hemoglobin A1c
c
Wound culture
d
MRI of sacrum
e
Total protein, albumin and prealbumin
how do cells respond to inflammation
increasing white blood cells and inflammatory mediators, such as bradykinin and histamine.
what is a vascular reaction in regards to inflammtion
vasodilation causing redness and warmth.
define infection colonization
If the micro-organism is present and multiplying but not overwhelming the immune system
local infection
occurs once the micro-organisms are sufficient in quantity to challenge the immune system.
unmanaged local infection
the infection can spread to surrounding tissues. If the infection continues, systemic infection can occur.
A nurse is caring for a client with a wound. The infectious disease health care provider has indicated that the wound has colonization. Which of the following does this mean?
Micro-organisms are present but are not causing infection.
who is at increased risk for skin infection
Clients who are over age 65, who smoke, who are immunocompromised, who use steroids, who are obese, or who have malnutrition are at increased risk for wound infection.
comorbities and skin inflammation
Celiac disease may be a comorbidity of inflammatory skin conditions because of the link between gluten and inflammation
phases of infection: contamination
number one
Micro-organisms are present, and the host has the opportunity to protect the wound from infection.
phases of infection
contamination
colonization
local infection
spreading infection
systematic infection
phases of infection: colonization
Microbes multiply but do not yet form an infection.
number 2
phases of infection: local infection
There is warm, red swelling and pain in and around the wound.
number 3
phases of infection: spreading infection
There is an extended area of erythema, swelling of lymph nodes, and general findings such as malaise and anorexia.
number 4
phases of infection: systematic infection
number 5
The infection spreads into the bloodstream and affects the organs of the body.
Which of the following best describes biofilm on a wound?
Layer of microbes that cover the wound bed
signs of anaphylaxis
Hives, gastrointestinal upset, feeling faint or dizzy, tightness in the throat, trouble breathing, wheezing, low blood pressure, elevated heart rate, a feeling of impending doom, and cardiac arrest.
medications that can cause anaphylaxis
Penicillin, aspirin, nonsteroidal anti-inflammatory drugs, and anesthesia
A school nurse is responding to a call from a teacher about a child who is experiencing sudden difficulty breathing, tightness in throat, wheezing, hives, and feeling dizzy. Which of the following should be the nurse’s priority action?
Administer epinephrine intramuscularly.
Be S.A.F.E for managing anaphylaxis
S- Seek treatment, call 911
A- Identify allergen
F- Follow up with an allergy specialist
E- Carry an Epinephrine kit
parkland formula to calculate fluid replacement
2 to 4 ml x kg x % TBSA burned
what can happen from severe burns
fluid loss (dehydration)
important to know the rule of 9s to know how much fluid to replace
rule of 9s
rule of how to calculate how much of the body is burned
front of face- 4.5%
back of face-4.5%
front of chest: 18%
back/trunk: 19%
front of one arm: 4.5%
back of one arm: 4.5%
(obviously applies to both left and right arms)
front of one leg: 9%
back of one leg: 9%
(obviously applies to both left and right legs)
perineal area: 1%
palm of hand: 1%
(obviously applies to both left and right palms)
burn depth
1st degree to 6th degree
1st degree burn
damage to epidermis
such as a sunburn
2nd degree burn
damage to both epidermis and dermis
3rd degree burn
damage to epidermis and dermis
requires skin grafting
4th degree burn
same as third degree-but extending to fat layer
5th degree burn
same as third degree-but extending muscle layer
6th degree burn
same as third degree-but extending to the bone
what can deep burns result in
release of myoglobin, which can lead to rhabdomyolysis and kidney damage
primary survey
ABC
D disability
E exposure
secondary survey
history of events
health history
head to toe assessment
determine depth, size, and severity of burn
diet recs with burns
meet protein, carbs, fats goals
as well as micronutrients (glutamate, vitamin C, zine, selenium)
burn center referral criteria (8 things)
-partial thickness burns greater than 10% OF YOUR BODY
-burns to the FACE, HANDS, GENITALIA, PERINEUM, MAJOR JOINTS
-THIRD degree of FULL thickness burns
-electrical burns, including lightening burns
-chemical burns
-inhalation injury
-clients with preexisting issues that could affect mortality
-clients who have burns PLUS other traumatic injuries
connections to burns
nutrition
mobility
perfusion
who grows more yeast infections
diabetic patients because yeast grows with sugar
what does Group A cause
flesh-eating bacteria
parasites on the skin
scabies
lice
ringworm
what happens to scabies patient
put in isolation
what should you always do before and after each care?
GOOD HAND HYGIENE
what makes an older person not have enough body temperature
skin becomes thinner and loses collagen/elasticity
or (sun damaged or chemical damaged skin)
skin cut reaction
platelets and fribrions clot in
vessels with vasoconstriction
pressure to stop bleeding and things form coming to cut the body
wound healing
hemostatis and inflammation
proliferation
tissue remodeling
does running water could as washing
NO
need soap and water and scrub
virus: shingles
one side of body (follows the nerve path)
isolation (until crusted over)
NO PREG PEOPLE CARING FOR PEOPLE WITH SHINGLES
virus: herpes
blisters, tingling, itchy, painful
around the MOUTH, GENITALS, HANDS
(dentists get this on their hands)
WART (test Q)
raised or flat spot
not painful or draining
scabies
Pimple-like, itchy
Treatment: ointment (all over body and wait before you shower)
Everyone should be treated
eczema/psoriasis
-red and flaky
-itchy
-plaque
-painful
acne
Occurs when oil from the skin blocks the hair follicles, producing lesions commonly referred to as pimples.
contact dermatitis (rash)
Itchy, red, inflamed skin is caused by contact with an irritant or allergen.
rosacea
Dry, thick raised patches. May have a scaly or plaque-like appearance. Often occurs on the scalp, elbows, and knees and may occur in flare-ups. It is caused by an overactive immune response.
urticaria
hives
Patches of red bumps that vary in size. Caused by an allergic response, stress, cold, or other unknown reasons.
phases of infection
contamination
colonization
local infection
spreading infection
systematic infection
contamination
Micro-organisms are present, and the host has the opportunity to protect the wound from infection.
colonization
Microbes multiply but do not yet form an infection.
local infection
There is warm, red swelling and pain in and around the wound.
spreading infection
There is an extended area of erythema, swelling of lymph nodes, and general findings such as malaise and anorexia.
systematic infection
The infection spreads into the bloodstream and affects the organs of the body.
Which of the following best describes biofilm on a wound?
Layer of microbes that cover the wound bed
A school nurse is responding to a call from a teacher about a child who is experiencing sudden difficulty breathing, tightness in throat, wheezing, hives, and feeling dizzy. Which of the following should be the nurse’s priority action?
Administer epinephrine intramuscularly.
serous exudate
thin, watery wound drainage
sanguineous exudate
bloody wound drainage
serosanguineous exudate
thin, watery wound drainage mixed with blood
purulent drainage
INFECTION
green/yellow wound drainage
risk factors for alterations in tissue integrity
mobility, age, chronic illness, accidents, diet, hygiene
wound healing: medications that can impact it
blood thinners
anti-inflammatory
steriods
immunosuppressors (chemo, radiation)
beta-blockers (decrease perfusion)
diabetic medications
test Q: cheeseburger or salmon soup for diet intake for someone would altered skin integrity?
salmon
LEAN piece of meat, healthy carbs
healthy carbs
sweet potato over normal potato
keloids
scarring
can burn off for treatment but doesn’t always work
delayed healing
age and medically ill
chronic wounds: excessive healing
hypertrophic
keloids
chronic wound healing
open for more than a month
doesn’t progress through normal wound healing stages
pain management for chronic wounds
NSAIDs
pain levels
LABS for wounds
CBC (platelets, WBCs, hemoglobin, hematocrit, anemia)
BMP ( heart failure (perfusion can be lowered)
albumin ( pulls the fluid back into the vascular system, like with swelling)
diagnostic tests for wounds
Biopsy, ultrasound, culture (swabbing) (find what it is resistant to)
acute vs chronic wounds
Acute: incision, skin tear, abrasions, moisture-associated damage
Heals within 4 weeks
Chronic: arterial ulcer, venous ulcer, diabetic ulcer
Does not heal within 4 weeks
minor burns
1st and 2nd degree don’t usually need medical attention but 3rd and 4th do
CARE FOR BURNS
3 C’s
cool water (NO ICE/creams)
cover the area (clean dry cloth to prevent infection)
clothing removal (not adhered, first thing to do with chemical burns)
first thing to do with chemical burns
uncover the area, remove clothing!
lactated ringers
treat fluids lost for severe burns
ISOTONIC (goes were you put it)
put it in a IV bag warmer so you dont cause patient to get hypothermic
BURN patient
AIRWAY
BREATHING
CIRULATION (fluid loss, electrolytes, POTASSIUM LEVELS)
