EXAM 4- Tissue Integrity Flashcards
(83 cards)
1
Q
what is the largest organ?
A
skin
2
Q
who is responsible for assessing & monitoring skin integrity?
A
RN
3
Q
can the RN delegate skin integrity monitoring?
A
yes
responsibility still falls on RN
4
Q
what is the skin’s main function?
A
protective barrier
5
Q
what is the purpose of the skin?
A
- proteciton
- sensory
- vintamin D (gut)
- fluid balance
- natural flora (fights bacteria/infection)
6
Q
true or false
you only have to assess the parts of the skin that are damaged/not intact when assessing
A
false
inspect the entire body
7
Q
where should you assess skin on the body?
A
inspect the entire body
* bony prominences (low fat/muscle, coccyx, shoulders, head)
8
Q
what senses do you use to assess the skin?
A
- visual & tactile- texture, temp
9
Q
what do you assess the skin for?
A
- rash & lesions
- hair distribution
- skin color
- blanch test (lack of blood flow)
all are @ risk for skin breakdown
10
Q
what can put a pt at risk for skin breakdown?
A
- age (young/old)
- diabetic
- incontinence
- bedbound
- poor level of sensation
- poor movement
- s/s of skin integrity
11
Q
how often should you assess the skin?
A
- on admission
- at least once/shift (2x/day)
- all @ risk pts: Q4, high risk/wounds Q2
12
Q
what might indicate a skin integrity problem?
A
- areas of redness
- non-blanchable
- pay attention to bony prominences, medical devices, adhesive tape
13
Q
what areas does the braden scale measure?
A
- sensory perception (able to feel & communicate pain)
- moisture (how wet is the skin usually?)
- activity (ambulation)
- mobility (movement/ position shift)
- nutrition (adequate protein, vitamins, frequency)
- friction & shear (sliding in bed)
14
Q
braden scale: sensory perception
A
- completely limited (unresponsive, limited ability to feel pain over most of body)
- very limited (painful stimuli, can’t comunicate discomfort, sensory impairment over 1/2 body)
- slightly limited (verbal commands, can’t always communicate discomfort, sensory impairment on 1-2 extremities)
- no impairment (verbal commands, no sensory deficit)
15
Q
braden scale: moisture
A
- constantly moist (perspiration, urine, etc., always)
- very moist (often but not always, linen changed Qshift)
- occasionally moist (extra linen changed Qday)
- rarely moist (usually dry)
incontinece, folet catheter, brief, sweat
16
Q
braden scale: activity
A
- bedfast (never OOB)
- chairfast (ambulation severly limited to non-existent, can’t bear weight, assisted to chair)
- walks occasionally (short distances daily w/ or w/o assistance, mostly in bed/chair)
- walks frequently (outside room 2x/day, inside room Q2)
17
Q
braden scale: mobility
A
- completely immobile (makes no change in body/extremity position)
- very limited (occasional slight changes in position, unable to make frequent changes independently)
- slightly limited (frequent slight changes independent)
- no limitation (major & frequent changes w/o assistance)
18
Q
braden scale: nutrition
A
- very poor (no complete meals, little protein, NPO, clear liquids, IV > 5 days)
- probably inadequate (rare complete meals, some protein, occasional dietary supplement, less that optimum liquid diet/tube feeding)
- adequate (eats over 50% of meals, adequate protein, usual supplement, tube feeding/TPN probably meets needs)
- excellent (eats most of meals, never refuses, plenty of protein, snacks, supplements not req)
19
Q
braden scale: friction & sheer
A
- problem (mod-max assistance in moving, frequently slides down in bed/chair, agitation/contractions leads to constant friction)
- potential problem (mooves feebly, req min. assistance)
- no apparent problem (moves in bed/chair ind., sufficient muscle strength to lift up completely during move, good position)
20
Q
braden scale: low risk
A
LOW RISK: 15-18
* regular turning schedule
* as much activity as possible
* protect heels
* manage moisture, friction & sheer
21
Q
if a pt is a low risk on the braden scale, do you still have to do skin assessments?
A
yes!! all pts are at risk!
frequent assessment & prevention is required
22
Q
braden scale: moderate risk
A
MODERATE RISK: 13-14
* regular turning schedule
* as much activity as possible
* protect heels
* manage moisture, friciton, & sheer
* HOB 30º, elevate w/ pillows/wedges
23
Q
braden scale: high risk
A
HIGH RISK: < 12
* regular turning schedule
* as much activity as possible
* protect heels
* manage moisture, friciton, & sheer
* HOB 30º, elevate w/ pillows/wedges
* small, frequent position shifts
* pressure redistribution
24
Q
what is the #1 thing you can do to promote skin & tissue integrity?
A
frequent repositioning
25
how long should a pt sit in the chair?
2 hours
26
what education should you teach your pt/family upon discharge?
turning schedule & prevention
27
CHANT
* **C**leanse
* **H**ydrate & Protect (moisture barrier)
* **A**lleviate pressure
* **N**ourish
* **T**reat
28
early intervention for red/excoriated peri area
* cleanse
* dry
* moisture barrier daily & PRN
29
early intervention for red/excoriated skin folds
* cleanse
* dry
* place inner dry or AG textil in skin folds
30
early intervention for red heels
* alleviate pressure
* elevate on pillows
* sage boot
* reduce friction
31
early intervention for red sacral/coccyx area
* change position Q1-2
* HOB 30º
* avoid excess moisture
* frequent peri care
* wrinkle free linen
32
steps for skin integrity assessment & interventions
1. assess & monitor skin integrity
2. identify risks for skin breakdown (braden scale)
3. identify present skin problems
4. plan, implement, & evaluete interventions
| prevent & monitor
32
what occurs during inflammatory response?
sequential response to cell injury
* neutralizes & dilutes inflammatory agent
* removes necrotic materials
* est. suitable healing/repairing environment
inflammation is NOT infection
* inflammation is always present with infection
* infection is NOT always present with inflammation
33
when can an inflammatory response occur?
* surgical wounds, skin injuries
* allergies
* autoimmune diseases
* skin infections
34
wound
any disruption of the integrity & function of tissues in the body
| can be intentional (surgery)or accidental (cut, pressure injury, trauma)
35
what actions are imperative for wound healing?
wound assessment & classification
36
when does the inflammatory response occur for tissue trauma?
within 24 hours
37
# true or false
the inflammatory response mechanism is the same regardless of the injuring agent
true
38
inflammatory response intensity depends on what?
* extent/severity of injury
* reactive capacity of the person
39
vascular response to inflammation
* increased capillary permeability, fluid moves to tissues (swelling), begins as serum fluid, tehn pulls fluid from vessels into the tissues
* redness, heat, swelling
* fibrinogen strengthens blood clots (prevents the spread of bacteria)
40
cellular response to inflammation
* neutrophils & monocyes move to injury (site of infection), increase WBC
* exudate (fluid & leukocytes) depends on severity (local or systemic)
41
clinical manifestations of local inflammation
* redness
* heat
* pain
* swelling
* loss of function
42
clinical manifestations of systemic inflammation
* leukocytosis
* malaise
* nausea, anorexia
* increased HR & RR (fever)
* fever
| occur due to the release of cytokines
43
types of inflammation
| 3
* acute
* subacute
* chronic
44
acute inflammation
* healing in 2-3 weeks, no residual damage
* neutrophils predominant cell type
45
subacute inflammation
* same as acute
* takes longer to heal
| potentially affected by comorbidities
46
chronic inflammation
* may last for years
* injurious agent persists/ repeated injury to site
* lymphocytes & macrophages are predominant cell types
ex: eczema, psoriasis
* symptoms can be treated, but not cured
| constant auto-immunity disorders
47
health promotion for inflammation
* prevention of injury
* adequate nutrition
* early recognition of infeciton/inflammation
* immediate tx
48
what is an early symptom of inflammation?
general malaise
49
change in vital signs for pts with infection
increase in:
* temp
* HR
* RR
50
fever management for infection
* may not be necessary, as mild-mod fevers are usually not harmful
* may make young/old pts more comfortable
* fever > 104 is an emergency
51
what is the final stage of inflammatory process?
healing
52
regeneration
replacement of lost cells/ tissue with the same cell type
53
repair
healing replacement with connective tissue cells, scar forms
* more complex & common
* occurs by primary, secondary, or tertiary intention
54
healing by primary intention
normal (3 phases)
ex: c-section, sewn, healed
55
healing by secondary intention
any trauma wound (not approximated)
* sewn the best way possible, not precise wound/scar
ex: MVC injury
56
healing by tertiary intention
primary intention gone wrong
* must heal from the inside out
ex: c-section, didn't report signs of infection, wound re-open/surgery
57
phases of healing by primary intention
| 3
1. **initial**: (3-5 days) acute inflammatory response
2. **granulation**: fibroblasts secrete collagen, wound is pink & vascular, resistant to infection
3. **maturation**: (begins after 7 days, lasts months/years) scar formation, fibroblasts disappear, wound becomes stronger
58
process of healing by secondary intention
same as primary proces, but inflammatory reaction may be greater, requires debridement before healing can occur
* uneven wound edges, lots of exudate, tissue loss
59
process of healing by tertiary healing
delayed primary inention due to delayed suturing of wound
* occurs when a contaminated wound is left open & sutured closed after the infection is controlled
60
what type of wounds are healed by regeneration?
partial-thickness wounds
61
what type of wounds are healed by repair?
full-thickness wounds
62
what factors influence wound healing?
* **nutrition**: protein, vitamins, sizc & copper, calories
* **tissue perfusion**: O2 fuels cellular functions (blanch test)
* **infection**: prolongs inflammatory response, delays collagen synthesis and epithelialization, increase in cytokines
* **age**: decreased function of macrophages> delayed inflammmatory response (slower healing)
63
complication of wound healing
* **hemorrhage**: excess bleeding
* **hematoma**: collection of blood under the skin
* **infection**
* **dehiscence**: when a wound breaks open (stiches/staples)
* **evisceration**: when something comes out of the wound (body part) (this is why we splint coughs)
64
skin tear
wound caused by friction
* partial or full thickness
* common for elderly pts (thinner skin)
65
what does wound identificaiton depend on?
* wound classification
* surgical/ non-surgical
* acute/ chronic
66
when should you assess wounds?
* on admission
* Qshift (2x/day)
67
when assessing wounds, what should you look for?
* locaiton
* size
* surrounding tissue
* wound base
* drainage (odor, color, consistency)
* factors that could delay healing (hemorrage, hematoma)
68
what does management of wounds depend on?
* type of dressing
* extent of injury
* character of wound
* healing phase
69
management of clean wounds
* cleansing
* closure (adhesive strips, sutures, staples)
70
management of wound dressings
should be clean & slightly moist
71
management of surgical wounds
sterile dressing (removed in 2-3 days)
72
should antimicrobial/bacterial solution be used for wounds & dressings?
no
they can damage new epithelial cells & delay healing
73
purpose of wound drains
remove excess fluid from surgical wounds
| most common is Jackson-Pratt
73
management of contaminated wounds
* **debridement** is required first for healing to occur (must be converted to clean wound)
* **dressings** absorb exudate & clean wound
74
wound dressing purposes
* **protection** - bacteria
* aids in **hemostasis**
* **absorbs drainage**/ debrides
* thermal **insulation**
* **moist** environment
75
types of surgical dressings
* gause
* transparent film
* hydrocolloid
* hydrogel
* foam
* composite
76
process of dressing changes
* review previous wound assessment
* evaluate pain> analgesics
* describe procedure
* remove tape
* recognize normal healing signs
* clean wound edges
* date, time, initial dressing
* document
77
how to clean a wound/drain site?
* clean from least contaminated>surrounding tissue
* irrigation: allow fluid to flow from least>most contaminated
78
suture/staple removal
* match the number that went in
* clip near skin, opposite of know
* document
79
steri-strips removal
* don't pull/ create tension
* allow to fall off naturally (10 days)
* may shower
80
surgical infection prevention
may be given prophylactic antibiotcs
81
pt ed for wounds
* healing process, normal changes
* home wound care
* infeciton prevention (hand hygiene)
* adequate nutrition
* s/s to report
