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CSON IM1 > EXAM 4- Tissue Integrity 2 > Flashcards

EXAM 4- Tissue Integrity 2 Flashcards

1
Q

pressure ulcer

A

localized injury to skin and/or underlying tissue

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2
Q

where do pressure ulcers typically occur?

A

bony prominences (sacrum/coccyx, heels)

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3
Q

how do pressure ulcers occur?

A
  • prolonged pressure
  • shear force/friction
  • medical devices
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4
Q

how do most pressure ulces heal?

A

secondary intention

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5
Q

pathophysiology of how pressure ulcers occur

A
  1. prolonged pressure, also affected by BMI
  2. lack of capillary flow to tissues
  3. deprives tissues of oxygen & nutrients
  4. cell death, tissue necrosis
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6
Q

influencing factors for pressure injuries

A
  • pressure intensity- amount, BMI, duration
  • braden scale- determines tissue tolerance (comorbidities)
  • shear forces- skin tears
  • moisture- leads to skin breakdown
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7
Q

risk factors for pressure injuries

A
  • mental- deterioration, neuro disorders, incontinence, age
  • vascular- anemia (low bloodflow to tissues), impaired circulation, vascular disease
  • physical- friction, immobility, obesity
  • medical- diabetes, low diastolic BP (< 60), pain, prolonged surgery, increased temp (sweat)
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8
Q

clinical manifestations of pressure ulcers

A

depends on the extent
* staged based on visible/palpable tissue in wound bed
* slough/eschar- unstageable until removed

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9
Q

appearance & texture of deep tissue injury

A
  • purple/maroon localized area
  • intact
  • may be a blood blister
  • painful
  • mushy, boggy, or firm
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10
Q

how do deep tissue injuries occur?

A

pressure/shear injury to underlying soft tissue

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11
Q

how do you assess for pressure ulcers in pts with darker skin?

A
  • appearance- darker than surrounding skin, purple, brown, or blue
  • texture- warm initially, boggy, painful/itchy for pt
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12
Q

stage I

A
  • intact, non-blanchable redness
  • firm, soft, warm or cool
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13
Q

stage II

A
  • partial thickness loss of dermis
  • shallow open ulcer
  • red/pink wound bed or serum-filled blister
  • shiny or dry

like grader on orange peel

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14
Q

stage III

A
  • full thickness skin loss
  • subQ visible
  • deep crater, possible undermining

like peeling orange peel

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15
Q

stage III

A
  • full thickness skin loss
  • subQ visible
  • deep crater, possible undermining

like peeling orange peel

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16
Q

stage IV

A
  • full thickness loss
  • bond, muscle, or tendon visible
  • possible undermining & tunneling
  • possible slough/ eschar

chunk out of orange

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17
Q

unstageable ulcer

A
  • full thickness tissue loss
  • wound bed completely covered by slough/ eschar (must be removed to stage)
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18
Q

slough

A

yellow, tan, green, grey, brown

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19
Q

eschar

A

brown, tan, black

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20
Q

complications of pressure ulcers

A

INFECTION
* leukocytosis
* fever
* ulcer size, odor, drainage increase
* necrotic tissue

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21
Q

what can infected pressure ulcers lead to?

A
  • cellulitis
  • icreased inflammatory, infection of subQ, connective tissue, bone
  • leads to sepsis & death
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22
Q

what is the most common complication for skin breakdown?

A

recurrence

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23
Q

who should you assess for skin breakdown?

A

all pts are at risk

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24
Q

when should you assess the skin?

A
  • on admission
  • at least Qshift (2x/day)
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25
Q

for pts with a pressure injury, how often should you reposition?

A

at least Q2

26
Q

how often should all pts be repositioned?

A

at least Q4

27
Q

how can you keep the skin healthy?

A
  • dry
  • clean
  • moisture barriers
28
Q

how does nutrition prevent pressure ulcers?

A

adequate nutrition & fluid intake

29
Q

care plan for pressure ulcers

A
  1. prevent skin breakdwon, decrease factors, pressure & infection
  2. promote healing
  3. prevent recurrence
30
Q

what should you document when providing care for a pressure ulcer?

A
  • size
  • locaiton
  • stage
  • exudate
  • infeciton
  • pain
  • appearance (photo)
31
Q

what do wound care specialists determine?

A
  • cleansing protocol
  • type of dressing
32
Q

how should you generally clean wounds?

A
  • normal saline
  • slightly moist
  • surgical tx: graft
33
Q

what should you teach your pt with a pressure injury upon discharge?

A
  • prevention- early s/s of inflammation/infection, turning schedule
  • promote- nutrition, care techniques, wound care
34
Q

other types of skin damage

A
  • moisture assoc. skin damade MASD
  • incontinence assoc. dermatitis IAD
  • medical adhesive related skin injury MARSI
  • skin tear
35
Q

why is ostomy care important?

A

they are prone to yeast infections

36
Q

lower extremity ulcers

A

r/t changes in blood flow to lower extremities due to chronic diseases

37
Q

arterial ulcers

A

skin is thin, shiny, dry, loss of hair on ankles & feet, creates ulcers

38
Q

what causes arterial ulcers?

A
  • ischemia &nutrition deprivation as a result of decreased circulation
  • PAD causes lack of blood flow to to arteries, blocked by plaque, usually caused by atherosclerosis
39
Q

who is at risk for arterial ulcers?

A
  • atherosclerosis
  • PVD
  • diabetes
  • smoking
  • HTN
  • age
  • obesity
  • cardiovascular disease
40
Q

where do arterial ulcers occur?

A
  • b/w toes
  • tips of toes
  • lateral malleolus
  • anywhere footwear rubs
41
Q

appearance of arterial ulcers

A
  • round, even margins “hole punch”
  • pale
  • deep
  • painful
42
Q

arterial ulcer treatment

A

stents to treat ischemia

43
Q

venous leg ulcers

A

venous insuficiency that occurs as bloow cannot flow upward from veins in legs
* valves damaged, leads to venous stasis

44
Q

who is at risk for venous leg ulcers?

A
  • obesity
  • DVT
  • pregnancy
  • incompetent valves
  • CHF
  • muscle weakness, decreased activity
  • age
  • family hx
45
Q

where do venous ulcers occur?

A

lower legs

46
Q

appearance of venous ulcers

A
  • irregular margins
  • ruddy, scaley, wet, thin
  • painless to mod. painful
47
Q

tx for venous leg ulcers

A

compression therapy (SCD)
* promotes blood return
* prevents pooling

48
Q

how do diabetic ulcers occur? where?

A
  • peripheral neuropathy, immunocompromised, diabetic foot deformities
  • occur on plantar foot, under heels & toes (bony areas)
49
Q

appearance of diabetic ulcers

A
  • even margin
  • round w/ callous
  • painless
50
Q

what can a diabetic ulcer lead to? what is the tx?

A
  • leads to cellulitis, osteomyelitis
  • tx: decrease pressure, debride, antibiotics
51
Q

clinical manifestations & cause of cellulitis

A

caused by inflammation/ infection (staph & strep) of subQ tissue following a skin break

clinical manifestations:
* hot
* tender
* red
* chills
* malaise
* fever

52
Q

what does cellulitis lead to? what is the tx?

A
  • can lead to gangrene if untreated
  • tx: moist heat, immobilization, elevation
53
Q

what is the best tx for infection?

A

PREVENTION!
* if infection occurs, tx with antibiotics

54
Q

which antibiotic is affective for C-diff & MRSA?

A

vancomycin

55
Q

what is a side effect of most antibiotics?

A

nausea

56
Q

how does bacteria develop antibiotic resistance?

A

bacteria acquire resistance as DNA for drug resistance is transferred

pt does not follow through with entire perscription

57
Q

psoriasis

A
  • chronic, autoimmine inflammation w/ plaque formation
  • mild- red patches w/ silver scales (scalp, elbows, knees, palms, & soles) (liveable)
  • severe- entire skin, high fever, leukocytosis, painfull fissure
  • caused by increased maturation of epidermal cells, increased activity of inflammatory cells
58
Q

tx for psoriasis

A
  • topical- decrease inflammatory cells
  • tar- decrease DNA synthesis, cell proliferation
59
Q

tx for systemic/severe psoriasis

A
  • goal is to decrease epidermal cells proliferation, decrease immune fuction & inflammatory response
  • safe sun exposure
  • photo therapy
  • coal tar
60
Q

what should pts with psoriasis avoid doing?

A
  • scrubbing/ removing scales
  • excessive exposure to water

CSON IM1 (15 decks)

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