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Clinical Instruction (Kass) > Skin Integrity > Flashcards

Skin Integrity Flashcards

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1
Q

What are pressure injuries also referred to as?

A

Pressure ulcers
Pressure sores
Bed sores
Decubitus ulcer

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2
Q

What is the definition of a pressure injury?

A

Localized damage to skin or underlying soft tissue usually over a bony prominence typically related to a medical device
The result of intense or prolonged pressure or pressure in combination with shear

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3
Q

How can a pressure injury present?

A

As intact skin
Open ulcer

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4
Q

T/F: pressure injuries do not occur on mucous membranes

A

False. Pressure sores can occur on mucous membranes on the lips, oral mucosa, tongue or inside the nares

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5
Q

What are pressure sores the result of?

A

A combination of pressure, temperature, surface moisture/humidity and airflow

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6
Q

What can affect the tolerance of soft tissue for pressure and shear?

A

Microclimate
Nutrition
Perfusion
Comorbidities
Condition of soft tissue

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7
Q

What is the first stage of pressure injuries?

A

Intact skin with non-blanchable redness
Changes in sensation, temperature or firmness may precede visual changes

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8
Q

What is the second stage of pressure injuries?

A

Partial thickness loss of skin involving epidermis and dermis
Presents as intact or open serum filled blister or crater

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9
Q

Which tissues are especially vulnerable to pressure sores from medical devices?

A

Mucosal medications

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10
Q

T/F: pressure injuries are not usually preventable

A

False. Pressure injuries are frequently avoidable

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10
Q

What is does MDRPI mean?

A

Medical device related pressure injury

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11
Q

What are the risks associated with hospital acquired pressure injuries?

A

Extend length of stay
Decreased health related quality of life
Increased risk of mortality
Increase 30 day readmission rate
Increase cost of patient care

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12
Q

What are medical devices that are frequently responsible for pressure injuries?

A

Nasogastric tubes
Orogastric tubes
Foley catheters
Ostomy tubes
Surgical drainis
Cervical collars
Casts

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13
Q

Where would NIV masks cause pressure sores?

A

Bridge of nose
Bony prominences
Anywhere that mask interface or head gear come in contact with skin

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14
Q

Where would endotracheal tubes cause pressure sores?

A

Lips
Tongue
Corners of mouth
Underneath tape/straps
Under ears
Back of neck

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15
Q

Where do ET tube holders cause pressure sores?

A

Lips
Cheeks
Ears
Back of neck
Skin above lips

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16
Q

Where would bite blocks cause pressure sores?

A

Mouth
Lips
Tongue

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17
Q

Where could tracheostomy tubes cause pressure sores?

A

Skin under the flange

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18
Q

Where could a HHFNC cause pressure sores?

A

Nares
Bony prominences of cheeks
Ears

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19
Q

Where could pulse oximeters cause pressure sores?

A

Under probe site on fingers, toes or ears

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20
Q

Where can a nasal cannula cause pressure sores?

A

Nares
Behind ears
Under chin

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21
Q

Where can facemasks and trach collars cause pressure sores?

A

Under mask straps
Contact points on nose face and neck

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22
Q

Where can CPAP masks cause pressure sores?

Study These Flashcards
A

Circumscribing nose
Bridge of nose
Nares
Chin

23
Q

Who is at the greatest risk for developing pressure sores?

Study These Flashcards
A

Chronically steroid dependent
Patients on vasopressors
Have fragile and edematous skin

24
Why are people who are chronically steroid dependent at greater risk for pressure sores?
Steroids slow process of wound healing
25
Why do patients on vasopressors have a greater risk for pressure sores?
They will have a lower blood pressure making it easier to cut off blood supply to surrounding tissue
26
What patients are generally chronically steroid dependent?
Asthma Osteoarthritis Rheumatoid arthritis Crohn's disease IBS
27
Which patients may have fragile or edematous skin?
Elderly Tissue edema Septic shock
28
What mechanical forces exasperate pressure sore formation?
Pressure Shear Friction Moisture
29
What can shearing forces do to the tissue?
Stretching, kinking and tearing of vessels in the subcutaneous tissues leading to deeper necrosis
30
How does moisture exacerbate skin breakdown?
Moist skin compromises tissue strength and increases risk of breakdown when exposed to pressure and shear
31
What can cause the skin to become moist?
Perspiration Wound drainage
32
How can we reduce skin moisture?
Clean skin routinely Use products that are absorbent and wick moisture away from skin
33
What are protective options to prevent skin breakdown?
Gecko gel pad Sleep comfort nasal pad Mepilex foam Ear protector tubing Skin barrier lotion/topical steroids
34
How long should protective skin barriers be changed?
When dirty Between 3-7 days depending on site conditions
35
T/F: gauze is an acceptable skin protective barrier
False. Never use gauze as a skin protective barrier
36
When using a mask for NIV, what can you do to avoid pressure sores?
Use skin protective barriers Rotate mask types
37
How tight should an NIV mask be?
Should be able to fit 2 fingers under the strap
38
Why should you avoid lifting 1 side of the mask?
Increases risk of injury from shearing forces
39
How do we prevent pressure sores for patients who are intubated?
Move position and check lips/mouth every 4 hours
39
Why should you limit the the number of on/off maneuvers performed when patients are wearing masks?
Limit risk of injury due to shear and friction
40
What can you do to limit the number of on/off procedures for patients on NIV?
Communicate, collaborate and cluster care to minimize on/offs
41
Describe how to remove NIV masks
Reverse of application Remove side clips simultaneously and lift mask from the chin upwards
42
How should the ETT stabilizer strip be positioned?
Should not be tough lips
43
How should the commercial tube holder be set up to avoid pressure injuries?
Dont let straps compress ears 2 finger tightness Change straps if wet, soiled and/or bloody
44
How tight should trach tubes be?
Fit 1 finger underneath
45
How often should oximetry probes be moved?
Every 2 hours
46
Describe the controversy associated with bed angle and pressure sores
>30 degrees reduces chances of VAP <30 degrees reduces changes of compressive pressure on the sacrum
47
What can result from hospital acquired pressure injuries?
Extend length of stay Increase cost of patient care Increase risk of mortality Increase 30 day readmission rate Decrease heath related quality of life
48
Pressure injuries result from a combination of excess
Pressure Temperature Surface Moisture
49
T/F: Patients should have a zero leak from their NIV mask
False
50
What can happen during shearing to blood vessels?
Stretching Kinked Torn
51
During a hand-off, what information about skin breakdown should be communicated?
patients skin integrity strategies for prevention patient risk factors
52
What do secretions or wound drainage on the skin around the tracheostomy site lead to
a decrease in skin integrity
53
How can a pressure injury present?
As intact skin As an open ulcer On the mucus membranes
54
T/F: the ETT stabilizer should not touch the patients lips
true
55
What are options for skin protective barriers?
Ear protector tubing gecko gel pads sleep comfort nasal pads

Clinical Instruction (Kass) (13 decks)

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