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Module 1 > Tissue integrity > Flashcards

Tissue integrity Flashcards

1
Q

skin is the _____ organ

A

largest

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2
Q

skin is a ________ barrier

A

protective

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3
Q

it is the _________ responsibility to assess and monitor skin integrity

A

nurses

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4
Q

purpose of skin (5)

A

-protection
-sensory
-vitamin D synthesis
-fluid balance
-natural flora

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5
Q

when assessing the skin, (6)

A

-look at bony prominences!
-visual and tactile
-assess and rashes or lesions
-note hair distribution
-skin color
-blanch test

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6
Q

skin assessment to do’s (6)

A

-identify the patient’s risk
-identify the signs and symptoms of impaired skin integrity or poor wound healing
-examine skin for actual impairment
-focus on : level of sensation, movement and continence
-assess skin on initiation of care, then at least once/shift
-high risk patients : assess every 4 hours or more

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7
Q

high risk patients should be assessed every _____ hours
-examples of high risk pts

A

4 hours
-diabetes, bedridden,

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8
Q

palpate areas of _______ to determine if skin is blanchable, paying attention to ____________, _____________, and _________________

A

redness
bony prominences
medical devices
areas with adhesive tape

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9
Q

tool used to assess skin - gives number

A

braden scale

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10
Q

braden scale score risk - low

A

15-18

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11
Q

braden scale score risk - Mod

A

13 or 14

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12
Q

braden scale score risk - high

A

12 or less

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13
Q

sensory perception - #1

A

completely limited
-unresponsive
-limited ability to feel pain over most of the body

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14
Q

sensory perception - #2

A

very limited
-Painful stimuli
-Cannot communicate discomfort -Sensory impairment over half the body

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15
Q

sensory perception - #3

A

slightly limited
-Verbal commands
-Cannot always communicate discomfort
-Sensory impairment – 1-2 extremities

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16
Q

sensory perception - #4

A

no impairment
-Verbal commands
-No sensory deficit

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17
Q

moisture - #1

A

constantly moist

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18
Q

moisture - #2

A

very moist
-change linen once per shift

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19
Q

moisture - #3

A

occasionally moist
-change linen twice per shift

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20
Q

moisture - #4

A

rarely moist

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21
Q

activity - #1

A

bedfast
-never OOB

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22
Q

activity - #2

A

chair fast

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23
Q

activity - #3

A

walks occasionally

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24
Q

activity - #4

A

walks frequently

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25
Q

mobility - #1

A

completely immobile
-makes no change in body or extremity position

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26
Q

mobility - #2

A

very limited
-occasional slight changes in position
-unable to make frequent/significant changes independently

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27
Q

mobility - #3

A

slightly limited
-frequent slight changes independently

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28
Q

mobility - #4

A

no limitation
-major and frequent changes without assistance

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29
Q

nutrition - #1

A

very poor
-never eats complete meal, very little protein
-NPO, clear liquids, IV > 6 days

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30
Q

nutrition - #2

A

probably inadequate
-rarely eats complete meal, some protein
-occasionally takes a dietary supplement
-receives less than optimum liquid diet or tube feeding

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31
Q

nutrition - #3

A

adequate
-eats over 1/2 of most meals, adequate protein
-usually takes a supplement
-tube feeding or TPN probably meets nutritional need

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32
Q

nutrition - #4

A

excellent
-eats most of meal, never refuses, plenty of protein
-occasionally eats between meals
-does not require supplements

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33
Q

friction and sheer - #1

A

problem
-moderate to maximum assistance in moving
-frequently slides down in bed or chair
-spasticity, contractures, or agitation leads to almost constant friction

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34
Q

friction and sheer - #2

A

potential problem
-moves freely, requires minimum assistance
-skin probably slides against sheets
-relatively good position in char or bed with occasional sliding

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35
Q

friction and sheer - #3

A

no apparent problem
-moves in bed and chair independently
-sufficient muscles strength to lift up completely during move
-good position in bed or chair

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36
Q

low risk (15-18) - (4)

A

-regular turning schedule
-enable as much activity as possible
-protect heels
-manage motions, friction and sheer

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37
Q

moderate risk (13-14) - (5)

A

-Regular turning schedule
-Enable as much activity as possible
-Protect heels
-Manage moisture, friction and sheer
-Position patient at 30 degree lateral incline using wedges or pillows

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38
Q

high risk (12 or less) - (7)

A

-Regular turning schedule
-Enable as much activity as possible
-Protect heels
-Manage moisture, friction and sheer
-Position patient at 30 degree lateral incline using wedges or pillows
-Make small shifts in position frequently
-Pressure redistribution surface

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39
Q

tissue integrity interventions
frequent repositioning (3)

A

-sitting in chair for 2 hour intervals
-HOB at 30 degrees
-written schedule of turning and positioning

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40
Q

wound staging
Stage I

A

nonblanchable redness

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41
Q

wound staging
Stage II

A

partial-thickness

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42
Q

wound staging
Stage III

A

full-thickness
skin loss

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43
Q

wound staging
Stage IV

A

full thickness
tissue loss

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44
Q

wound staging
unstageable/unclassified

A

full-thickness skin or tissue loss depth unknown

45
Q

wound staging
suspected

A

deep-tissue injury-depth unknown

46
Q

C.H.A.N.T wound protocol

A

C-cleanse
H-hydrate (and protect) skin
A-alleviate pressure
N-nourish
T-treat

47
Q

red/excoriated peri/rectal area
early intervention protocol (3)

A

-cleanse
-dry thoroughly
-moisture barrier daily and prn

48
Q

red heels
early intervention protocol (4)

A

-Position pressure off of heels
-Elevate on pillows
-Sage boot
-Reduce friction

49
Q

redness/excoriation between skin folds
early intervention protocol (3)

A

-cleanse
-dry thoroughly
-place inner dry or dry AG textile in skin folds

50
Q

red sacral/coccyx area
early intervention protocol (5)

A

-change position q 1-2 hours
-HOB <30 degrees unless contradicted
-avoid excess moisture
-frequent peri care
-wrinkle free linen

51
Q

nursing priorities for skin (4)

A

-assess and monitor skin integrity
-identifying risks for skin problems
-identifying present skin problems
-planning, implementing, & evaluating interventions to maintain skin integrity

52
Q

inflammatory response - sequential response to cell injury (3)

A

-Neutralizes and dilutes inflammatory agent
-Removes necrotic materials
-Establishes an environment suitable for healing and repair

53
Q

inflammation =/ infection

A

inflammation is always present with infection, but infection is not always present with inflammation

54
Q

inflammatory response occurs with multiple conditions like (4)

A

-surgical wounds, other skin injuries
-allergies
-autoimmune disease
-skin infections

55
Q

wound def :

A

any disruption of the integrity and function of the tissues in the body

56
Q

wound __________ and ___________ is important to wound healing

A

assessment
classification

57
Q

tissue trauma causes an _____________ ___________ in the first _____ hours

A

inflammatory response
24 hours

58
Q

intensity of inflammatory response depends on (3)

A

-extent and severity of injury
-reactive capacity of injured person
-immune system

59
Q

inflammatory response is _______ regardless of __________ agent

A

same
injuring

60
Q

local response to inflammation (6)

A

ONE AREA
- see and feel
-redness
-heat
-swelling
-pain
-loss of function

61
Q

systemic response so inflammation (6)

A

WHOLE BODY
- can see in vital signs, bloodwork
-increased WBC count
-malaise
-nausea and anorexia
-increase pulse and RR
-fever

62
Q

type of inflammation - acute

A

-healing 2-3 weeks, no residual damage
-neutrophils predominant cell type at site

63
Q

type of inflammation - subacute

A

-same features as acute, but longer length

64
Q

type of inflammation - chronic (4)

A

-may last for years
-injurious agent persists or repeats injury to site
-predominant cell type : lymphocytes and macrophages
-may result from changes in immune system

65
Q

nursing & interprofessional management
health promotion (4)

A

-prevention of injury
-adequate nutrition
-early recognition of injury inflammation
-immediate treatment

66
Q

nursing & interprofessional management
observation / recognition

A

-classic manifestations of inflammation may be masked for immunosuppressed patient, early symptom may be general malaise

67
Q

nursing & interprofessional management
vital signs

A

-important to note, especially if infection present. temp, pulse, RR may increase

68
Q

nursing & interprofessional management
fever management

A

-antipyretics may/not necessary
-fever great than 104 can be damaging

69
Q

final phase of inflammatory process is ______

A

healing

70
Q

healing of wound - 2 components

A
  1. regeneration
  2. repair
71
Q

regeneration of wound

A

replacement of lost cells and tissues with cells of the same type

72
Q

wound repair

A

healing as a result of lost cells being replaced by connective tissue, results in scar formation
- more common
- more complex
- occurs by primary, secondary or tertiary intention

73
Q

initial phase is __ - __ days
_________ inflammatory response

A

3-5
acute

74
Q

granulation phase
fibroblasts secrete ___________
wound __________ and _____________
risk for ____________________
resistant to ______________

A

collagen
pink & vascular
dehiscence
infection

75
Q

maturation phase beings __ _______ after injury and continues for ________/____________

A

7 days
months/years

76
Q

primary intention

A
  1. initial phase
  2. granulation phase
  3. maturation phase and scar formation
77
Q

secondary intention
-wounds have _________ margins with extensive tissue loss
-edges __________ be approximated
-healing process is same as ___________, but inflammatory action may be ___________. wound may be need to be ________________

A

-irregular
-cannot
-primary / greater / debrided

78
Q

tertiary intention
-delayed ______________ intention due to delayed ___________ of wound
-occurs when ______________________

A

-primary / suturing
-a contaminated wound is left open and sutured closed after infection is controlled

79
Q

partial thickness wounds (regeneration)
-_________ components in healing process
-__________________ response
-epithelial _______________ and ________________
-reestablisment of ______________ layers

A

-three
-inflammatory
-proliferation and migration
-epidermal

80
Q

full thickness wounds (repair)
-____ phases in healing process
-____________
-_______________ phase
-______________ phase
-___________
-extend into___________, heal by _______ formation

A

-four
-hemostasis
-inflammatory
-proliferation
-maturation
-dermis / scar

81
Q

factors that influence wound healing

A

-nutrition (protein, vitamins, trace minerals of zinc and copper/adequate calories)
-tissue perfusion (O2 fuels cellular functions)
-infection (prolongs inflammatory stage, delays collagen synthesis, prevents epithelialization, increases cytokine production)
-age

82
Q

hemorrhage - complication

A

bleeding

83
Q

hematoma - complication

A

bleeding under skin

84
Q

infection - complication

A

bacteria, virus

85
Q

dehiscence - complication

A

wound opens up
(pt doesn’t use pillow to cough-splinting, staples open)

86
Q

evisceration - complication

A

wounds open up and things inside begin coming out

87
Q

wound classification and identification

A

-
skin tear
-
-

88
Q

wound classification and identification
classified by ________ and ________
-_________ or non-___________ ; ___________ or ___________
-_____________, _____________ thickness, or _______ thickness

A

cause and depth
-surgical or non surgical ; acute or chronic
-superficial, partial thickness or full thickness

89
Q

wound classification and identification
_________ tear ; wound caused by shear __________ and/or blunt _________
-___________ thickness or ______ thickness
-common in ________ and those ___________/___________ ill

A

skin / friction / force
-partial or full
-older adults / critically or chronically ill

90
Q

wound assessment
-asses skin on __________ and every ___________
-include : (4)
-any ___________ - __________, __________ & ________
-determine if there are factors that could ________ healing

A

-admission/shift
-location, size, condition of surrounding tissue, wound base
-drainage - consistency , color, odor
-delay

91
Q

management of wounds depends on (3)

A

type, extent, and character of wound and phase of healing

92
Q

cleaning wounds
-may need ________ and some type of wound ________ closure, ex. 3 )
-various ___________ available to keep wound ______ and slightly ___________
-_____________ wounds may be covered with _________ dressing, removed in ___-___ days
-____________ is enemy of wound _____________

A

-cleaning / closure / adhesive strips, sutures, staples
-dressings / clean / moist
-surgical / sterile / 2-3 days
-dryness / healing

93
Q

common drain for wound
purpose?

A

Jackson-Pratt drain
remove excess fluid

94
Q

common drain for wound
purpose?

A

Jackson-Pratt drain
remove excess fluid

95
Q

contaminated wounds

A

-must be converted to clean wound before healing can occur
-debridement (removal of dead tissue and debris) may be necessary
-dressings are available that can absorb exudate and clean the wound

96
Q

purposes of dressings (6)

A

-protects from microorganisms
-aids in hemostasis
-promotes healing by absorbing drainage or debriding a wound
-supports wound site
-promotes thermal insulation
-provides a moist environment

97
Q

types of dressings

A

-gauze
-transparent film
-hydrocolloid
-hydrogel
-foam
-composite

98
Q

changing dressings - what to know

A

-know type of dressing, placement of drains, and equipment needed

99
Q

preparing pt for dressing change (6)
-review previous _________ assessment
-evaluate ___________, if indicated, administer ________
-_____________ procedure
-gather all _________________
-recognize normal signs of ____________
-answer _____________ about the procedure or wound

A

-wound
-pain / analgesics
-describe
-supplies
-healing
-questions

100
Q

dressing change comfort measures (7)

A

-administer analgesic meds 30-60 mins before
-carefully remove tape
-gently clean wound edges
-carefully manipulate dressings and drains to minimize stress on sensitive tissue
-turn and position patient carefully
-date and time dressings
-document

101
Q

cleaning skin and drain sites

A

-basic skin cleaning
-clean from least contaminated to the surrounding skin
-use gentle friction
-when irrigating, allow the solution to flow from the least to most contaminated area

102
Q

suture removal

A

-review policy (NII) and orders prior to removing sutures
-how many? document
-clip near skin, opposite of knot

103
Q

steri strips

A

-don’t pull or crate tension
-teach to allow them to fall off naturally (about 10 days), may shower

104
Q

prophylactic doses of antibiotics can _____ the ________ ____ ________ in certain kinds of surgery

A

decrease
incidence of infection

105
Q

prophylactic use of antibiotics for these types of surgeries
contaminated surgeries -

A

-cardiac
-peripheral vascular
-ortho
-GI
-OB/GYN
-contaminated surgeries (fractures, perforated abdominal organs) : antibiotics are treatment, not prophylaxis, as infection rates of these is 100%

106
Q

prophylactic antibiotics should be given _______ surgery and may be __________ if surgery is unusually long

A

prior to
re-doses

107
Q

important things to remember :

A

-Surgical Site Infection prevention - may be given prophylactic antibiotics
-Patient may be distressed about appearance, fear of scars or permanent disfigurement
-Caregivers’ facial expressions can cause further alarm & mistrust
-Teach patient & family healing process & normal changes to wound as it heals, as well as home care of wound, infection prevention (hand washing), s/s to report, adequate nutrition

108
Q

initial phase is __ - __ days
_________ inflammatory response

A

3-5
acute

Module 1 (13 decks)

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