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Module 1 > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

1
Q

Florence Nightingale quote

A

If the patient has a bedsore, it is not the fault of the disease, but the nursing

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2
Q

Skin

A

-Largest organ
-Protective barrier
-Nursing responsibility to assess and monitor skin integrity

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3
Q

Vitamin D synthesis

A

Calcitriol- activated form of vitamin D

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4
Q

Natural Flora

A

Staph, Strep, E.coli

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5
Q

Dermis

A

-Eccrine sweat gland
-Apocrine sweat gland

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6
Q

Assessment of the skin

A

-Inspect entire body
-ESPECIALLY BONY PROMINENCES
-Visual & tactile
-Assess any rashes or lesions
-Hair distribution
-Skin color
-Blanch test

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7
Q

Healthy skin should

A

Blanch

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8
Q

What light is the best for skin assessment?

A

Natural light

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9
Q

Assess the skin when?

A

On initiation of care, then a least once a shift

High-risk patients- assess every 4 hours or more

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10
Q

Friction

A

Skin dragging against surfaces
-can cause skin tears and blisters

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11
Q

Shear

A

Sliding movement of skin and subq tissue while the underlying muscle and bone are stationary.
Causes stretching and tearing of blood vessel which reduce blood flow increase blood pooling and can lead to cell damage

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12
Q

Avoid shearing when

A

Raising the HOB

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13
Q

Sensory perception

A

Ability to respond meaningfully to pressure-related comfort

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14
Q

Moisture

A

Degree to which skin is exposed to moisture

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15
Q

Activity

A

Degree of physical activity

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16
Q

Mobility

A

Ability to change and control body position

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17
Q

Nutrition

A

Usual food intake pattern

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18
Q

Braden Scale Low Risk

A

15-18
-Regular turning schedule
-Enable as much activity as possible
-Protect heels
-Manage moisture, friction, and shear

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19
Q

Moderate risk

A

13-14
-Position patient at 30 degree lateral incline using wedges or pillows

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20
Q

High risk

A

12 or less
-position patient at 30 degree lateral incline using wedges or pillows
-make small shifts in position frequently
-pressure redistribution surface

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21
Q

Tissue integrity interventions

A

-frequent-repositioning
-sitting in chair for 2 hour intervals
-keep HOB at 30º

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22
Q

HOB no higher than 30º for

A

Skin integrity purposes
If patient can’t breathe, raise higher

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23
Q

C.H.A.N.T

A

Cleanse
Hydrate (and protect) skin
Alleviate pressure
Nourish
Treat

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24
Q

Red/Excoriated Peri/Rectal area

A

-Cleanse
-Dry thoroughly
-Moisture barrier daily and prn

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25
Q

Redness/Excoriation between skin folds

A

-Cleanse
-Dry thoroughly
-Place inter dry or dry AG textile in skin folds

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26
Q

Red Heels

A

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

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27
Q

Red Sacral/Coccyx area

A

-Change positions q 1-2 hours
-HOB <30º unless contraindicated
-Avoid excess moisture
-Frequent peri care
-Wrinkle free linen

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28
Q

sequential response to cell injury

A

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

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29
Q

Inflammation ≠ Infection

A

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

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30
Q

Inflammatory response occurs with multiple conditions

A

-Surgical wounds, other skin injuries
-Allergies
-Autoimmune diseases
-Skin infections

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31
Q

Wound

A

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

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32
Q

What is important to wound healing

A

Wound assessment and classification

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33
Q

Mast cells

A

Secrete factors that mediate vasodilation and vascular constriction. Delivery of blood, plasma, and cells to injured area increases

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34
Q

Neutrophils

A

New white blood cells, secrete factors that kill and degrade pathogens

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35
Q

5 cardinal signs of inflammation

A

Pain
Heat
Redness
Swelling
Loss of function

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36
Q

Type of exudate

A

Serous
Purulent
Serosanguineous
Sanguineous

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37
Q

Serous

A

Clear, watery plasma

38
Q

Purulent

A

Thick, yellow, green, tan, or brown

39
Q

Serosanguineous

A

Pale, red, watery: mixture of serous and sanguineous

40
Q

Sanguineous

A

Bright red, indicates active bleeding

41
Q

Systemic response to inflammation

A

-Increased WBC count
-Malaise (Lethargic)
-Nausea and anorexia
-Increased pulse and respiratory rate
-Fever

42
Q

Types of inflammation

A

-Acute
-Subacute
-Chronic

43
Q

Acute inflammation

A

-Healing in 2-3 weeks, no residual damage
-Neutrophils predominant cell type at site

44
Q

Subacute inflammation

A

Same features, but lasts longer

45
Q

Chronic inflammation

A

-May last for years
-Injurious agent persists or repeats injury to site
-lymphocytes and macrophages
-May result from changes in immune system

46
Q

Final phase of inflammatory process is

A

Healing

47
Q

Regeneration healing

A

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

48
Q

Repair healing

A

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

49
Q

Healing by primary intention

A

-Initial phase: acute inflammatory response
-Granulation phase: wound pink & vascular, resistant to infection
-Maturation phase: scar formation: 7 days after injury, mature scar forms

50
Q

Eschar

A

Dead tissue

51
Q

Wound approximation

A

Edges of wound able to be pulled together

52
Q

Healing by secondary intention

A

-Wounds from trauma, ulceration, & infection have large amounts of equate and wide, irregular wound margins
-Edges cannot be approximated
-Wound may need to be derided before healing can take place

53
Q

Healing by tertiary intention

A

-Delayed primary intention due to delayed suturing of wound
-Occurs when contaminated wound is left open and sutured close free infection is controlled

54
Q

Factors that affect wound healing

A

-Nutrition
-Tissue perfusion
-Infection
-Age

55
Q

Complications of wound healing

A

Hemorrhage
Hematoma
Infection
Dehiscence
Evisceration

56
Q

Dehiscence

A

Separation/splitting open layers of surgical wound

57
Q

Hemorrhage

A

Bleeding

58
Q

Hematoma

A

Bleeding under skin (bruise)

59
Q

Evisceration

A

Extrusion of visceral or intestine through a surgical wound

60
Q

Wounds are classified by

A

Cause: Surgical or non-surgical, acute or chronic
Depth: Superficial, partial thickness, full thickness

61
Q

Skin tear

A

Wound caused by shear, friction, and/or blunt force

62
Q

Wound assessment, include:

A

Location
Size
Condition of surrounding tissue
Wound base
Any drainage (consistency, color, odor)
Factors that could delay healing

63
Q

What is the enemy of wound healing

A

Dryness

64
Q

Never use __________ on a wound

A

Peroxide

65
Q

Granulating

A

Tissue that is in the process of healing

66
Q

Goal is for wound to be as moist as

A

Healthy skin

67
Q

Surgical wounds may have a drain placed to

A

Help remove excess fluid
(Jackson-Pratt drain is common)

68
Q

Purpose of dressings

A

-Protects from microorganisms
-Aids in hemostasis
-Promotes healing by absorbing drainage or debrieding a wound
-Supports wound site
-Promotes thermal insulation
-Provides moist environment

69
Q

Types of dressings

A

-Gauze
-Transparent film
-Hydrocolloid
-Hydrogel
-Foam
-Composite

70
Q

What do you need to do to dressings?

A

Put date and time

71
Q

Removing sutures

A

-Remove every other suture
-Document how many
-Clip near skin
-Steri strips

72
Q

Pressure ulcer/injury

A

-Localized injury to skin and/or underlying tissue (usually over bony prominences)
-Results from prolonged pressure or pressure in combo with shearing
-Will generally heal by secondary intentio

73
Q

Pressure ulcer/injury influencing factors

A

Pressure intensity
Pressure duration
Tissue tolerance factors
Shearing forces
Moisture

74
Q

Pressure ulcer/injury risk factors

A

-Age
-Anemia
-Diabetes
-Increased temp
-Friction
-Impaired circulation
-Low BP
-Obesity
-Shear

75
Q

Slough

A

Thick yellow/white/grey covering of the wound bed

76
Q

Stage I

A

-Intact skin — non-blanchable redness of a localized area
-most common over bony prominence

77
Q

Stage II

A

-Partial thickness loss of dermis
-Shallow open ulcer with red/pink wound bed
-May also present as intact or ruptured blister
Fat and deeper tissues not visible

78
Q

Stage III

A

-Full thickness skin loss
-Subq tissue may be visible,but bone, tendon, or muscle are not
-Presents as deep crater

79
Q

Stage IV

A

-Full thickness loss, extends to muscle, bone, or supporting structures
-Bone, tendon, or muscle may be visible or palpable
-Slough or eschar may be present
-Undermining and tunneling may also occur

80
Q

You cannot stage a wound if

A

Slough is covering it

81
Q

Unstageable ulcer

A

-Full thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed

82
Q

Suspected deep tissue injury

A

-Purple or maroon localized area of discolored intact skin or blood filled blister

83
Q

Cellulitis

A

Systemic infection caused by localized skin injury

84
Q

Stage III and IV pressure injuries acquired after admission

A

NEVER want to happen

85
Q

Venous leg ulcrs

A

-Poor blood return to heart
-Surrounding skin may be red, scaly, weepy, and thin
-Shallow, irregular shape

86
Q

Diabetic ulcers

A

-Located on sole of floor, under heels and on toes

87
Q

Cellulitis

A

-Inflammation of subq tissue, often following break in skin
-Treatment:moist heat, immobilization, elevation

88
Q

The most important treatment for infection is

A

Prevention!

89
Q

Psoriasis

A

-Common, chronic autoimmune inflammatory disorder characterized by plaque formation with varying degrees of severity

90
Q

Mild psoriasis

A

red patches covered with silvery scales on scalp, elbows, knees, palms, and soles

91
Q

Severe psoriasis

A

May involve entire skin surface and mucous membranes, superficial pustules, high fever, painful fissuring of the skin

92
Q

Psoriasis treatment

A

Avoid:
-Scrubbig
-Long exposures to water
-Trying to remove scales

Module 1 (15 decks)

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