Tissue Integrity 2 - Exam 4 Flashcards by Star Harlin

Also called pressure injury

Pressure ulcers

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localized injury to skin or underlying tissue
usually over bony prominences
most common on sacrum and heels

Pressure ulcers

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Results from prolonged pressure or pressure in combination with shearing forces

Pressure ulcers

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Can be injury related to medical or other devices

Pressure ulcers

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Will generally heal by secondary intention

Pressure ulcers

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Pressure intensity

Amount of pressure

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Pressure duration

Length of time pressure is exerted on the skin

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Tissue tolerance factors

Ability of tissue to tolerate the pressure
- nutrition
- perfusion
- co-morbidities
- condition of soft tissue

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When skin adheres to a surface and skin layers slide in direction of body movement

Shearing forces

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Excessive moisture that leads to skin breakdown

Moisture

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Risk factors of pressure ulcers

Advanced age
Anemia
Diabetes
Elevated body temperature
Friction
Immobility
Impaired circulation
Incontinence
low BP
mental disorientation
Neurological disorders
Obesity
Pain
Prolonged surgery
Vascular disease

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

Suspected deep tissue injury

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Indicates damage of underlying soft tissue from pressure and or sheer

Suspected, deep tissue injury

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May be preceded by tissue that is painful, firm, mushy, and boggy

Suspected deep tissue injury

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May be difficult to detect in patients with dark skin tones

Suspected deep tissue injury

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Boggy or edematous tissue may indicate what stage of pressure ulcer

Stage I

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Intact skin- non blanchable redness of a localized area

STAGE I

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common over bony prominence
May be painful, firm, soft, warmer, or cooler as compared to adjacent tissue

STAGE I

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darkly pigmented skin may not have visible blanching

STAGE I

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Partial thickness loss of dermis

STAGE II

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Shallow open ulcer with red/pink wound bed

STAGE II

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May also present as an intact or ruptured serum- filled blister

STAGE II

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Can be shiny or dry shallow ulcer without slough or bruising

STAGE II

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Adipose is NOT visible, and deeper tissues are NOT visible

STAGE II

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Full thickness skin loss

STAGE III

Subcutaneous tissue may be visible, but bone, tendon, or muscle are NOT

STAGE III

Presents as deep crater with possible undermining or adjacent tissue

STAGE III

Ulcer depth varies by location, depending on depth of tissue in that area

STAGE III

Full thickness loss, extends to muscle, bone, or supporting structures

STAGE IV

Bone, tendon, or muscle may be visible or palpable

STAGE IV

Slough or Eschar May be present on some parts of the wound bed

STAGE IV

Undermining and tunneling May also occur

STAGE IV

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

Unstageable ulcer

Slough may be yellow, tan, green, grey, or brown

Unstageable ulcer

Eschar may be tan, brown, or black in the wound bed

Unstageable ulcer

Slough or Eschar must be removed to expose the base of the wound in order to stage

Unstageable ulcer

Stable, dry Eschar on heels should not be removed - which stage is this

Unstageable ulcer

What are some complications of pressure ulcers - infection wise

- leukocytosis - fever - increased ulcer size, odor, or drainage - necrotic tissue - infuriated, warm, painful

Untreated ulcers may lead to

Cellulitis

Osteomyelitis can lead to

Sepsis and death

Signs of infection include

Swelling, redness, foul odor

What is a key sign of infection

Foul odor

Nurses play a critical role in the —— & ——

Prevention & treatment

Assess skin of —— patient on admission and every shift

Every

Assess all patients for risk for skin breakdown every —- hours

Stage —- & —- pressure injuries acquired after admission. NEVER want to happen

III, IV

Sensory/mental - Braden scale

1. Totally limited 2. Very limited 3. Slightly limited 4. No impairment

Moisture - Braden scale

1. Constantly moist 2. Very moist 3. Occasionally moist 4. Dry

Activity - Braden scale

1. Bedfast 2. Chairfast 3. Walks with assistance 4. Walks without assistance

Mobility - Braden scale

1. 100 mobility 2. Very limited 3. Slightly limited 4. Full mobility

Nutrition- Braden scale

1. Very poor 2. 1/2 daily portion 3. Most of portion 4. Eats everything

Friction/ shear

1. Frequent sliding 2. Freebie corrections 3. Independent corrections

15-18 is considered mild risk for ?

> 75 years old

15-16

Mild risk

12-14

Moderate risk

<12

High risk

If incontinent

Clean with no rinse perineal cleaner & supply barrier ointment

Reposition patient

- draw sheet or transfer board - position patient at 30 degrees - HOB at 30 degrees - trapeze bar

What schedule helps prevent pressure ulcers

Turning schedule

What to DOCUMENT when your patient has a pressure ulcer

Stage, size, location, exudate, infection, pain and tissue appearance

Who determines specific cleansing protocols and which types of dressing are appropriate

Wound care specialist

Clean with normal —- to avoid damaging cells

Saline

Keep slightly—- to encourage re-epithelialization

Moist

Skin grafts, skin flaps, or muscuocutaneous flaps are all surgical interventions to aid in

Healing

What can we teach patient and caregivers about pressure ulcers

Early signs of skin breakdown and tissue injury

—- — —- causes problems with blood flow in arteries, becoming narrow or blocked, usually caused by _____

peripheral artery disease; atherosclerosis

Artierial Ulcers are caused by

Ischemia Nutritional deprivation

Arterial ulcers are a result of

Decreased circulation

Are found between toes or on tips of toes, on phalangeal head, lateral malleolus, or areas with rubbing footwear

Arterial ulcers

Even wound margins, punched-out appearance, pale, deep wound bed

Arterial ulcers

Must revascularize with stents to treat ischemia, then topical treatments will help with healing ulcer

Arterial ulcer

Venous insufficiency occurs when blood cannot flow upward from veins in the legs

Venous leg ulcers

Chronic venous insufficiency occurs when valves are damaged, allowing blood to leak backward, resulting in venous stasis

Venous leg ulcers

Patients with obesity, deep vein thrombosis, pregnancy, incompetent valves, CHF, muscle weakness, decreased activity, advanced aged, and family history are at increased risk for

Venous leg ulcers

Found in lower legs, have irregular wound margins and superficial, ruddy granular tissue

Venous leg ulcers

Surrounding skin may be red, scaly, weepy, and thin

Venous leg ulcers

Caused by peripheral neuropathy, fissures in skin and decreased ability to fight infection as well as diabetic foot deformities caused by damage to ligaments and destruction to bone

Diabetic ulcers

Located on plantar aspect of foot over metatarsal heads, under heels and on toes

Diabetic ulcer

Can easily turn into cellulitis or osteomyelitis

Diabetic ulcers

Inflammation of subcutaneous tissue Often following break in skin Staph and strep most often cause of infection

Cellulitis

Hot tender, erythematous, edematous area with diffuse borders Chills, malaise, fever

Cellulitis

Moist heat, immobilization, elevation Systemic antibiotic therapy Hospitalization if IVs therapy warranted Progressions to gangrene if left untreated

Cellulitis treatment

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

Psoriasis

Red patches covered with silvery scales on scalp, elbows, knees, palms, and soles What severity of psoriasis is this?

Mild

May involve entire skin surface and mucous membranes, superficial postures, high fever, leukocytosis, and painful fissuring of the skin What severity of psoriasis is this

Severe

Tissue Integrity 2 - Exam 4 Flashcards

(85 cards)