Tissue Integrity Part 1 Flashcards by Osvaldo Colmenero

Where are pressure injuries most common?

Bony Prominences, more specifically, the sacrum and heels

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What are the 2 causes of pressure ulcers?

Pressure and shearing force (insides rubbing against skin)

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What Pressure ulcers generally heal by?

Second intention healing

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Influencing factors of pressure ulcers

Pressure intensity
Pressure duration
Tissue tolerence (4 Factors)
- Nutrition
- Perfusion
- Co Morbidities
- Condition of soft tissure
Shearing force
Moisture

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How to assess skin

Look for darker ares
Temp
Skin Constitute/Consistency
Patient Sensations

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Main identifier for Stage I pressure ulcer?

Non Blanchable Redness
Different Temp
Different Color
Skin Fully intact

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Main Identifiers for Stage II pressure ulcers?

Partial Thickness Loss/Slightly Open Skin
Fat and inner tissue/Muscle are NOT visible
No slough or eschar

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Main Identifiers for Stage III pressure ulcers?

Full thickness loss(Dermis and Epider.)
Fat may be visible but bone, tendons, or muscle are not
Possible undermining or tunneling

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Main identifiers for Stage IV pressure ulcers?

Full thickness loss as well as muscle bone and supporting structures are visible
Slough/Eschar present

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What causes an Unstageable Ulcer?

Too much Slough or Eschar

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Possible Slough and Eschar Colors

Slough:
- Yellow
- Tan
- Green
- Grey
- Brown

Eschar
- Tan
- Brown
- Black

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How to notice a Suspected Deep Tissue Injury?

Purple or maroon area or Bloodfilled blister

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What can untreated ulcers lead to?

Cellulitis (Systemic)

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How often should you assess patient for RISKS of skin breakdown?

q 12 hours

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6 categories on Braden scale

Sensory
Moisture
Activity
Mobility
Nutrition
Friction/Shear

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T/F: On braden Cale higher number is better

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Risk Categories from Braden scale

15-16 is Mild
13-14 Moderate
12 or less High

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Difference between HOB levels for SKIN and for Oxygen purposes

Skin: 30 or less
Oxygen: 30 or more

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If pt is incontinent, how can you help prevent ulcers?

Clean with no rinse care and use barrier ointment

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Care plan steps

Prevent deterioration
Reduse factors
Prevent Infection
Promote healing
Prevent recurrence

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What can we not doc for ulcers?

If there’s an infection or not

Who determines how to clean ulcers

Wound care specialists

What to teach pt’s families for prevention?

Early signs
Nutritional support
Care techniques
Turn Schedule

3 other types of skin damage

Moisture associated
Incontinece Associated
Med adhesive related

How do lower extremitiy ulcers differ from pressure ulcers? Common Cause?

Cause by blood flow issues usually due to chronic disease Peripheral Artery Disease (PAD) Blood is stuck or cannot get to LE

Signs of PAD

Hair loss Brittle Nails Dry, Shiny, Scaly Skin Ulcers Bruits

What causes venous leg ulcers?

Poor blood flow to heart from legs

Where can you find venous ulcers?

Lower legs

Venous Ulcers characteristics?

Irregular margins, superficial

Surrounding skin of venous ulcers

Red Scaly Thin Much Darker

What usually causes diabetic ulcers?

Neuropathy (Lack of sensation)

Where are diabetic ulcers usually found?

Bottom of foot (plantar)

Why are diabetic ulcers dangerous?

Can easily turn into cellulitis

How to treat cellulitis?

Moist heat Immobilization Elevation Systemic antibiotics therapy IV hospitalization if severe infection

What is the best way to help skin and wound infection?

PREVENTION

What meds can treat skin and soft tissue infections?

Cephalosporins Some penicillins(Narrow spectrum) Carbapenems Vancomycin Clindamycin Linezolids Daptomycin Levofloxacin

What are the narrow spectrum penicillins>

Pen. G V Nafcillin Oxavillin Dicloxacillin

How can you give Penicillin's?

PO IM IV

What should never be mixed in same IV solution?

Penicillins and aminoglycosides

What is penicillin not effective against?

MRSA

Why is penicillin great?

Least toxic, it is very safe clinically

Where is pen. metabolized and eliminated?

Kidneys

Pen. adverse reactions

Allergies, pain at injection site, neurotoxicity

What are cephalosporins?

Bactericidal

Examples of Cephalosporins>

Ceftriaxone: Surgery, Bone/Joint infection, Skin Infection Cefepime: Pseudomonas Ceftaroline: MRSA

Psoriasis

Chronic Autoimmune Inflammatory Disorder causing plaque formation of varying levels

Mild Psoriasis

Red Patches with SILVERY SCALES on scalp, elbows, knees, palms and soles

Severe Psoriasis

Entire Skin Surface affected as well as mucous membranes High Fever Leukocytes Painful Skin Fissures

How to treat Psoriasis:

Goal is to reduce inflammation Topical and systemic treatments Phototherapy, SUNLIGHT

What to avoid when treating psoriasis?

Scrubbing/Scratching Long exposure to water Removing scales