Tissue Integrity Part 2

Question 1

What is at fault when a pt gets a bedsore?

Answer 1

The Nurse

Question 2

What are some natural flora on the skin?

Answer 2

Staph.
Strep.
E. Coli

Question 3

What is the activated form of Vitamin D?

Answer 3

Calcatriol

Question 4

What layer of skin are most structures located in?

Answer 4

the dermis

Question 5

What does the subcutaneous layer of skin hold?

Answer 5

Maybe some of the apocrine glands
blood vessels
fat

Question 6

What can a lack of hair indicate?

Answer 6

Low/Bad Circulation

Question 7

What is the best light source to assess skin?

Answer 7

Natural light

Question 8

When should you assess HIGH RISK pt’s?

Answer 8

even 4 hours

Question 9

What should you watch for on pt’s when a pt has medical devices? (Like IV’s or Call Lights)

Answer 9

They can rub against and damage skin

Question 10

On the Braden scale, what is the difference between Mobility and Activity?

Answer 10

Activity = Ability to move out of bed/Walking around
Mobility = Moving around in bed

Question 11

What can cause a 1 on the Braden Scale for moisture?

Answer 11

Inflammation

Question 12

How does Nutrition play a role in skin health?

Answer 12

Protein and fats are very important to help skin

Question 13

Signs of No, Potential or obvious problems for friction/shear?

Answer 13

No = Can move independently
Potential = Moves feebly w/ lil assist.
Obv = Moderate to max assistance

Question 14

Braden scale ranges.

Answer 14

15-18 = Low Risk
13-14 = Moderate risk
12 or less = High risk

Question 15

What devices are used on high risk pt’s?

Answer 15

Pressure redistribution devices

Question 16

What’s a good method of frequent repositioning?

Answer 16

Sitting in chair for 2-hour intervals

Question 17

What is the early intervention protocol for skin integrity?

Answer 17

C.H.A.N.T
Cleanse
Hydrate skin
Alleviate pressure
Nourish
Treat

Question 18

Excoriated

Answer 18

Diaper Rash

Question 19

On heavier pt’s, where can you see skin breakdown?

Answer 19

In between skin folds

Question 20

What can you place in skin folds to help?

Answer 20

Dry tactile to reduce rough friction

Question 21

What should you make sure linens are free of on pt beds?

Answer 21

Wrinkles

Question 22

Wound

Answer 22

Any disruption of the integrity and function of tissue

Question 23

How fast can trauma cause inflammatory responses?

Answer 23

24hr

Question 24

What are Mast Cells?

Answer 24

Ball of Chemical Mediators. Helps w/ vasodilation/constriction to stop bleeding

Question 25

Whatre neutrophils?

Answer 25

New White Blood Cells

Question 26

Inflammatory Process?

Answer 26

1. Bacteria enters wound 2. Platlests stop blood 3. Mast cells activate 4. Neutrophils secrete factors 5 Neu. and Macrophages removes pathogens 6. Macrophages secrete cytokines to attract tissue repair

Question 27

5 signs of inflammations

Answer 27

Redness Heat Pain Swelling Loss of Function (Rare)

Question 28

What is exudate made of?

Answer 28

Fluid and leukocytes

Question 29

What is the vascular response to inflammation?

Answer 29

More cap. permiability Serous fluid Causes the signs of inflammation Activates fibrin to strengthen blood clots

Question 30

Types of exudate?

Answer 30

Serous Purulent Serosanguineous Sanguineous

Question 31

What to do when there's lots of sero/sanguineous fluid

Answer 31

Apply pressure

Question 32

Systemic Responses to inflammation?

Answer 32

More WBC Malaise/Lethargy N&V ^ Pulse and resp. FEVER

Question 33

3 types of inflammation?

Answer 33

Acute (2-3 weeks w/ no damage) Subacute (Just lasts a bit longer) Chronic: Years2

Question 34

2 major types of would healing?

Answer 34

Regeneration: Replacing lost cells w/ cells of same type Repair: Lost cells replaces w/ conn. tissue, causes scars, more common and complex, caused by primary, secondary,, or tertiary intention

Question 35

3 phases of primary intention healing? What is it also called?

Answer 35

Initial Phase: Acute Inflammation Granulation: Collagen secreted, Maturation & Scarring: 7 days after injury, lasts months/years, fibroblasts leave, Edge-Edge or Wound Approximation

Question 36

What causes secondary intention healing?

Answer 36

Trauma, ulcers, Infection

Question 37

What can wounds healed by sec. intention not do? How do they heal?

Answer 37

Cannot approximate. They heal from the inside out

Question 38

What causes tert. intention healing?

Answer 38

Delaying primary intention by SUTURING WOUNDS due to INFECTED WOUNDS

Question 39

How to use tert. healing

Answer 39

Clean infected wound Suture wound Let heal

Question 40

Factors affecting wound healing?

Answer 40

Nutrition Perfusion Infection Age

Question 41

Dehiscence

Answer 41

Opening of surgical wounds

Question 42

Evisceration

Answer 42

Intestines dropping from surgical wounds

Question 43

5 complications of wound healing?

Answer 43

Hemorrhage Hematoma Infection Dehiscence Evisceration

Question 44

How are wounds classified?

Answer 44

Cause and Depth Surgical or non Acute/Chronic

Question 45

What's a skin tear?

Answer 45

Caused by shear friction or blunt force Has the skin flap

Question 46

How to assess and doc wounds?

Answer 46

Include: Location Size Surrounding tissue condition Wound Base Any Drainage

Question 47

What is the enemy of wound healing?

Answer 47

Dryness, but it can't be too moist either, theres a fine line

Question 48

Debridement

Answer 48

Cleaning of a wound

Question 49

What are the purposes of dressings?

Answer 49

Protects from microorganisms Helps Hemostasis Absorbs drainage and cleanse Supports wound site Thermal insulation Gives moist environment

Question 50

Types of dressings

Answer 50

Gauze Transparent Film Hydrocolloid Hydrogel Foam Composite

Question 51

When changing dressings, what must you know?

Answer 51

Type, drains placement, needed equipment

Question 52

How to prep a pt to change dressing?

Answer 52

Review wound assessment Evaluate pain give analgesics if needed Describe procedure Gather supplies Check for normal healing signs Answer questions

Question 53

How to change dressings?

Answer 53

give analgesic meds 30-60 mins before Remove tape Clean wound edges place dressings and drains carefully Reposition pt Date, time, document

Question 54

How to properly clean skin and drain sites

Answer 54

Clean from left to most contaminated sites Use gentle friction

Question 55

How to cute sutures before you remove them?

Answer 55

Cut as close to the skin as possible without harming pt

Question 56

How long do steri-strips last

Answer 56

10 days

Question 57

Most common drug for skin infection?

Answer 57

Cephalosporins

Question 58

When about to do surgery, when should antibiotics be given?

Answer 58

Before surgery and MAYBE one after but very rarely

Question 59

For what type of surgeries can you give antibiotics before?

Answer 59

Surgical Site Infection