Tissue Integrity and Pressure Injuries - CCC1 Exam 2

What is tissue integrity?

Structurally intact and properly functioning epithelial tissue (skin and mucous membranes).

What concepts are interrelated with tissue integrity?

Infection, perfusion & gas exchange, nutrition, mobility, fluid & electrolytes, pain & comfort.

What causes impaired tissue integrity?

Trauma, loss of perfusion, immunologic reactions, infection, infestation, thermal/radiation injury.

Examples of trauma causing impaired tissue integrity?

Lacerations and surgical incisions.

Example of loss of perfusion injury?

Diabetic foot ulcer.

Example of immunologic skin disorder?

Psoriasis.

Example of infection affecting skin?

Cellulitis.

Examples of thermal injuries?

Frostbite and sunburn.

What does the Braden Scale assess?

Risk for pressure injuries.

What are the Braden Scale categories?

Sensory perception, moisture, activity, mobility, nutrition, friction & shear.

What does a low Braden score indicate?

High risk for pressure injury.

What color changes should be assessed in skin?

Jaundice, cyanosis, ecchymosis, erythema.

What does blanchable redness mean?

Temporary redness.

What does non-blanchable redness indicate?

Possible Stage 1 pressure injury.

What are high-risk areas for skin breakdown?

Skin folds, bony prominences, under medical devices.

Common wound types?

Abrasion, laceration, burn, surgical incision, pressure injury, skin tear, ulcer.

How is wound length measured?

Head-to-toe direction.

How is wound width measured?

Side-to-side.

How is wound depth measured?

Deepest point using sterile applicator.

Healthy wound base appearance?

Pink/red with granulation tissue.

Unhealthy wound base appearance?

Yellow, green, or black with slough or eschar.

What are drainage amounts?

Scant, small, moderate, copious.

What is serous drainage?

Clear and watery.

What is serosanguineous drainage?

Pink.

What is sanguineous drainage?

Bright red blood.

What is purulent drainage?

Thick yellow, green, or brown drainage.

Types of wound edges?

Approximated, unapproximated, rolled edges.

What should be assessed in periwound skin?

Redness, swelling, breakdown.

What is tunneling?

Narrow channel extending from wound base.

How is tunneling documented?

Measure depth and use clock method.

What is undermining?

Tissue destruction under wound edges.

Steps for wound culture collection?

Clean gloves, cleanse with saline, change gloves, sterile applicator for drainage, avoid surrounding skin, label and send to lab.

Why avoid hydrogen peroxide in wounds?

It damages new tissue.

Purpose of dressings?

Protect wound, control moisture, maintain moist environment.

What is debridement?

Removal of dead or damaged tissue.

Key nutrients for wound healing?

Protein, Vitamin A, Vitamin C.

What is a pressure injury?

Tissue damage from prolonged pressure over bony prominences.

High-risk conditions for pressure injuries?

Obesity, spinal cord injury, stroke, musculoskeletal trauma, heart failure, PAD, COPD, diabetes.

Characteristics of deep tissue pressure injury?

Persistent non-blanching deep red, maroon, or purple discoloration; may feel boggy.

Stage 1 pressure injury characteristics?

Non-blanchable redness, skin intact.

Stage 2 pressure injury characteristics?

Partial thickness, exposed dermis, pink/red bed, no slough.

Stage 3 pressure injury characteristics?

Full thickness skin loss, visible adipose tissue, no exposed bone.

Stage 4 pressure injury characteristics?

Full thickness tissue loss with exposed bone, tendon, or ligament.

What is an unstageable pressure injury?

Covered by eschar or slough so depth cannot be determined.

Should stable heel eschar be removed?

No.

Purpose of negative pressure wound therapy?

Removes exudate, decreases edema, increases blood flow, promotes granulation, draws edges together.

How often is a wound vac changed?

Every 72 hours by trained nurse.

Contraindications for wound vac?

Large necrotic tissue, exposed major vessels/organs, malignant tumors.

Types of debridement?

Surgical, irrigation, biological (enzymes or larvae therapy).

How often should bed-bound patients be repositioned?

Every 2 hours.

How often should chair-bound patients be repositioned?

Every 1 hour.

Proper head-of-bed elevation to reduce pressure injury risk?

Less than 30 degrees.

Should bony prominences be massaged?

No.

Recommended daily hydration for prevention?

About 2500 mL per day (if not contraindicated).

Stage 2 equals what depth?

Partial thickness.

Stage 3 key feature?

Visible adipose tissue.

Stage 4 key feature?

Bone exposed.

Non-blanchable redness equals?

Stage 1 pressure injury.

Eschar covering a wound indicates?

Unstageable.

Best environment for wound healing?

Moist, not soggy.

What must always be assessed with wounds?

Nutrition and perfusion.