Tissue Integrity - Summary / Podcast

From Engage Fundamentals RN 2.0 - Skin integrity

The skin’s integrity is influenced greatly by __ and other conditions, including __ and _.

The skin’s integrity is influenced greatly by age, and other conditions, including immobility and cancer.

The main functions of the skin are to provide a barrier against __ , __, _ _ , and fluctuations in __ changes.

injury, infection, ultraviolet radiation, temperature

_____ ___ refers to at-risk, vulnerable skin.

Skin frailty - refers to at-risk, vulnerable skin.

An important aspect of nursing care is maintaining clients’ skin __.

An important aspect of nursing care is maintaining clients’ skin integrity

Wound care includes __ , various types of __ , and __ changes.

Wound care includes irrigation, various types of debridement, and dressing changes.

Wound dressings are classified as either or .

dry or wet

____ _____ are used when there is a large amount of drainage present that hinders wound healing.

Wound drains

The most often identified risk factors for pressure injury development are ____ , ____ , impaired ____, and ____ impairment.

The most often identified risk factors for pressure injury development are immobility , malnutrition , impaired perfusion, and sensory impairment.

Tight hair braids next to the scalp can increase the risk of __ injury development.

Tight hair braids next to the scalp can increase the risk of pressure injury development.

The ____ ___ rates a client’s risk for alterations in tissue integrity using __ categories.

The Braden scale rates a client’s risk for alterations in tissue integrity using 6 categories.

__ __ are classified into stages according to the amount of skin and tissue damage observed.

Pressure injuries are classified into stages according to the amount of skin and tissue damage observed.

Nurses can decrease clients’ risk of tissue breakdown through regular skin __.

Nurses can decrease clients’ risk of tissue breakdown through regular skin assessments

Wounds are classified as or based on their origin and healing progression.

Wounds are classified as acute or chronic based on their origin and healing progression.

__ skin care addresses not just tissue injury prevention, but also a comprehensive plan covering clients’ hygiene, nutrition , hydration, and circulation needs.

Holistic skin care addresses not just tissue injury prevention, but also a comprehensive plan covering clients’ hygiene, nutrition , hydration, and circulation needs.

Prevention of pressure injuries focuses on two main components: identification of clients at __, and implementation of __ designated to reduce their risk.

Prevention of pressure injuries focuses on two main components: identification of clients at risk, and implementation of interventions designated to reduce their risk.

____ __ infections may be superficial and localized, or they may extend deep into tissues.

Surgical site infections may be superficial and localized, or they may extend deep into tissues

Major complications of wounds include _____, ____ , ____ , and __/_.

Major complications of wounds include infections, dehiscence, evisceration and bleeding/hemorrhage

The skin has three layers: the __ , the __ , and a fatty __ layer of adipose tissue.

The skin has three layers: the epidermis, the dermis , and a fatty subcutaneous layer of adipose tissue.

______ and _____ fibers in the Dermis layer help protect clients from alterations in tissue integrity.

Collagen and elastin fibers in the Dermis layer help protect clients from alterations in tissue integrity.

Individuals in infancy have skin that is immature, which increases the risk for __ and __.

Individuals in infancy have skin that is immature, which increases the risk for maceration and dermatitis

Wounds can be classified as either __ or __ an example of an unintentional wound is a injury such as a __. An example of an intentional wound is a __ wound.

Wounds can be classified as either intentional or ; Unintentional an example of an unintentional wound is an injury such as a gunshot. An example of an intentional wound is a surgical wound

Wounds are classified as clean, clean-contaminated, contaminated, or dirty based on __ load.

Wounds are classified as clean, clean-contaminated, contaminated, or dirty based on Bacterial load.

___ can be serous, serosanguinous, sanguinous, or purulent.

Exudate can be serous, serosanguinous, sanguinous, or purulent.

__ exudate is clear, thin, and watery.

Serous exudate is clear, thin, and watery.

__ exudate is thin, pink, watery in its presentation as well. It is common in the early stages of wound healing.

Serosanguinous exudate is thin, pink, watery in its presentation as well. It is common in the early stages of wound healing.

___ is that fresh, bloody exudate that appears when skin is breached, whether from surgery, injury, or other [audio out]. And sanguinous drainage is bright red and somewhat thicker in its consistency.

Sanguinous is that fresh, bloody exudate that appears when skin is breached, whether from surgery, injury. And sanguinous drainage is bright red and somewhat thicker in its consistency.

____ wounds can evolve from conditions like venous insufficiency, peripheral artery disease, and diabetes.

Chronic

Who is at risk for chronic wounds?

People who are at risk for chronic wounds include ______, those who are _______, and individuals who are _____.

People who are at risk for chronic wounds include smokers, those who are undernourished, and individuals who are immobilized.

When assessing a wound, what should a nurse pay attention to?

A nurse should note the wound ______, which can give important information about the wound's healing process.

A nurse should note the wound exudate, which can give important information about the wound's healing process.

During wound assessment, the wound should also be ____.

measured

_____ drainage is distinctively thick, yellowish, grayish, or greenish in color and consists largely of __ cells and dead or dying microorganisms.

Purulent drainage drainage is distinctively thick, yellowish, grayish, or greenish in color and consists largely of inflammatory cells and dead or dying microorganisms.

The presence of ______ drainage indicates that infection is present in the wound.

purulent

_______ drainage is undesirable because it signals infection, which can delay the healing process and potentially worsen the condition.

Purulent drainage

What type of dressing is commonly used for wound care?

____ ____ gauze dressings help create and maintain a moist environment, which provides optimal conditions for wound healing.

Wet to dry gauze dressings help create and maintain a moist environment, which provides optimal conditions for wound healing.

__ __ may be necessary for serious wounds to clean the wound and remove dead tissue that can prevent healing.

Surgical debridement

What is one of the most common complications of wound healing?

______ is one of the most common complications of wound healing.

Infection

Infection can present with __ around the wound, __ to touch, __ odor, and __ exudate .

Infection can present with redness around the wound, warmth to touch, foul odor, and purulent exudate .

If the infection persists, then the client is at risk for the infection becoming __.

If the infection persists, then the client is at risk for the infection becoming systemic

What happens if a wound infection becomes systemic?

The symptoms for this include ____, ___, ____,____, increased ___, and possibly changes in ____ status  Needs to be treated with _____ ____.

The symptoms for this include fever, chills, nausea, vomiting, increased white blood cells, and possibly changes in mental status  Needs to be treated with systemic antibiotics.

How should the edges of a healing wound appear?

The edges of a healing wound should meet _____ and be held ____ together by sutures or staples.

The edges of a healing wound should meet neatly and be held closely together by sutures or staples.

__ is a rare but severe surgical complication where the surgical incision is no longer approximated, and the abdominal organs protrude or come out of the incision.

Evisceration

__ is an emergency and should be treated immediately, with the goal of protecting the exposed organs and seeking urgent medical care.

Evisceration

__ is a complication where the edges of a wound no longer approximate, meaning they do not meet.

Dehiscence

Evisceration is a rare but severe surgical complication where that surgical incision is no longer approximated, and the __ organs protrude from the incision.

Evisceration is a rare but severe surgical complication where that surgical incision is no longer approximated, and the abdominal organs protrude from the incision.

The nurse should recognize that the client who is __ , __ , _ , or has decreased _ perception is at increased risk for wounds.

The nurse should recognize that the client who is malnourished, immobile, incontinent, or has decreased sensory perception is at increased risk for wounds.

It is important to assess for ___-___ skin damage wounds caused by exposure to feces, urine, and wound exudate.

moisture-associated

Higher bacterial loads in a wound can interfere with __.

Higher bacterial loads in a wound can interfere with healing

Wound dressing changes may involve __ to dry gauze changes to maintain a moist environment.

Wound dressing changes may involve wet to dry gauze changes to maintain a moist environment.

Wound healing can be complicated by the presence of __ , which may lead to __ infections if persistent.

Wound healing can be complicated by the presence of infection, which may lead to systemic infections if persistent.

The major risk factor for pressure injuries is __, which can lead to greater risk for tissue trauma and skin tears.

The major risk factor for pressure injuries is immobility, which can lead to greater risk for tissue trauma and skin tears.

Maintenance of hygiene, nutrition, and hydration is essential for promoting __ wound healing.

Maintenance of hygiene, nutrition, and hydration is essential for promoting Holistic wound healing.

It is essential for the nurse to develop a __ _ __ to minimize risk for clients at risk.

It is essential for the nurse to develop a plan of care to minimize risk for clients at risk.

Wounds often require surgical __ to clean and remove non-viable tissue preventing healing.

Wounds often require surgical debridement to clean and remove non-viable tissue preventing healing.

The size of the wound can be assessed through visual__ and __t.

The size of the wound can be assessed through visual inspection and measurement.

Safety interventions should include regular skin assessments and maintaining a __ and __ environment for clients.

Safety interventions should include regular skin assessments and maintaining a clean and dry environment for clients.

__ drainage is indicative of infection and typically presents as thick, yellowish, grayish, or greenish in color.

Purulent drainage is indicative of infection and typically presents as thick, yellowish, grayish, or greenish in color.

The __ of the skin must be preserved to prevent complications and promote healing in clients.

The Integrity of the skin must be preserved to prevent complications and promote healing in clients.

The wound healing process can be disrupted by __ , __ , and __.

The wound healing process can be disrupted by infection, evisceration, and dehiscence.

Skin and soft tissue assessments should be conducted regularly to identify changes in __.

integrity

A risk assessment for pressure injuries should be part of a comprehensive nursing __ for each client.

assessment

Effective treatment of wounds includes not only cleaning and dressing but also addressing __ components of care.

emotional

What factors may exacerbate skin fragility?

Many factors, such as ___ , decreased ___, and _____, may exacerbate the vulnerability of the skin.

Many factors, such as age, decreased mobility, and malnutrition, may exacerbate the vulnerability of the skin.

What determines the choice of dressing for a wound?

Various types of dressings are available for use, depending on the wound base, healing rate, and amount of exudate.

What helps protect clients from alterations in tissue integrity?

____ and ____ fibers in the dermis layer help protect clients from alterations in tissue integrity.

Collagen and elastin fibers in the dermis layer help protect clients from alterations in tissue integrity.

The second layer is the ___ , which contains ___, ___ vessels, and ____ vessels.

dermis

What is the role of the subcutaneous tissue layer?

The subcutaneous tissue, mainly composed of _____ tissue, helps insulate the body, absorb shock, and protect internal organs and structures.

The subcutaneous tissue, mainly composed of adipose tissue, helps insulate the body, absorb shock, and protect internal organs and structures.

Why are people later in life at greater risk for tissue trauma, skin tears, and infection?

As people age, their skin becomes ____ and loses ____, making it more prone to tissue trauma, skin tears, and infections

As people age, their skin becomes thinner and loses elasticity, making it more prone to tissue trauma, skin tears, and infections.

What is the difference between clean, clean-contaminated, contaminated, and dirty wounds in terms of bacterial load?

Clean and clean-contaminated wounds have a _____ bacterial load, while contaminated and dirty wounds have a _____ bacterial load.

Clean and clean-contaminated wounds have a minimal bacterial load, while contaminated and dirty wounds have a higher bacterial load.

What is exudate, and when does it typically occur in wound healing?

Exudate is a fluid that most wounds produce, and it is a normal part of the ________ phase of healing.

Exudate is a fluid that most wounds produce, and it is a normal part of the inflammatory phase of healing.

What are moisture-associated skin damage wounds, and who is at higher risk for them?

_____-______ skin damage wounds are caused by prolonged exposure to ____, ____, or ____ exudate. They can lead to pain, itching, and increase the risk of pressure injuries. Clients with _____ issues are at higher risk and should be assessed regularly.

Moisture-associated skin damage wounds are caused by prolonged exposure to feces, urine, or wound exudate. They can lead to pain, itching, and increase the risk of pressure injuries. Clients with mobility issues are at higher risk and should be assessed regularly.