Tissue Integrity Lecture Review

Flashcards covering tissue integrity, pressure injuries, wound healing, wound assessment, and related nursing interventions based on lecture notes.

What age-related changes increase the risk of tissue integrity issues in older adults?

Reduced skin elasticity, thinning of underlying tissues and muscles, and decreased collagen.

What factors cause pressure injuries?

Pressure Intensity, Pressure Duration, and Tissue Tolerance.

What are the common risk factors for pressure injuries?

Impaired Sensory Perception, Impaired Mobility, Alteration in Level of Consciousness, Shear, Friction, and Moisture.

Which patient populations are at high risk for developing pressure injuries?

Older adults, trauma patients, individuals with spinal-cord injuries (SCI), those with a fractured hip, patients in long-term care or hospice, individuals with diabetes, and patients in critical care settings.

What are examples of bony prominences where pressure injuries commonly occur?

Skull, shoulder/scapula, elbow, ear, wrist, breast, hip, knee, ankle, heel, sacrum, coccyx, buttocks, toes.

Describe a Stage 1 pressure injury.

Intact skin with a localized area of nonblanchable erythema, possibly appearing differently in darkly pigmented skin. No purple or maroon discoloration.

Describe a Stage 2 pressure injury.

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister. Adipose, deeper tissues, granulation tissue, slough, and eschar are not visible.

Describe a Stage 3 pressure injury.

Full-thickness loss of skin, with visible adipose (fat). Granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Fascia, muscle, tendon, ligament, cartilage, and bone are not exposed. Undermining and tunneling may occur.

Describe a Stage 4 pressure injury.

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur.

When is a pressure injury classified as "Unstageable"?

If slough or eschar obscures the extent of tissue loss.

What characterizes a Suspected Deep Tissue Injury?

Intact or nonintact skin with a localized area of persistent nonblanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.

How is a wound typically measured during assessment?

Measure the longest length and widest area of the wound. For depth, insert a sterile applicator swab and measure against a guide.

What is wound undermining?

When the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge.

What are the three main types of wound healing processes?

Primary Intention (wound closed), Secondary Intention (wound edges not approximated), and Tertiary Intention (wound left open, then approximated).

What does the acronym COCA stand for in wound assessment?

Color, Odor, Consistency, Amount (of exudate).

What does the acronym REEDA stand for in wound assessment?

Redness, Edema, Ecchymosis, Drainage, Approximation.

What is the primary consideration for a patient before wound cleansing?

Patient comfort, including pain medication.

Describe Autolytic debridement.

Removal of dead tissue via lysis of necrotic tissue by the white blood cells and natural enzymes of the body.

Describe Chemical debridement.

Removal of dead tissue using topical enzyme preparations, Dakin’s solution, or sterile maggots.

Describe Surgical debridement.

Removal of devitalized tissue with a scalpel, scissors, or other sharp instrument.

What are common complications of wounds?

Hemorrhage, Infection, Dehiscence, and Evisceration.

According to the Braden Skin Scale, what score indicates a patient is at risk for developing pressure ulcers?

A total score below 18.

What factors affect wound formation and healing?

Nutrition, Tissue Perfusion, Infection, and Age.

How often should a skin assessment be performed for a high-risk patient?

At a minimum of once a shift, high-risk patients need more frequent skin assessments, such as every 4 hours.

What is a key nursing intervention to reduce pressure over vulnerable areas of the body?

Repositioning the patient frequently (e.g., every 90 minutes) and using a drawsheet to minimize friction/shear.

What height should the head of the bed be elevated to minimize pressure and shear on the sacrum and coccyx?

No more than 30 degrees (unless contraindicated for specific conditions like hip replacement).

What is the rationale for using a moisture barrier ointment over a pressure injury?

It decreases friction, provides moisture to the open tissue, and encourages healing.

What are the basic principles of sterile technique?

A sterile object remains sterile only when touched by another sterile object; only sterile objects may be placed on a sterile field; a sterile object/field out of vision or below waist is contaminated; prolonged air exposure contaminates; contact with wet contaminated surface contaminates; fluid flows with gravity; edges are contaminated.

What is the purpose of gauze sponges as a wound dressing?

They are absorbent and useful for wicking away wound exudate.

What is a benefit of transparent dressings?

They adhere to undamaged skin, don't need a secondary dressing, and permit viewing of the wound.

What is a key consideration when choosing a wound dressing?

It should continuously provide a moist environment, keep periwound skin dry, control exudate without dehydrating the wound bed, and be monitored and reassessed regularly.

What is the physiological response of heat therapy?

Vasodilation, reduced blood viscosity, reduced muscle tension, increased tissue metabolism, and increased capillary permeability.

What are the therapeutic benefits of heat therapy?

Improved blood flow, promoted delivery of nutrients and waste removal, enhanced delivery of leukocytes and antibiotics, muscle relaxation, and pain reduction from spasm or stiffness.

What is the physiological response of cold therapy?

Vasoconstriction, local anesthesia, reduced cell metabolism, increased blood viscosity, and decreased muscle tension.

What are the therapeutic benefits of cold therapy?

Reduced blood flow to injured site (preventing edema), reduced inflammation, reduced localized pain, reduced oxygen needs of tissues, promoted blood coagulation, and pain relief.