NURS Fundamentals Exam 4 Prep - Tissue Integrity

What are the structures of the skin?

epidermis, dermis, subcutaneous

What is the epidermis?

outer most layer

What makes up the epidermis?

protective waterproof layer of keratin

What is specific to the cell of the epidermis?

have no blood vessles of their own

What part of the skin regernerates easily and quickly?

epidermis

What makes up the dermis?

elastic tissue made primarily of collagen

What are components of the dermis?

nerves, hair follicles, glands, immune cells, and blood vessels

What is the subcutenous (hypodermis) layer?

anchors the skin layers to underlying tissues

What are functions of the skin?

protection, body temp. regulation, psychosocial, sensation, immunologic, absorption, elimination

What does the skin produce?

vitamin D

What are risk factors for impaired tissue integrity?

age, obesity, impaired mobility, chronic diseases

What are developmental nursing considerations?

aging adult

What are state of health nursing considerations?

chronic illness

What are types of nursing considerations?

developmental, state of health, therapeutic measures

What is epithelialization?

stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of “ground glass” to pink

What is the first phase of wound healing?

hemostasis

What is hemostasis?

occurs immediately after the initial injury primarily to stop the bleeding and activate the white blood cells to fight any invading bacteria

What is the second phase of wound healing?

inflammatory phase

What is the inflammatory phase?

lasts about 2 to 3 days; leukocytes and macrophases move to the wound, clear away bacteria and debris, and signal the body to begin tissue repair

What is the third phase of wound healing?

proliferation/repair phase

What is the proliferation/repair phase?

lasts for several weeks; new tissue is built to fill the wound space, primarily through the action of fibroblast

What is part of the proliferation phase?

granualtion

What is granulation?

tissue that forms the foundation for scar tissue development

What is the fourth phase of wound healing?

maturation/remodeling phase

What is the maturation/remodeling phase?

final stage of healing; collagen in the wound is remodeled, making the healed wound stronger and more like adjacent tissue

What is an intentional wound?

skin or tissue injury that is deliberately and carefully created by a healthcare professional for a specific therapeutic, diagnostic, or medical purpose

What is an unintentional wound?

physical injury that breaks the skin or damages body tissues as the result of an unplanned, accidental event rather than a deliberate act or medical procedure

What is an open wound?

occurs from intentional or unintentional trauma; skin surface is broken increasing the risk for infection, includes bleeding and tissue damage

What are examples of open wounds?

incisions and abrasions

What is a closed wound?

results from a blow, force, or strain; skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur

What are examples of a closed wound?

ecchymosis and hematomas

What are acute wounds?

usually heal withing days to weeks; wound edges are well approximated, and the risk of infection is low; usually progress through the healing process interrupted

What is an example of an acute wound?

surgical incision

What is a chronic wound?

wound edges are often not approximated, the risk of infection is increased, normal healing time is delayed; remain in the inflammatory phase of healing

What are examples of chronic wounds?

wounds related to diabetes, arterial or venous insufficiency, and pressure injuries

What is a Jackson-pratt drain?

bulb (closed) suction device; drains blood and fluid

What is Penrose drain?

open drain; drain blood and fluid

What is a hemovac?

closed drain; negative pressure suction device that drains blood and fluid

What is a NPWT drain?

negative pressure wound therapy; uses gentle continous or intermittent suction to heal complex or slow-healing wounds

How often are wound drained?

every 8 hours or when they are half-full

What are local (in the wound) factors that affect wound healing?

pressure, desiccation (dehydration), maceration (over hydration), necrosis (perfusion), biofilm (microbes), trauma, edema, excessive bleeding

What are systemic factors that affect wound healing?

age, perfusion, nutritional status, wound etiology, medications, health status, immunosuppression, treatment plan adherence

What are wound complications?

infection, hemorrhage, dehiscence and evisceration, fistula and abscess formation

What is external hemorrhage?

heavy or uncontrolled loss of blood that flows out of the body through a break in the skin or a natural body opening

What is an internal hemorrhage?

loss of blood from damaged blood vessels or organs that collects inside the body instead of escaping through a break in the skin

What is dehiscence?

parital or toatal seperation of wound layers as a result of excessive stress on wounds that are not healed

What is evisceration?

most serious complication of dehiscence; abdominal wound completely seperates, with protusion of viscera through the incisional area (primarily with abdominal incisions)

What are nursing considerations for dehiscence and evisceration?

emergency action and risk factors

What is a fistula formation?

abnormal passage form an internal organ or vessel to the outside of the body, or from one internal organ or vessel to another

What is an abscess formaiton?

collection of infected fluis that has not drained

Who is at risk for pressure injuries?

friction and shear, immobility, nutrition and hydration, moisture, mental status, age, medical devices

What is used to assess pressure injury risk?

braden scale

What is the braden scale?

lower score means one is at a higher risk

What does the braden scale measure?

sensory perception, mositure, activity, mobility, nutrition, friction and shear

What is most susceptible for pressure injuries?

bony prominences

What is assessed on admission for HAPIs?

four eyes (two people), not discovered “own it”, assessing darkly pigmented skin

What is risk assessment for HAPIs?

braden score, lower is higher risk, must put preventative interventions in place, reassessment frequency based on policies and driven by recommendatioins

What is prevention for HAPIs?

turn/reposition, pressure relieving devices, elevate heels, avoid friction shear, skin health, nutrition support, incontinence management, protect wiht hydrocolloids or barrier creams, don’ts massage bony prominences

What is the importance of turning/repositioning?

avoid prolonged pressure; minimum every 2 hours

What are pressure relieving devices?

air flow mattress, chair cushions

What is skin health?

hydration

What is nutrition support?

high calorie diet, high protein, zinc supplement

What is staged?

pressure injuries only

What is a stage 1 pressure injury?

non blanchable (redness remains upon pressure) erythema of inteact skin

What is a stage II pressure injury?

partial thickness loss

What is a stage III pressure injury?

full thickness loss; can see adipose tissue

What is a stage IV pressure injury?

full thickness with tissue loss; can see bone

What is an unstageable pressure injury?

has slough or eschar

What is slough?

dead tissue that appears moist, yellow, stringy tissue

What is eschar?

death tissue that appears dry, black, and leathery

What is a deep tissue injury (DTI)?

intact or nonintact skin with localized area of persistent nonblanchable deep red, marron, or purple discoloration or epidermal seperation revealing a dark wound bed or blood-filled blister

What is wound measurement?

measure length, width (side-to-side), depth

What is undermining?

open area extending under tintact skin along the edge of the wound; use a cotton swab

What is tunneling/sinus tract?

a narrow channel or passage-way extending in any direction from the base of the wound

What can result from tunneling/sinus tract?

dead space with a potential risk for abscess formation

What is used to describe the locaiton and extent of tunneling and/or undermining?

clock format

What is 12:00?

head of the patient

What is 6:00?

foot of the patient

What is measuring of a pressure ulcer?

width, depth tunneling, clock (head is 12), tunneling, undermining

What is staging of a pressure ulcer?

stages I-IV, non stageable, DTI, medical device PI

What are descriptors for a pressure ulcer?

wound bed, exudate, presence of slough or eschar, wound edges

How is progress of a pressure ulcer assessed?

PUSH tool, RYB (red, yellow, black) tool

What is multipronged support for pressure ulcers?

nutrition, lab values, glucose control, wound care, prevent infection

What is ulceration?

superficial loss of surface tissue as a result of death of cells

What are arterial ulcers?

related to insufficient blood suply to the extremitires resulting in tissue ischemia; deep and painful

What are venous ulcers?

more common than arterial ulcers; occur due to the impaired return of venous blood from the tissue to the heart, shallow and irregular

What are neuropathic ulcers?

occur due to reduced blood supply to the nerves also known as microvascular damage which van lead to neuropathy; loss of sensation

What are examples of arterial ulcers?

toes and heels, presssure points

What are examples of venous ulcers?

medial ankle

What are examples of neuropathic ulcers?

diabetic foot ulcer

What are pyschological considerations for pressure injuries?

pain, anxiety and fear, ADLs, changes in body image

What are dressings?

absorb drainage, provide proteciton, reduce pain, provide psych. comfort, protecting surround skin, optimize the healing process, act as a bacterial barrier, maintain a moist environment

What is a gauze dressing?

packed loosely so the wound is allowed to drain, allows healing from base of wound

How are wound dressings performed?

sterile surgical/clean medical

What are kinds of dressings and treatments?

adhesives, cleanse agents, NS or irrigating a wound gently, binders, sutures, fibrin sealants, NPWT, growth factor, Hyperbaric oxygen therapy

What is precise documentation for wounds?

wound bed appearance, wound edges (approximated or not), measurements, surrounding skin, exudate, wound care provided

What is serous exudate?

composed primarily of the clear, serous portion of the blood and from serous membranes; clear and watery

What is serosanguineous exudate?

mixture of serum and red blood cells; light pink to blood tinged

What is purulent exudate?

made up of white blood cells, dead and live bacteria, thick, foul odored, varies on color (dark yellow or green)

What is sanguineous exudate?

consists of large numbers of red blood cells and looks like blood