Unit 2 Revision - Tissue Integrity

Secondary Intention

Tissue loss, not approximate, granulation tissue must form and fill in wound (pressure ulcer, severe laceration); higher chance of infection d/t longer healing time.

Sinus

A fistula leading from a purulent exudate-filled cavity to the outside of the body.

Which factors affect wound healing in the older adult? -1. PVD -2. Atherosclerosis -3. Improved immune function -4. Reduced liver function

-1. PVD -2. Atherosclerosis -4. Reduced liver function Rationale: 1,2-impairs blood flow, impeding healing. 4-impairs synthesis of blood factors, which can impede healing.

Which of the following statements should the nurse use to describe a stage 3 pressure ulcer? -Unbroken skin with an un-blancheable erythema -Full-thickness tissue loss extending to underlying support structures -A shallow, ruptured or intact skin blister without slough -A deep crater without visible bone, tendon, or muscle

-A deep crater without visible bone, tendon, or muscle Rationale: A stage 3 pressure ulcer is deep and might or might not have undermining. It extends down to the layers of the skin and subcutaneous tissue, but does not have visible support tissue (bone, tendon, or muscle), that would be a stage 4 pressure ulcer.

What is a major sign of impending wound dehiscence?

-An increase in the flow of serosanguineous drainage into the wound dressing.

Polymyxin B

-Antibiotic agent used widely to treat infected wounds.

A nurse in an outpatient facility is preparing to administer Nafcillin Im to an adult client who has an infection. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Select a 25‑gauge, ½‑inch needle for the injection. B. Administer the medication deeply into the ventrogluteal muscle. C. Ask the client about an allergy to penicillin before administering the medication. D. Monitor the client for 30 min following the injection. E. Tell the client to expect a temporary rash to develop following the injection

-B. Administer the medication deeply into the ventrogluteal muscle. -C. Ask the client about an allergy to penicillin before administering the medication. -D. Monitor the client for 30 min following the injection.

Zinc oxide

-Barrier cream/ointment used for patients prone to skin breakdown from pressure, shear, or incontinence. -Intended for prevention and for resolving new-onset problems, such as a Stage 1 pressure ulcer.

Which of the following cephalosporin abx should the nurse expect to be prescribed for a patient with a gram-negative CSF infection? -Cefaclor -Cefazolin -Cefepime -Cephalexin

-Cefepime, more likely to be effective against this infection . More effective against gram-negative bacteria, more resistant to destruction by beta-lactamash, and more able to reach CSF.

What are 7 signs of systemic infection?

-Change in LOC -Persistent recurrent fever -Tachycardia -Tachypnea -Hypotension -Oliguria -↑ WBC

Papain-urea

-Chemical debridement agent used for pressure ulcers that have slough or eschar, or for infected wounds with poor wound edges.

What types of dressings should be used on a Stage 4 pressure ulcer?

-Chemical enzyme formulas may be used to help debride eschar. -Wet-to-dry dressing may be used to aid the sloughing of necrotic tissue. -NPWT

Treatment of a stage 6 pressure ulcer should include what 4 things?

-Clean and/or debride. -Perform non adherent dressing changes q12hr. -Treatment may include skin grafts, hyperbaric oxygen, or NPWT. -Provide nutritional supplements. -Administer analgesics. -Administer antimicrobials (topical and/or systemic).

Treatment of a stage 3 pressure ulcer should include what 4 things?

-Clean and/or debride. -Provide nutritional supplements. -Administer analgesics. -Administer antimicrobials (topical and/or systemic).

Which of the following actions should the nurse take when obtaining a wound drainage specimen for a culture in a patient with a known wound infection? -Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimens. -Irrigate the wound with an antiseptic prior to obtaining the specimen. -Include intact skin at the wound edges in the culture. -Swab an area of skin away form the wound to identify normal flora.

-Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimens. Rationale: The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.

Chemical debridement

-Dakin solution or sterile maggots, used occasionally with necrotic tissue that is not responding to other treatments. -Used on Stage 4 pressure ulcers.

List 4 reasons older adults are at greater risk for skin breakdown than younger patients.

-Decreased muscle mass -Less connective tissue -Decreased elastin and collagen -Less moisture in their skin (More friable and prone to shearing/pressure ulcers)

List 3 contributing risk factors for pressure injuries.

-Dehydration -Obesity -Edema

A nurse is collecting data from a client who has been receiving cefotaxime IV for the past week. Which of the following findings indicates a potentially serious adverse reaction to this medication that the nurse should report to the provider? -Diaphoresis -Epistaxis -Diarrhea -Alopecia

-Diarrhea

A nurse is teaching a client who has a prescription for prednisone and takes 1,500mg/day of calcium carbonate to reduce the risk of osteoporosis. Which of the following information should the nurse include? (Select all that apply.) -Take calcium tablets w/ food. -Drink 240mL (8oz) H2O w/ calcium tablets. -Chew tablets before swallowing them. -Take the drugs 1hr apart. -Divide the daily dosage of calcium into three 500mg doses.

-Drink 240mL (8oz) H2O w/ calcium tablets (ensure complete passage of drug, maintain hydration). -Chew tablets before swallowing them (↑ bioavailability). -Take the drugs 1hr apart (glucocorticoids ↓ absorption of calcium carbonate). -Divide the daily dosage of calcium into three 500mg doses (⌀ take >600mg of calcium carbonate at a time, dividing increases absorption).

In what steps of wound healing would you expect to find exudate?

-Exudate is a result of the healing process and occurs during the inflammatory and proliferative phases of healing.

Methotrexate (Rheumatrex, Trexall)

-For treatment of severe psoriasis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis unresponsive to conventional therapy. -May cause bone marrow depression (avoid those who are sick/large crowds). -Teratogenic, contraception should be used. -Many adverse effects that affect the CNS, respiratory, term, and hematology systems, such as anemia, leukopenia, and thrombocytopenia. -Take with 2-3L H2O/day to promote excretion and prevent kidney damage. May also take sodium bicarb to ↑ urine alkalinity and reduce drug precipitation, which can lead to kidney damage. -Periodic lab tests for kidney/liver damage; CBC. -Monitor for jaundice and abdominal pain (indicates liver damage); avoid alcohol. -May cause thrombocytopenia, report bruising or petechiae. -May cause GI ulceration, monitor for blood in stool or emesis.

Stage 3 Pressure Ulcer

-Full-thickness skin loss -Damage/necrosis of subcutaneous tissue. -Ulcer extends to, but not through, underlying fascia. -Appears as deep crate w/ or w/o undermining/tunneling. -No exposed muscle/bone. -Drainage/infection common.

Unstageable Pressure Ulcer

-Full-thickness skin or tissue loss w/ unknown depth. -Unable to determine stage d/t eschar or slough obscuring the wound.

Stage 4 Pressure Ulcer

-Full-thickness tissue loss -Destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. -May be sinus tracts, deep pockets of infection, tunneling, undermining. -Eschar and slough

Alginate dressings

-Help establish hemostasis while providing a moist environment for healing and good absorption of exudate. -Non-adhesive; removal unlikely to cause further bleeding.

Basic steps for maintaining a closed wound drainage unit:

-Hold device w/ spout pointing away, release vacuum. -Do not touch/contaminate spout/plug. -Empty/measure (note appearance). -Clean spout/plug w/ separate alcohol swabs for each. -Re-compress. -Secure device below wound.

What types of dressings should be used on a Stage 2 pressure ulcer?

-Hydrocolloid, foam, or hydrogel dressing; protect against bacterial contamination.

A nurse is caring for a client who has a prescription for methotrexate. Which of the following drugs would likely be prescribed in conjunction during the initial treatment for rheumatoid arthritis? -Aspirin -Salicylates -Sulfonylureas -Ibuprofen

-Ibuprofen Rationale: NSAIDS are often prescribed along with methotrexate during the initial course of treatment for RA. It can take weeks for DMARDs to reach therapeutic levels and begin relieving joint inflammation and pain, so ibuprofen can be administered concurrently to help make the client more comfortable while waiting for methotrexate's therapeutic effects. Aspirin, salicylates, and sulfonylureas can increase toxicity.

List 7 major risk factors for pressure injuries.

-Immobility/Inactivity -Moisture -Malnutrition -Advanced age -Altered sensory perception -Lowered mental awareness -Friction and shear

An adolescent patient in the hospital with type 1 diabetes mellitus is at risk for which of the following factors? -Extremes in age -Impaired circulation -Impaired/suppressed immune system -Malnutrition -Poor wound care

-Impaired circulation -Impaired/suppressed immune system

Negative pressure wound therapy (NPWT)

-Increase development of granulation tissue by mechanical stretch and removal of fluid, which increases blood flow; keeps wound bed moist. -Decreases bacterial counts after a few days. -If infected, may change q12-24hr. -If clean, change 3x/week. -Contraindications: bleeding, exposed organs, exposed vessels/nerves, malignant tissue. -If interrupted 2+ hours, irrigate wound pre-restarting.

Stage 1 Pressure Ulcer

-Intact skin, nonblanchable erythema. -May feel warmer or colder than adjacent tissue. -Tissue is swollen and has congestion, with possible discomfort at the site. -With darker skin tones, the ulcer can appear blue or purple.

For lice, list the following: manifestations, and management.

-Intense itching; small, red bumps on scalp; nits on hair shaft. -1% permethrin shampoo; spinosad 0.9% topical suspension; remove nits with a comb, repeat 7 days s/p shampoo; wash clothing/bedding in hot water w/ detergent; malathion 0.5% in difficult cases.

A client taking alendronate should monitor for which adverse effects? (Select all that apply.) -Jaw pain -Drowsiness -Blurred vision -Tinnitus -Muscle pain

-Jaw pain (alendronate can cause osteonecrosis of the jaw) -Blurred vision (may cause ocular inflammation) -Muscle pain

Hydrocolloid dressing

-Keep wound moist -Water/air occlusive; self-adhesive -Facilitates autolytic debridement, provides thermal insulation -May remain in place 3-5 days, or until non-adhesive. -Not recommended for heavily draining wounds. -⌀ if wound is infected.

The nurse is facilitating an education session for a newly licensed practical nurse and emphasizes that the following are manifestations that are characteristic of rheumatoid arthritis and help distinguish it from osteoarthritis? (Select all that apply.) -Heberden's nodes -Activity increases pain -Low-grade fever -Early morning stiffness -Autoimmune disease -Involvement of other major organs

-Low-grade fever -Early morning stiffness -Autoimmune disease -Involvement of other major organs

Treatment of a stage 2 pressure ulcer should include what 4 things?

-Maintain a moist healing environment (saline or occlusive dressing. Apply hydrocolloid dressing). -Promote natural healing while preventing the formation of scar tissue. -Provide nutritional supplements. -Administer analgesics.

Which of the following oral abx would you expect to be administered specifically to suppress normal flora in the GI tract?

-Neomycin

What are 6 risk factors for wound dehiscence?

-Obesity -Poor nutrition -Multiple traumas -Excessive coughing, vomiting, sneezing -Suture failure -Dehydration -Greatest risk is on the 4th-5th day post-op, before extensive collagen has built up.

Regeneration

-Occurs if the blood supply has been disrupted to the new wound bed and necrosis has occurred. -New cells similar in structure and function to the dead cells are produced if the tissue is a type that will regenerate. -Skin, mucous membranes, bone marrow, muscle, bone, liver, kidney, and lung tissue capable of regeneration.

Adverse reactions to gentamicin include:

-Paresthesia of the hands and feet -Urticaria, rash, and pruritus. -Hematuria (kidney toxicity) -Muscle weakness and respiratory depression (neuromuscular blockade) -Vertigo, ataxia, hearing loss.

Stage 2 Pressure Ulcer

-Partial thickness -Involves the epidermis and the dermis. -Visible ulcer with reddish-pinkish wound bed (abrasion, blister, or shallow crater). -Persistent edema; no slough or bruising. -May become infected, or have exudate.

What are the 4 classes of antibiotics that affect the bacterial cell wall?

-Penicillins -Cephalosporins -Carbapenems -Monobactams

Mechanical debridement

-Physical removal by irrigation or hydrotherapy (whirlpool, ultrasound mist) -Wet-to-dry dressings

Debridement is not recommended for which type of necrotic wound?

-Pressure ulcer on the heel (if dry, and ⌀ edema, erythema, drainage).

A client with RA reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (Select all that apply.) -Recent influenza -Decreased RoM -Hypersalivation -Increased BP -Pain at rest

-Recent influenza (some conditions, such as a recent infection, can exacerbate RA symptoms). -Decreased RoM -Pain at rest

What are the three basic wound types (color)?

-Red: Clean and ready to heal; protection is the best method of treatment. -Yellow: Layer of yellow fibrous debris or exudate (large amount of leukocytes). Needs frequent cleansing, dressing should be absorbable; often becomes infected. -Black: Need debridement of the eschar in order to heal. Eschar can be debrided surgically, or softened by soaks/enzyme substances.

Pressure Ulcer Staging

-Stage 1: Intact, nonblanchable erythema. Warmth, edema, and induration compared to surrounding tissue. -Stage 2: Partial-thickness skin loss (deep crater). Wound bed is pink/red and moist, may/may not be intact. -Stage 3: Full-thickness skin loss, often large crater. Subcutaneous tissue damaged or necrotic; fat visible. Tunneling may be present. -Stage 4: Full-thickness skin loss with extensive tissue necrosis or damage to muscle/bone/supporting structures. Infection usually widespread. May appear dry/black, buildup of tough necrotic tissue (eschar); wet/oozing. -Unstageable: Loss of full thickness tissue. Base of injury covered by eschar, or base contains slough. -Deep Tissue: Localized discolored intact skin that is maroon/purple, or blood-filled blister d/t damage of underlying soft tissue from pressure or shearing.

For impetigo contagiosa, list the following: causative organism, manifestations, and management.

-Staphylococcus -Reddish macule becomes vesicular; erupts easily and becomes purulent and oozes before forming dry crusts; spreads peripherally and by direct contact; pruritus common. -Topical bactericidal or triple antibiotic ointment; oral or parenteral abx for severe cases, wash crusts with soap and water.

For cellulitis, list the following: causative organism, manifestations, and management.

-Streptococcus, staphylococcus, and haemophilus influenzae -Firm, swollen, red area of skin/subcutaneous tissue; warm to touch; possible systemic effects (fever/malaise) -Oral or parenteral abx, rest and immobilization of affected area; warm soaks as needed; acute care for systemic manifestations.

Slough

-Stringy and whitish/yellow/tan necrotic tissue that is firmly attached to the wound bed. (eschar is hard or soft tan/black/brown necrotic tissue)

Internal hemorrhage is evidenced by:

-Swelling or distension -Sanguineous drainage -Hematoma (bluish-red swelling, ↑ body temp, may put pressure on/obstruct surrounding vessels) -Hypovolemic shock, if extensive (↓BP, ↑HR/RR, diaphoresis, clammy) -Greatest risk w/in 48hrs post-op

List the 4-5 clinical signs of the inflammatory process.

-Swelling or edema -Erythema (↑ blood supply) -Heat -Pain (pressure on nerve receptors) -Sometimes possible loss of function d/t aforementioned

The nurse conducting a pressure ulcer risk assessment on clients in a long-term care facility identifies which of the following risk factors? (Select all that apply.) -Temp of 101ºF -Decreased response to painful stimuli -Consumes a high-protein diet -Drinks six glasses of water daily -Walks occasionally for a short distance

-Temp of 101ºF -Decreased response to painful stimuli -Walks occasionally for a short distance Rationale: An elevated temperature puts the client at risk d/t ↑ need for oxygen to the tissues. The client who has limited sensory response is a t risk because she does not feel the pain associated with compressed tissues. Only walking occasionally because the client is in bed or a chair for the majority of the time.

Raloxifene (Evista)

-Treat osteoporosis in postmenopausal women (mimics effects of estrogen on bone tissue). -↑ physical activity d/t risk of DVT. -Category X drug, use contraceptive. -↑ intake of calcium and vitamin D to improve effectiveness/bone mass. -Monitor for leg pain/swelling/warmth (DVT).

Autolytic debridement

-Uses body's own enzymes; longer process. -Best on small, uninfected wounds (dressing used makes warm, moist environment = possible bacteria proliferation). -Closely monitor for infection.

Sharp debridement

-Uses sterile scissors, forceps, and scalpel to remove necrotic tissue. -Used when signs of cellulitis or sepsis present. -Usually MD or NP, can be RN..

Enzymatic debridement

-Uses topical substances that break down/;liquefy dead tissue. -Placed in wound, dressing placed over top. -Useful for uninfected wounds.

Which of the following medications puts a client, that is taking imipenem-cilastatin IV, at risk? -Regular insulin -Furosemide -Valproic acid -Ferrous sulfate

-Valproic acid Rationale: Imipenem-cilastatin decreases the blood levels of valproic acid (an anti seizure medication), putting the client at risk for increased seizure activity. If the client must take these two medications concurrently, the nurse should monitor for seizures.

A nurse is reinforcing discharge teach to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins should the nurse include in the teaching as promoting wound healing? (Select all that apply.) -Vitamin A -Vitamin B12 -Vitamin C -Vitamin D -Vitamin E

-Vitamin A -Vitamin C Rationale: Vitamin A promotes tissue synthesis, wound healing, and immune function. Vitamin C plays a role in capillary formation, tissue synthesis, and wound healing.

What 4 vitamin and mineral supplements should be provided for nutritional support, if indicated?

-Vitamin A -Vitamin C -Zinc -Copper

A nurse is caring for a client who has a closed wound drainage system connected to a portable bulb suction device. Which of the following actions should the nurse take to care for the drain? (Select all that apply.) -Allow the drain to fill completely before emptying. -Flush the drainage tube with sterile water each shift. -Wipe the top of the drainage port with an alcohol swab after emptying. -Milk the drainage port to promote emptying. -Squeeze the suction bulb while inserting the plug into the drainage port.

-Wipe the top of the drainage port with an alcohol swab after emptying. -Squeeze the suction bulb while inserting the plug into the drainage port.

Abscess

A localized infection; an accumulation of purulent exudate made up of debris from phagocytosis when microorganisms have been present.

Inflammation Stage (include 4 major components)

A localized protective response brought on by injury or destruction of tissues. -Begins immediately after injury, lasts ~3-4 days. -Constriction of vessels, platelet aggregation, formation of fibrin, and epithelial cell migration.

The nurse is reviewing a care plan for the client at risk for pressure ulcers. Appropriate interventions include:(Select all that apply.) -Providing a high carb, low protein diet -Scrubbing the skin with minimal force and friction -Position the HOB no more than 45º -Use trapeze when lifting a client to change position -Change wound dressings 3-4x/day

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List 3 complications of wound healing.

-1. Hemorrhage -2. Infection -3. Dehiscence and Evisceration

Note if serum albumin levels are below ___g/dL. What are good dietary sources of protein?

-3.5 g/dL -meat, fish, poultry, eggs, dairy, beans, nuts, whole grains

List 6 factors affecting wound healing.

-Age: Younger = ↑ metabolism (blood flow), immune function, liver function, oxygen, resilient. -Nutrition: Protein, adequate fluid intake, among other things important. ↑ adipose tissue delays healing. -Lifestyle (exercise, smoking) -Medications: Steroids, immunosuppressants, anti-inflammatory drugs, anticoagulants, antineoplastic agents interfere w/ healing. -Infection -Chronic Illness

What are the two primary methods of wound healing?

Replacement and regeneration

Proliferation/Granulation Stage

The wound is filled with new connective tissue, and new epithelium will cover the wound (deep pink). -Begins on 3-4th day s/p injury; lasts 2-3 weeks. -Macrophages continue to clean, stimulating collagen-synthesizing fibroblasts. -New capillary networks support collagen and further synthesis of granulation tissue.

Blanch

To turn skin white, or on darker skin, to become pale.

Eschar

Slough produced by a thermal burn, corrosive material, or gangrene. -Often associated with pressure ulcers (if present = unstageable).

Maceration

Softening of tissue that increases the chance of trauma or infection.

What types of dressings should be used on a Stage 3 pressure ulcer?

-Dressing that will absorb exudate and maintain moist environment. -For infected pressure ulcers, a nonexclusive dressing is always used. -NPWT

How often should a pressure injury risk assessment (Braden Scale) be performed on patients in each acute care, long-term care, and home care?

-Every shift -Weekly for 4 weeks, then quarterly -Each nurse visit

What are the 3 phases of wound healing?

-Inflammatory Phase -Proliferation/Reconstruction Phase -Maturation/Remodeling Phase

Tegaderm dressing

-May be used on Stage 1 or 2 pressure injury. -Useful for superficial, partial-thickness wounds. -May remain in place 3-7 days or until non-adhesive. -⌀ on infected wounds.

List 4 indications of local wound infection.

-Pain -Redness -Warmth -Purulent exudate

What types of dressings should be used on a Stage 1 pressure ulcer?

-Protective dressings (thin film) to prevent from shearing and keep moist. -Barrier creams/ointments

JP Drain

-Should be drained/recompressed at least q4h and/or when they are at least 2/3 full.

Alendronate (Fosamax)

-Treatment and prevention of osteoporosis (↓ activity of osteoclasts). -Contraindicated in patients who can't sit upright. -Drink 240mL and sit upright 30min to prevent esophagitis. -May cause joint/muscle pain, nausea, visual disturbances, esophagitis.

Calcitonin-salmon spray

-Treatment of osteoporosis. -Perform skin testing (salmon/fish) prior to starting treatment. -Report rash/itching, seek medical attention if swelling/rash occurs. -Spray x1 in 1 nostril daily, alternate to avoid irritation. -May need parenteral admin if nasal irritation. -Monitor for rebound hypercalcemia (n/v, flank pain, lethargy, deep bone pain).

A nurse is assisting with the development of a teaching plan for a client who has psoriasis. Which of the following statements should the nurse include in the plan?

-Treatment will include coal tar preparations.

Etanercept (Enbrel)

-Treats RA -Etanercept directly binds to the TNF, preventing the attachment of TNF onto the cell's surface. This prevents the autoimmune response and subsequent inflammation of the joints. -↑ risk of serious infection, especially in patient's with DM. -Periodically check CBC. -Check for TB prior to starting the medication. -Can cause heart failure, manifesting as SOB, cough, HTN, tachycardia and hemoptysis. -Can cause GI hemorrhage (hematochezia/tarry stools) -Monitor for skin rash/blisters (Stevens-Johnson syndrome or toxic epidermal necrolysis)

Avulsion

Tearing away of a structure or a part; also known as degloving.

What discharge instructions would you give a patient about assessing for signs of wound infection?

Tell the patient to observe for redness, heat, increased swelling, foul odor or discharge, pain, and, if around a joint, decreased mobility.

Reactive Hyperemia

Process in which the blood rushes to where there is a decrease in circulation. (As occurs after blanching)

A braden score of < __ indicates pressure injury risk.

18

Cellulitis

An inflammation of the tissue surrounding the initial wound, with redness and induration.

Fistula

An abnormal passage or communication usually formed between two internal organs or leading from an internal organ to the surface of the body. -May result from an infection, congenital, or surgically created.

Primary/First Intention

Little tissue loss, edges approximate, small chance of infection.

A nurse is caring for a client who has subacute bacterial endocarditis and is receiving several abx, including streptomycin IM. For which of the following manifestations should the nurse monitor as an adverse effect of this medication?

Parasthesias of the hands and feet are a common adverse effect.

Maturation/Remodeling Stage

Scar maturation/remodeling is the process of collagen lysis and synthesis by macrophages, creating strong scar tissue.

A nurse is preparing to administer penicillin V to a client who has a streptococcal infection. The client tells the nurse that she has difficulty swallowing tablets and doesn't tolerate liquid chewable medications because the taste gags her. The nurse should request a prescription for which of the following meds? -Fosfomycin -Amoxicillin -Nafcillin -Cefaclor

Nafcillin is an acceptable alternative within the penicillin classification.

Replacement

Occurs in the form of fibrous connective tissue that does not have the same functional characteristics as the tissue lost when the wound occurred. When cells are not damaged beyond recovery, they restore themselves with little to no permanent evidence of injury.

Tertiary Intention

Occurs when granulation tissue begins to form before wound is sutured/closed. -Wound purposely kept open to allow infection or contamination to resolve.