Integumentary and Musculoskeletal Systems 2% Flashcards

1
Q

Wet to Dry Dressings

A
  • -Wet to dry dressing changes remove healthy granulating tissue required for wound healing
  • Mechanical debridement
  • Place moist saline gauze onto the wound bed, then allowing it to dry and adhere to the tissue in the wound bed
  • Repeated every 4 to 6 hours.
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2
Q

Infiltration/Extravasation RX

A

Phentolamine

  • adrenergic blocker that dilates peripheral blood vessels
  • prevent necrosis and sloughing
  • diluted with normal saline
  • injected throughout area of extravasation

Hyaluronidase

  • treatment of IV extravasations
  • enzyme which temporarily (24-48 hours) breaks down the hyaluronic acid of tissue and promotes more rapid reabsorption of extravasated fluid
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3
Q

Dressing Considerations

A
  • Depth of wound
  • Amount of exudate
  • Degree of contamination
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4
Q

Pressure Injury - Stage II

A
  • Definition
    • Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough
    • May also present as an intact or open/ruptured serum-filled or sero-sanguineous filled blister
  • Description
    • Presents as a shiny or dry shallow ulcer without slough or bruising
    • This stage should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation.
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5
Q

Pressure Injury - Stage III

A
  • Definition
    • Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Some slough may be present.
    • May include undermining and tunneling
  • Description
    • The depth of a stage III pressure ulcer varies by anatomical location
      • Bridge of the nose, ear, occiput, and malleolus do not have “adipose” subcutaneous tissue and stage III ulcers can be shallow
      • In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers
    • Bone/tendon is not visible or directly palpable
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6
Q

Pressure Injury - Stage IV

A
  • Definition
    • • Full thickness tissue loss with exposed bone, tendon, or muscle . – Slough or eschar may be present.
    • • Often include undermining and tunneling .
  • Description
    • • The depth of a stage IV pressure ulcer varies by anatomical location .
      • The bridge of the nose, ear, occiput, and malleolus do not have “adipose” subcutaneous tissue and stage IV ulcers can be shallow.
    • • Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis or osteitis likely to occur.
    • • Exposed bone/tendon is visible or directly palpable.
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7
Q

Systemic Antimicrobials

A

Preferred when there is a systemic infection.

Do not penetrate necrotic tissue.

Not used for management of chronic wounds

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8
Q

Hydrogel Dressing

A
  • Able to absorb large volumes of exudate from wounds.
  • Reduces the need for dressing changes.
  • Used for wounds with little secretions and infected wounds
  • Made with materials that have high water content
  • Advantages
    • Promotes moist environment
    • Provides autolytic debridement
    • Moderate absorbency
    • Helps reduce pain
    • Some applications provides visual of wound
    • Rehydrates necrotic eschar
  • Disadvantages
    • Do not use for heavy exudating wounds
    • May cause maceration to surrounding skin
    • May require a secondary dressing
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9
Q

IV Placement

A
  • Consider areas that prevent infiltration or extravasation.
  • Avoid areas of joint flexion, small/fragile veins, edematous/neurologic areas of impairment
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10
Q

Muscle Strength Grades

A
  • Grade 5: Normal power/movement
  • Grade 4: full active ROM against gravity and resistance
  • Grade 3: full ROM against gravity
  • Grade 2: full ROM against some resistance, no gravity
  • Grade 1: contraction felt, but no limb movement
  • Grade 0: no contractions; paralysis
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11
Q

Wound Healing Promotion

A

Optimized wound healing:

  • Hydration
  • Glucose control
  • Nutritional support
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12
Q

Pressure Injury Sites

A
  • Sacral area
  • Greater trochanter
  • Ischial tuberosity
  • Heel
  • Lateral malleolus
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13
Q

Osteomyelitis Treatment

A
  • Give intravenous antibiotics
  • Give intravenous fluids
  • Immobilize area if needed
  • Give pain medications
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14
Q

Braden Scale

A

Risk for pressure injury

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15
Q

Immobility Prevention

A
  • Turn & reposition Q2hr.
  • Active & passive ROM Q4 - 8hr.
  • HOB > 30while in bed
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16
Q

Vitamin Deficiency

A
  • Vitamin D deficiency: common in aging adults and nutritional deficiencies.
    • Lead to patient falling and failing to thrive
17
Q

Vascular Access

A

Central venous access - prevent infiltration or extravasation with the use of vesicants or vasopressors

18
Q

Osteomyelitis S/S

A
  • Pain/tenderness to area
  • Redness
  • Exudate
  • Warmth
  • Fever due to infection
19
Q

Infiltration

A
  • Unplanned administration of a medication or nonvesicant solution into the surrounding tissue
20
Q

Extravasation

A
  • Unplanned administration of a medication or vesicant solution into the surrounding tissue
  • Vesicant solution: any medication or agent that can cause blistering
    • cytotoxic medications such as certain chemotherapy drugs
    • dyopamine
    • phenytoin
    • norepinephrine
    • phenylephrine
  • S/S: pain, swelling, redness or blistering at the IV site, lack of blood return, increase in resistance or change in the quality of infusion
21
Q

Pressure Injury Stage I

A
  • Definition
    • Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
      • Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area
  • Description
    • Area may be more painful, firm, or soft, or warmer or cooler than adjacent tissue
    • May be difficult to detect in person with dark skin tones
22
Q

Infiltration/Extravasation Grading

A
23
Q

Infiltration / Extravasation Treatment by Grade

A
24
Q

Hydrocolloid Dressing

A
  • Occlusive, provide:
    • moist healing environment
    • autolytic debridement
    • insulation
  • Impermeable to bacteria and other contaminants
  • Self-adherent and mold well (adhere to intact skin only)
  • Not recommended for wounds with heavy exudate, sinus tracts, or infection
  • Made with gel-forming agents
  • Advantages
    • Promotes a moist environment
    • Provides autolytic debridement
    • Highly absorbent
    • Waterproof
  • Disadvantages
    • May promote the growth of anaerobic bacteria
    • Not best choice of patients with fragile skin
    • May be difficult to stay in position
    • Sometimes produces odor
  • When to use:
    • burns
    • noninfected wound with scant to moderate drainage
    • necrotic or granular wound
    • dry wound
    • partial- or full-thickness pressure wounds
    • venous ulcers
    • protection of intact skin or a newly healed wound
  • Change Q3-5 days
  • Example: allevyn
25
Q

Alginate Dressing

A
  • Used for wounds with high amounts of wound drainage
  • Made from seaweed
  • Contact dressings
    • When alginate comes into contact with exudate, it turns into a gel
  • Can absorb up to 20 times its own weight
  • Advantages:
    • Promotes a moist environment
    • Reduce pain
    • Absorbent
    • Suitable for bleeding wounds
    • Autolytic debridement
  • Disadvantages:
    • Not for dry wounds
    • Requires secondary dressing
    • Sometimes cause stinging or discomfort
  • Example: Aquacel Ag, silver alginate
26
Q

Collagen Dressing

A
  • Stimulate new tissue growth
  • Encourage the deposition and organization of newly formed collagen fibers and granulation tissue in the wound bed
  • chemically bind to matrix metalloproteinases (MMPs) found in the extracellular fluid of wounds
  • Indications
    • Partial- and full-thickness wounds
    • Minimal to heavy exudate
    • Skin grafts and skin donation sites
    • Second-degree burns
    • Granulating or necrotic wounds
    • Chronic nonhealing wounds
  • Contraindications
    • Third-degree burns
    • Patient sensitivity to bovine, porcine, or avian products
    • Wounds covered in dry eschar
  • Example: Collagen matrix, fibracol, puracol, collagen gel
27
Q

Dressing Types

A
28
Q

Pressure Injury - Unstageable

A
  • Definition
    • Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
  • Description
    • Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined but it will be either a Stage III or IV
    • Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.
29
Q

Suspected Deep Tissue Injury

A
  • Definition
    • Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear
  • Description
    • The area may be preceded by tissue that is painful, firm, mushy, or boggy, or warmer or cooler than adjacent tissue
    • Deep tissue injury may be difficult to detect in individuals with dark skin tone.
    • Evolution may include a thin blister over dark wound bed. The wound may further evolve and become covered by thin escar
    • Evolution may be rapid, exposing additional layers of tissue even with treatment