tissue integrity

• what is undermining?

  an open area extending under the skin along the edge of the wound
• what is benchmarking?

  comparing results and outcomes to other sources of similarly received data
• what is a stage 1 pressure injury?

  a non-blanchable wound that has intact skin and erythema
• what is a stage 2 pressure injury?

  partial thickness skin loss
• what is a stage 3 pressure injury?

  full thickness skin loss with adipose tissue exposed
• what is a stage 4 pressure injury?

  full thickness tissue loss with bones, muscles, tendons, and ligaments exposed
• why can you not determine a stage for an unstageable pressure injury?

  because the wound is covered in slough or eschar
• what is slough?

  yellow stringy nonviable tissue that covers a wound
• what is eschar?

  black or brown necrotic tissue that covers a wound
• what is revealed once eschar is removed?

  a stage 3 or 4 pressure injury
• what is a deep tissue injury?

  a localized non-blanchable wound that results from intense pressure and shearing force
• what color are deep tissue injuries?

  deep red, maroon, or purple
• what are the most common causes of device related pressure injuries?

  oxygen masks, oxygen tubing, urinary catheters, cervical collars, and compression stockings
• what is a mucosal membrane pressure injury?

  an injury to a mucous membrane caused by the pressure related to the insertion or placement of a foreign device
• what are the most common causes of mucosal membrane pressure injuries?

  endotracheal tubes, oxygen tubes, feeding tubes, urinary catheters, and drainage tubes
• can mucosal membrane pressure injuries be staged?

  NO
• what may be the first indicators of pressure injuries in clients with darkly pigmented skin?

  skin temperature and level of moisture
• what are other indicators of pressure injuries in clients with darkly pigmented skin?

  edema, hardened skin, and localized pain
• what should the nurse do when assessing a dark skinned client for pressure injuries?

  apply light pressure and then observe for an area that is darker than the surrounding skin
• how can skin appear in dark skinned clients?

  taut, shiny, and indurated
• when are pressure injuries assessed and documented?

  during admission to the health care facility, during routine assessments, and with each dressing change
• what should the nurse recommend to the provider for a wound that is not healing according to expectations?

  further diagnostic testing such as a tissue biopsy
• what should the nurse include when documenting pressure injuries?

  location, stage, size, description of tissue, color of the wound bed, condition of the surrounding tissue, appearance of wound edges, presence of undermining and tunneling, and any foul odors
• what should the nurse also document the presence and characteristics of?

  any wound drainage and pain at the wound site
• what are the types of wound care?

  surgical debridement, irrigation, and biological debridement
• what is surgical debridement?

  the process of surgically removing dead tissue and other debris that can cause infection
• what does the surgeon use to remove dead tissue and biofilm off of wounds?

  scalpel or scissors
• what does surgical debridement do?

  decrease the number of bacteria in the wound and it stimulates wounds closure and epithealization
• how often must chronic wounds be debrided?

  multiple times before healing occurs
• what is done for clients whose wounds are infected?

  tissues can be sent for culture and sensitivity testing so that the proper antibiotics can be ordered
• what does irrigation do?

  removes surface materials and decreases bacterial levels in the wound
• where is irrigation performed?

  at the bedside or in the surgical suite
• what is commonly used to irrigate wounds?

  0.9% sodium chloride
• what is biological debridement?


  the use of living organisms to removed necrotic or dead tissue
• what is commonly used in biological debridement?

  the larvae of the green bottle fly and the australian sheep blowfly
• why are the larvae of the green bottle fly and the australian sheep blowfly used in debridement?

  because they secrete an enzyme that liquifies necrotic tissue
• how does biological debridement work?


  the larvae use an enzyme to liquify that necrotic tissue and then they ingest the dead tissue
• what is also thought to stimulate wound healing and has an antimicrobial action?

  larvae therapy
• what does careful selection of the correct dressing facilitate?

  wound healing, minimized scarring, and strengthened tissue as it heals
• what is required for a wound to heal?

  a moist wound bed