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MS and skin
foundations exam 3
| Question | Answer |
|---|---|
| healthy history MS and skin assessment | recent changes in skin, activity and mobility, nutrition, pain, elimination |
| recent changes in skin while doing MS and skin assessment | existing wounds/lesions |
| MS and skin assessment: activity and mobility | are you able to walk? assisted? use wheelchair? bedrest? |
| MS and skin assessment: nutrition | protein malnutrition, hydration status |
| MS and skin assessment: elimination | incontinence bowel and/or bladder |
| skin assessment | inspection and palpation |
| how should you perform the skin assessment? | systematically- head to toes, include boney prominences |
| how often should you perform the skin assessment? | on admission and at regular intervals |
| How often should you perform the skin assessment in acute care? | every shift |
| How often should you perform a skin assessment in long term settings? | weekly for 4 weeks then quarterly |
| How often should you perform a skin assessment in home health care? | each visit |
| structures of the skin | epidermis, dermis, subcutaneous |
| epidermis | protective waterproof layer of keratin, cells have no blood vessels of their own, regenerates easily and quickly |
| dermis | elastic tissue made primarily of collagen, nerves, hair follicles, glands, immune cells, and blood vessels |
| subcutaneous | anchors the skin laters to underlying tissues |
| What do unbroken and healthy skin and mucosa membranes do? | defend against harmful agents |
| What is resistance to injury affected by? | age, amount of underlying tissues, and illness |
| Adequately nourished and hydrated body cells are resistant to what? | injury |
| What is necessary to maintain cell life? | adequate circulation |
| Focus: activity implications for health | skin issues if problems with neuro or M/S system, hazards of bed rest, ROM for pt |
| developmental considerations for older adults | circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure |
| Who is more susceptible to skin injury? | very thin and very obese people |
| What does fluid loss during illness cause? | dehydration and predisposes skin to breakdown |
| What does jaundice cause? | yellowish, itchy skin |
| What can diseases of the skin, such as eczema and psoriasis cause? | lesions |
| types of wounds | intentional (surgical) or unintentional (traumatic), neuropathic or vascular, pressure related (HAPI), device related, open or closed, acute or chronic, partial thickness, full thickness, complex |
| device-related injury | any harm or damage to a patient's body caused by a medical device used during care |
| what type of injury is a device-related injury typically? | skin injuries but can include other types of trauma, such as nerve damage, burns, or infections |
| When do device-related injuries most commonly happen? | when devices apply prolonged pressure, friction, or shear to the skin or underlying tissues |
| examples of device related injuries | oxygen tubing or masks, IV catheters or securement devices, CPAP or BiPAP masks, neck collars or braces, endotracheal tubes |
| how can oxygen tubing or masks cause injury? | cause pressure or skin breakdown on the ears, nose, or cheeks |
| How can IV catheters or securement devices cause injury? | cause skin tears |
| How can CPAP or BiPAP masks cause injury? | cause facial ulcers |
| How can neck collars or braces cause injury? | cause skin breakdown |
| How can endotracheal tubes cause injury? | cause pressure injuries to the lips or mouth |
| pressure injury cause | sustained pressure |
| what do device related injuries directly correspond with? | the shape of the device |
| What do you document as the cause of device related injuries? | the device, do not stage |
| example sites of device related injuries | ears, nostrils, cheeks, nose, lips |
| Where are pressure injuries common? | on bony prominences (sacrum, heels, hips) |
| What do you document for pressure injuries? | HAPI |
| example sites of pressure injuries | sacrum, heels, hips, shoulders |
| intact skin | first line of defense against microorganisms |
| careful hand hygiene is used... | in caring for a wound |
| an adequate blood supply is essential for... | normal body response to injury |
| normal healing is promoted when the wound is... | free from foreign material |
| the extent of damage and the person's state of health affects... | wound healing |
| When is response to a wound more effective? | if proper nutrition is maintained |
| factors affecting pressure injury development | aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, altered level of consciousness, spinal cord and brain injuries, neuromuscular disorders |
| what factors affecting pressure injury development can we control? | immobility, malnutrition, fecal and urinary incontinence |
| HAPI | healthcare-acquired pressure injury |
| examples of HAPIs | pressure ulcer, decubitus, decubiti, bedsore |
| What is usually the cause of HAPIs? | pressure of the patients own body weight |
| pressure, preventing blood flow, results in? | decreased perfusion-> leads to cell and tissue death-> exposes underlying tissue |
| mechanisms in pressure injury development | external pressure compressing blood vessels, friction or shearing forces tearing or injuring blood vessels, microclimate: temperature and moisture of skin |
| risks for pressure injury development | nutrition and hydration, immobility, mental status, age |
| pressure points | those that bear weight and are least padded with sub q tissue, so that the skin over them is subject to pressure |
| what does pressure depend on? | position in bed |
| What can you do to prevent pressure injuries? | padding, air bed on, pressure alternating mattresses, turning and proper positioning, skin barriers on, heel, elbow protectors on |
| How long should a patient sit a chair to prevent pressure injuries? | 2 hours max if not moving or being moved |
| If adequate pressure-redistribution support surfaces are used, what repositioning intervals may be acceptable? | 2-3 hour |
| low fowlers | HOB raised 15-30 degrees |
| semi fowlers | HOB 30-45 degrees |
| standard fowlers | HOB 45-60 degrees |
| High fowlers | HOB 60-90 degrees |
| What is typically used for patients eating in bed? | high fowlers |
| resting position | semi fowlers |
| when is prone position used? | not typical, used for severe pulmonary reasons |
| lateral or "side lying" important note | watch for skin to skin contact, use pillows to separate |
| patient positioning | supine, fowlers, prone, lateral or side lying, sims position, trendelenburg's position, reverse trendelenburg, lateral |
| when is reverse trendelenburg used? | in certain circumstances (heart catheterization, neuro injury, etc.) |
| how often should you assess at risk patient's to prevent pressure injuries? | daily |
| How often should you cleanse the skin to prevent pressure injuries? | routinely |
| preventing pressure injuries | use moisturizers, protect skin from excessive moisture, minimize skin injury, proper positioning, turning, appropriate support surfaces, adequate nutrition and hydration, improve mobility and activity, skin barrier cream |
| How often should you turn when a patient has pressure relieving devices on? | Q2-3 hour |
| prevention od shearing injuries- EVIDENCE | silicone foam dressings (heels and sacrum), low friction or film dressings/ barrier films |
| mepilex silicone borders | dressings to prevent shearing and friction injuries |
| How are pressure injuries staged? | 1-4, deep tissue pressure injury, or unstageable |
| What is staging based on? | visualization of underlying structures |
| stage 1 pressure injury | intact skin with a localized area of non-blanchable erythema |
| What may precede visible changes in stage 1 pressure injury? | changes in temperature, consistency, sensation |
| stage 2 pressure injury | partial thickness loss of dermis; wound bed is viable, pink/ red, moist, and may present as an intact or ruptured serum filled blister; no visible subcutaneous fat or deeper structures; granulation tissue, slough, and eschar not present |
| stage 3 pressure injury | full thickness skin loss in which adipose (fat) is visible, and granulation tissue, epibole (rolled edges), undermining or tunneling may occur; slough/eschar may be present |
| stage 4 pressure injury | full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone; slough or eschar may be present, and epibole, undermining or tunneling often occur |
| unstageable pressure injury | full thickness skin and tissue loss in which the extent of damage is obscured by slough or eschar in the wound bed |
| When can an unstageable pressure injury be staged? | when the overlying tissue is removed (or slough clears) the wound cannot be reliably staged as stage 3 or stage 4 |
| deep tissue pressure injury | intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, or purple discoloration, or a blood filled blister; an epidermal separation may reveal a dark wound bed |
| What are deep tissue pressure injuries often preceded by? | changes in pain or temperature |
| What does a deep tissue pressure injury indicate? | there is an injury to vasculature, nerve involvement, etc. |
| measuring pressure wounds | check for tunneling, measure outside, may be worse than it looks |
| slough | dead tissue, usually cream or yellow |
| eschar | dry, black, hard necrotic tissue |
| necrotic tissue | non-viable tissue due to reduced blood supply |
| how to remove slough? | surgical debridement may be necessary |
| maceration | excessive moisture softens the skin, turns it white and causes it to breakdown; exudate leaked from ulcers can also cause maceration, leading to larger ulcers or satellite ulcers |
| wound assessment: appearance | size of wound, depth of wound, presence of undermining, tunneling, or sinus tract |
| wound assessment: drainage | serous, sanguineous, serosanguineous, purulent |
| skin tears | traumatic wound caused by mechanical forces that involves separation of skin layers but does not extend through SQ tissue |
| do you stage skin tears? | no |
| skin tear treatment | stop bleeding, gentle cleansers, do not remove viable flap, non adherent dressing, silicone dressings, no dry gauze, transparent film or hydrocolloid dressings may be harmful if difficult to remove and are not recommended |
| treatment of wounds | prevention (pressure points and nutrition), dressing to keep wound moist, do not get surrounding tissue wet, pack loosely, wet to dry only if ordered, wound VAC |
| what can packing wounds tightly do? | occlude arteries |
| braden scale | six point risk assessment tool for skin breakdown: pressure injury risk |
| How does a braden scale work? | obtain score of patient which corresponds with their risk of obtaining HAPI; computer shows what to do to prevent pressure injuries for that patient |
| 6 points of braden scale | sensory perception, moisture, activity, mobility, nutrition, frication and shear |
| shear | the result of skin being pulled in one direction, however supporting structures such as muscle and bone do not move, or move in the opposite direction (happens underneath skin) |
| friction | the result of the skin being moved one way while a surface is stationary, or moves in the opposite direction (happens outside skin) |
| How to move patient up in bed? | two people to move at minimum, use draw sheet/pad, HOB down, knees bent, heels on bed, not to push, chin down |
| What happens if patient doesn't put their chin down when moving them up in bed? | can cause hyperextension of neck otherwise |
| document-skin assessment | make sure you get this on admission or your agency takes responsibility; document prevention as well as treatment and education, document stage |
| local factors that impede wound healing | inadequate blood supply, increased skin tension, poor surgical apposition, wound dehiscence, poor venous drainage, presence of foreign body and reactions, continued presence of microorganisms, infection, excess local mobility, usch as over a joint |
| systematic factors that impede wound healing | advancing age, obesity, smoking, malnutrition, deficiency of vitamins, malignancy and illness, shock, chemo and radiotherapy, immunusuppressant drugs, neutrophil disorders, impaired macrophage activity |
| hazards of bedrest | pressure injury and much more, sever impact on m/s system and cardiac, pulmonary, nutritional, mental impact |
| What is necessary to maintain strength? | muscle contractions of certain minimal force and frequency |
| how much does muscle strength decrease in the absence of any voluntary contraction? | 5% each day |
| young men at bed rest lose muscle strength at the rate of? | 1.o% to 1.5% per day (10% per week) |
| hazards of immobility and bedrest (beyond pressure ulcers) | loss of muscle mass and bone density, high potential for neuro involvement, DVT |
| What can DVTs cause | pulmonary embolism |
| interprofessional collaboration | get consults for PT and OT |
| What is key to patient return to past or optimal functioning? | prevention: positioning, ROM, exercise in bed |
| assessing joints (MS) | inspection, palpation, ROM, strength |
| Why ROM? | motion limited by a mechanical problem within the joint, swelling of tissue around the joint, spasticity of the muscles, pain or disease |
| contracture | fixed tightening of muscle, tendons, ligaments, or skin; prevents normal movement of the associated body part |
| foot drop | inability to lift the front part of the foot off the ground |
| Why is prevention of foot drop imperative? | can be permanent |
| What kind of ROM is best? | active |
| passive ROM | extend, flex, and rotate; any way the joint moves normally, we imitate and do for the patient; work one joint at a time |
| passive ROM at least once per day | each 10x to the point of resistance, slowly watching the patient's face, moving until patient feels a slight stretch, but don't force a movement; move only to the point of resistance; keep limbs supported throughout motion |
| abduction | away from the body |
| adduction | towards the body |
Created by:
camrynfoster