MED SURG Exam 3 Review- West Coast University

2/9/202




1 Mobility and Tissue Integrity
• Inflammation and Wound Healing
• Integumentary System and Problems
• Musculoskeletal System, Trauma, and Orthopedic Surgery
2 Week 3 Objectives
Tissue Integrity
Summarize the nursing process in care of patients with alterations in tissue integrity
Classify priorities in the care of patients with alterations in tissue integrity using the following
applicable concepts: fluid regulation, infection/inflammation, pain, communication, health
promotion.
Identify the interprofessional collaboration/team management needs of the patient with
alterations in tissue integrity.
Examine the pharmacologic, nutritional, developmental, and teaching needs of the patient with
alterations tissue integrity.

3 Topics Covered
Lewis Ch. 11: Inflammation and Healing
Lewis Ch. 22: Assessment: Integumentary System
Lewis Ch. 23: Integumentary Problems
Lewis Ch. 24 (read only): Burns
Lewis Ch. 61: Assessment: Musculoskeletal System
Lewis Ch. 62: Musculoskeletal Trauma and Orthopedic Surgery
ATI Ch. 67: Musculoskeletal Diagnostic Procedures
ATI Ch. 68: Arthroplasty
ATI Ch. 69: Amputations
ATI Ch. 70: Osteoporosis
ATI Ch. 71: Musculoskeletal Trauma
ATI Ch. 74: Skin Disorders
ATI Ch. 75 (read only): Burns


4 Inflammation vs. Infection
Inflammatory Response
A sequential reaction to cell injury
Neutralizes and dilutes the inflammatory agent
Removes necrotic material
Establishes an environment suitable for healing and repair
Infection
Invasion of tissues or cells by microorganisms
Bacteria
Fungi
Viruses

5 Local Manifestations of Inflammation

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Redness
Heat
Pain
Swelling
Loss of Function
6 Pressure Ulcer
Pressure sore, Bedsore, Decubitous ulcer, “Decube”
Localized injury to the skin and underlying tissue as a result of pressure or pressure in
combination with shear
Shear: pressure exerted on the skin when it adheres to the bed and the skin layers slide in the
direction of body movement
Keep HOB at 30 degrees, if pt tolerates it
Typically occurs over a bony prominence
Excessive moisture can increase risk for skin breakdown
Highest risk
Elderly
Incontinent
Unable to reposition
Unaware of need to reposition


7 Most pressure ulcers occur:


 Sacrum
Coccyx
Calcaneus


8 Pressure Ulcer Staging
Stage 1
• Intact Skin
• Non- blanchable redness
• May be painful
•

9 Pressure Ulcer Staging
Stage 2
• Partial-thickness loss
• A shallow, open ulcer
• Red/pink wound bed

10 Pressure Ulcer Staging
Stage 3

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• Full thickness tissue loss
• Subcutaneous fat may be visible
• Slough may be present
• May have undermining and tunneling


11 Pressure Ulcer Staging
Stage 4
• Full thickness tissue loss
• Exposed bone, tendon, or muscle
• Slough or eschar may be present
• Often has undermining and tunneling

12 Pressure Ulcer Staging
Unstageable
• Full-thickness tissue loss
• Slough and/or eschar on the wound bed
• Above must be removed in order to stage

13 Nursing Management
Pressure Ulcer
Do a risk assessment with a valid tool
Braden Scale
Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear
Best treatment is PREVENTION
Turn/reposition patient frequently
Provide adequate nutrition
Pain management
Document size (length, width, depth)
Clean with NS
Moist dressing for wound healing
Do NOT use a wet to dry dressing if granulation tissue is healthy
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17 Contact Dermatitis
d/t irritants and allergens
red, itchy rash caused by direct contact
Steroid creams or anti-itch ointments
Cortisone-10 (hydrocortisone cream with aloe), Calamine lotion
In severe cases, oral corticosteroids to reduce inflammation, antihistamines to relieve itching, or
antibiotics to fight a bacterial infection.