Class 5 - Tissue Integrity Flashcards

1
Q

What does a PVS assessment involve?

A

Includes inspecting and palpating the patients arms and legs

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2
Q

What does a PVS assessment inform to the nurse?

A

Informs the nurse about the patient’s peripheral perfusion, or the body’s ability to circulate blood to and from the extremities

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3
Q

Physiological functions of the skin

A
  • Protection
  • Prevention of penetration
  • Temperature regulation
  • Wound repair
  • Absorption and excretion
  • Production of vitamin D
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4
Q

Embody (social) functions of skin

A
  • Perception
  • Communication
  • Identification
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5
Q

Physiological skin changes result in

A
  • Decreased protection
  • Decreased temperature regulation
  • Delayed healing
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6
Q

Skin changes leads to an increased risk for

A
  • Wounds
  • Heat stroke (reduced ability to sweat)
  • Hypothermia (reduced adipose tissue)
  • Greater risk for infection
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7
Q

Integumentary system: subjective data (12)

A
  • Previous history of skin disease (Allergies, hives, psoriasis, eczema)
  • Change in pigmentation
  • Change in mole size or colour
  • Excessive dryness or moisture
  • Pruritis
  • Excessive bruising
  • Rashes or lesions
  • Medications
  • Hair loss
  • Change in nails
  • Environmental or occupational hazards
  • Self-care behaviours
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8
Q

Integumentary system: objective data (12)

A
  • Colour
  • Temperature
  • Moisture
  • Texture
  • Thickness
  • Edema
  • Mobility and turgor
  • Vascularity and bruising
  • Rashes or lesions
  • Nails
  • Oral cavity
  • Scalp
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9
Q

Objective data: Colour of skin

A
  • Colour change: Pallor (white), erythema (red), cyanosis (blue), jaundice (yellow)
  • Darker pigmentation
  • Lighter pigmentation
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10
Q

Objective data: Temperature of skin

A

Palpate the skin… is it hypothermia or hypethermia? Use the back of your hand

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11
Q

Objective data: Moisture of skin

A
  • Diaphoresis or profuse perspiration
  • Dryness
  • Dehydration (oral mucous membranes)
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12
Q

Objective data: Texture of skin

A

Smooth, firm, with an even surface

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13
Q

Objective data: Thickness of skin

A

Are they calloused or thin or shiny?

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14
Q

Objective data: Edema of the skin

A
  • Fluid that accumulates in the intercellular spaces
  • Imprint your thumb firmly against the ankle malleolus or the tibia
    — Unilateral edema or bilateral edema
  • Can be pitting edema or non-pitting edema
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15
Q

Pitting edema

A

1+ = mild pitting, slight indentation, no perceptible swelling of the leg (2mm)
2+ = moderate pitting, indentation subsides rapidly (4mm)
3+ = deep pitting, indentation remains for a short time, swelling of leg (6mm, 20-40 seconds)
4+ = very deep pitting, indentation last a long time, gross swelling and distortion of leg (8mm, deep, stays a while)

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16
Q

Objective data: Mobility and turgor of the skin

A
  • Pinch up a large fold of skin on the anterior aspect of the chest under the patient’s clavicle
    Mobility = skins ease of rising
    Turgor = skins ability to promptly return to place
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17
Q

Objective data: Vascularity of skin

A

Any bruises? Signs of recreational IV drug use?

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18
Q

Objective data: Rashes or lesions on skin

A

Types of lesions, described them

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19
Q

Types of abnormal lesions

A

Primary = when a lesion forms on unaltered skin
Secondary = when a lesion changes over time (scratching/itching)

20
Q

Assessment of abnormal findings: Lesions

A

Health history
- Pain, healing, cause, when/where did it start, spreading, contagious, environmental, itching, fever, stress
Inspection
- Colour, elevation, pattern or shape, size, location and distribution on the body, any exudate?
Palpitation
- Depth, pain, temperature, easily removed “brushed off” cause bleeding?, blanch with pressure?

21
Q

Primary skin lesions

A

Macule/patch
Papule/plaque
Nodule/tumour
Wheal/urticaria
Vesicle/bulla
Cyst/pustule

22
Q

Common shapes - skin

A

Annular = circular
Confluent = merge, multi-shaped
Discrete = distinct, separate
Grouped = cluster
Gyrate = snakelike, coil
Target = iris, bullseye
Linear = scratch, streak
Polycyclic = annular grow together
Zosteriform = along the nerve route

23
Q

How do you assess moles?

A

ABCDE Characteristics
Asymmetry
Border irrregularity
Colour variation
Diameter > 6mm
Evolution

24
Q

Objective data: Nail beds

A

Clubbing? Discolouration?

25
Objective data: Oral cavity
Moist mucous membranes? Any lesions? Halitosis? (Bad breath) Furrowed tongue? Condition of the teeth (broken, clean, bleeding gums)
26
Objective data: Scalp
Tenderness Sores/lesions Infestations
27
Peripheral vascular assessment: Subjective data
Leg pain/cramps: OPQRSTUV Skin changes on arms/legs r/t PVD Swelling in arms/legs r/t PVD Lymph node enlargement Medications
28
Objective data: PVD
Palpate/compare Colour, Warmth, Sensation, Movement Assess cap refill Palpate pulses
29
Laboratory assessment for tissue integrity
Wound cultures Albumin Biopsy
30
Pressure ulcers: Etiology
Pressure - skin and soft tissue compressed Shearing force - skin stationary, tissue below moves Friction - surfaces rub the skin Excessive moisture
31
Pressure ulcers: Risk factors
Loss of mobility Confusion Poor nutritional status Dehydration
32
Causes of lethal cell injury
- Cellular ischemic - Physical damage - Microbial injury - Immunological injury (own immune system damages the body) - Normal substances with unintended contact (gastric acid leads into abdominal activity) - Neoplasticism growth (benign or cancerous)
33
Necrosis
Uncontrollable passive pathological process of cell death. Occurs when cells are exposed to extreme conditions. Causes cells to SWELL and RUPTURE, leading to inflammation and damage of surrounding tissue
34
Necrosis: Coagulative
Caused by ischemia, free radical, still looks like a cell for a while
35
Necrosis: Liquefactive
Caused by the body releasing enzymes to kill bacteria, but causing damage (liquefy) of neighbouring cells (abscess)
36
Necrosis: Caseous
A distinct form of coagulative necrosis, where tissue is no longer recognizable, cheese-like appearance. Caused by mycobacteria’s infections (TB) or tumour necrosis
37
Necrosis: Gangrene
Build-up of decomposing dead tissue, usually refers to appendage/limb with ischemic necrosis
38
Necrosis: Dry gangrene
Chronic/slow, caused by degenerative diseases (arteriosclerosis, diabetes) may auto-amputate
39
Necrosis: Wet gangrene
Acute/quick, caused by sudden elimination of blood flow (severe burn or traumatic crush injury) possible bacteria
40
Expected wound healing
Serous and serosanguineous
41
Active bleeding
Sanguineous
42
Possible infection
Purulent
43
Wound healing: Primary intention
Incision with blood clot -> Edges approximated with suture -> Fine scar
44
Wound healing: Secondary intention
Irregular, large wound with blood clot -> Granulation tissue fills in wound -> Large scar
45
Wound healing: Tertiary intention
Contaminated wound -> Granulation tissue -> Delayed closure with suture