Class 5 - Tissue Integrity Flashcards
What does a PVS assessment involve?
Includes inspecting and palpating the patients arms and legs
What does a PVS assessment inform to the nurse?
Informs the nurse about the patient’s peripheral perfusion, or the body’s ability to circulate blood to and from the extremities
Physiological functions of the skin
- Protection
- Prevention of penetration
- Temperature regulation
- Wound repair
- Absorption and excretion
- Production of vitamin D
Embody (social) functions of skin
- Perception
- Communication
- Identification
Physiological skin changes result in
- Decreased protection
- Decreased temperature regulation
- Delayed healing
Skin changes leads to an increased risk for
- Wounds
- Heat stroke (reduced ability to sweat)
- Hypothermia (reduced adipose tissue)
- Greater risk for infection
Integumentary system: subjective data (12)
- 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
Integumentary system: objective data (12)
- Colour
- Temperature
- Moisture
- Texture
- Thickness
- Edema
- Mobility and turgor
- Vascularity and bruising
- Rashes or lesions
- Nails
- Oral cavity
- Scalp
Objective data: Colour of skin
- Colour change: Pallor (white), erythema (red), cyanosis (blue), jaundice (yellow)
- Darker pigmentation
- Lighter pigmentation
Objective data: Temperature of skin
Palpate the skin… is it hypothermia or hypethermia? Use the back of your hand
Objective data: Moisture of skin
- Diaphoresis or profuse perspiration
- Dryness
- Dehydration (oral mucous membranes)
Objective data: Texture of skin
Smooth, firm, with an even surface
Objective data: Thickness of skin
Are they calloused or thin or shiny?
Objective data: Edema of the skin
- 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
Pitting edema
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)
Objective data: Mobility and turgor of the skin
- 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
Objective data: Vascularity of skin
Any bruises? Signs of recreational IV drug use?
Objective data: Rashes or lesions on skin
Types of lesions, described them
Types of abnormal lesions
Primary = when a lesion forms on unaltered skin
Secondary = when a lesion changes over time (scratching/itching)
Assessment of abnormal findings: Lesions
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?
Primary skin lesions
Macule/patch
Papule/plaque
Nodule/tumour
Wheal/urticaria
Vesicle/bulla
Cyst/pustule
Common shapes - skin
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
How do you assess moles?
ABCDE Characteristics
Asymmetry
Border irrregularity
Colour variation
Diameter > 6mm
Evolution
Objective data: Nail beds
Clubbing? Discolouration?
Objective data: Oral cavity
Moist mucous membranes?
Any lesions?
Halitosis? (Bad breath)
Furrowed tongue?
Condition of the teeth (broken, clean, bleeding gums)
Objective data: Scalp
Tenderness
Sores/lesions
Infestations
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
Objective data: PVD
Palpate/compare Colour, Warmth, Sensation, Movement
Assess cap refill
Palpate pulses
Laboratory assessment for tissue integrity
Wound cultures
Albumin
Biopsy
Pressure ulcers: Etiology
Pressure - skin and soft tissue compressed
Shearing force - skin stationary, tissue below moves
Friction - surfaces rub the skin
Excessive moisture
Pressure ulcers: Risk factors
Loss of mobility
Confusion
Poor nutritional status
Dehydration
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)
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
Necrosis: Coagulative
Caused by ischemia, free radical, still looks like a cell for a while
Necrosis: Liquefactive
Caused by the body releasing enzymes to kill bacteria, but causing damage (liquefy) of neighbouring cells (abscess)
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
Necrosis: Gangrene
Build-up of decomposing dead tissue, usually refers to appendage/limb with ischemic necrosis
Necrosis: Dry gangrene
Chronic/slow, caused by degenerative diseases (arteriosclerosis, diabetes) may auto-amputate
Necrosis: Wet gangrene
Acute/quick, caused by sudden elimination of blood flow (severe burn or traumatic crush injury) possible bacteria
Expected wound healing
Serous and serosanguineous
Active bleeding
Sanguineous
Possible infection
Purulent
Wound healing: Primary intention
Incision with blood clot -> Edges approximated with suture -> Fine scar
Wound healing: Secondary intention
Irregular, large wound with blood clot -> Granulation tissue fills in wound -> Large scar
Wound healing: Tertiary intention
Contaminated wound -> Granulation tissue -> Delayed closure with suture
