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NURS 2500 > Class 5 - Tissue Integrity > Flashcards

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
Q

Objective data: Oral cavity

A

Moist mucous membranes?
Any lesions?
Halitosis? (Bad breath)
Furrowed tongue?
Condition of the teeth (broken, clean, bleeding gums)

26
Q

Objective data: Scalp

A

Tenderness
Sores/lesions
Infestations

27
Q

Peripheral vascular assessment: Subjective data

A

Leg pain/cramps: OPQRSTUV
Skin changes on arms/legs r/t PVD
Swelling in arms/legs r/t PVD
Lymph node enlargement
Medications

28
Q

Objective data: PVD

A

Palpate/compare Colour, Warmth, Sensation, Movement

Assess cap refill

Palpate pulses

29
Q

Laboratory assessment for tissue integrity

A

Wound cultures
Albumin
Biopsy

30
Q

Pressure ulcers: Etiology

A

Pressure - skin and soft tissue compressed
Shearing force - skin stationary, tissue below moves
Friction - surfaces rub the skin
Excessive moisture

31
Q

Pressure ulcers: Risk factors

A

Loss of mobility
Confusion
Poor nutritional status
Dehydration

32
Q

Causes of lethal cell injury

A
  • 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
Q

Necrosis

A

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
Q

Necrosis: Coagulative

A

Caused by ischemia, free radical, still looks like a cell for a while

35
Q

Necrosis: Liquefactive

A

Caused by the body releasing enzymes to kill bacteria, but causing damage (liquefy) of neighbouring cells (abscess)

36
Q

Necrosis: Caseous

A

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
Q

Necrosis: Gangrene

A

Build-up of decomposing dead tissue, usually refers to appendage/limb with ischemic necrosis

38
Q

Necrosis: Dry gangrene

A

Chronic/slow, caused by degenerative diseases (arteriosclerosis, diabetes) may auto-amputate

39
Q

Necrosis: Wet gangrene

A

Acute/quick, caused by sudden elimination of blood flow (severe burn or traumatic crush injury) possible bacteria

40
Q

Expected wound healing

A

Serous and serosanguineous

41
Q

Active bleeding

A

Sanguineous

42
Q

Possible infection

A

Purulent

43
Q

Wound healing: Primary intention

A

Incision with blood clot -> Edges approximated with suture -> Fine scar

44
Q

Wound healing: Secondary intention

A

Irregular, large wound with blood clot -> Granulation tissue fills in wound -> Large scar

45
Q

Wound healing: Tertiary intention

A

Contaminated wound -> Granulation tissue -> Delayed closure with suture

NURS 2500 (8 decks)

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