Exam 3- Skin Integrity Flashcards
Skin Integrity
Definition
Tissue Integrity
Tissue integrity is the state of structurally intact and
physiologically functioning epithelial tissues such as
the integument (including the skin and subcutaneous
tissue) and mucous membranes
Scope
Tissue Integrity
- Intact
- Partial thickness injury
- Full Thickness injury
Parts of the epidermis
3
- Stratum Corneum
- 3 middle layers
- Stratum Germinativum
Impaired Tissue Integrity
Individual Risk factors
9
- Poor peripheral perfusion
- Malnutrition
- Dehydration
- Edema
- Impaired mobility
- Immunosupression
- Diabetes
- Exposure to irritants
- Tissue trauma (friction, moisture, pressure)
Parts of Braden Scale
6
- Sensory Perception
- Moisture
- Mobility
- Activity
- Nutrition
- Friction
Papule
solid raised lesion with defined borders
Nodule
raised solid mass with defined borders that extends to the dermis
Wheal
Irregularly shaped area of edema
Primary intention
heals quickly, minimal scarring
Secondary Intention
new tissue must fill in from the bottom and sides
Tertiary Intention
When there is a delay from injury to to close, leaving the wound open for some time after
Assessing Ulcer
9
- acute or chronic
- location
- size (depth and width)
- undermining/tunneling
- color
- cleanliness
- drains present?
- drainage?
- Staging
Stage 1 ulcer
intact nonblistered skin, persistant redness in area exposed
Stage 2 Ulcer
partial thickness, shallow no more part dermis
also includes ruptured blisters
Stage 3 Ulcer
full thickness wound, into subq layer, not to muscle or bone
