Integumentary Flashcards
A flat, small (1 centimeter or less) lesion with color change. Seen in rubeola, rubella, scarlet fever, roseola infantum.
Macule
An elevated, sharply
circumscribed, small (1
centimeter), colored lesion. May
be pink, tan, red, or any
variation. Seen in ringworm and
psoriasis.
Papule
A bulging, small (under 1 centimeter), sharply defined lesion filled with clear, free fluid. Seen as groups in herpes simplex, varicella, poison ivy, and herpes zoster.
Vesicle/blister
Large (over 1 centimeter) vesicles. Seen
on soles and palms in scarlet fever and
in sunburn.
Bullae
An elevated, sharply circumscribed lesion (less than 1 centimeter) filled with pus. Seen in impetigo, acne, and staphylococcus infections.
Pustule
An elevated, white to pink edematous
lesion that is unstable and associated
with pruritus. Wheals are evanescent –
they appear and disappear quickly.
Seen in mosquito bites and hives
Wheal
Tiny, reddish purple, sharply circumscribed spots of hemorrhage in the superficial layers of the skin or epidermis. Petechiae may indicate severe systemic disease such as meningococcemia, bacterial endocarditis, or non-thrombocytopenic purpura and must be reported immediately.
Petechiae
This type of wound exudate is also known
• Thin, clear and a little thicker than water,
as the fresh blood that comes from a recent
serous drainage occurs during the healing
wound, and is characterized by a bright red
process of the wound. Most types of
color. Most commonly, it is seen in partial
wounds excrete some amount of serous
thickness and full thickness wounds.
drainage, and is usually not anything to
Sanguineous drainage should not be
worry about. However, if the serous
common in wounds after a few hours or
drainage being gets increasingly heavy or
days, and this type of drainage later on may
comes at a rate to regularly soak through
be indicative of trauma to the wound site.
dressings, it may indicate a larger issue, and
the wound should be examined by a
clinician.
Sanguineous
Thin, clear and a little thicker than water,
as the fresh blood that comes from a recent
serous drainage occurs during the healing
wound, and is characterized by a bright red
process of the wound. Most types of
color. Most commonly, it is seen in partial
wounds excrete some amount of serous
thickness and full thickness wounds.
drainage, and is usually not anything to
Sanguineous drainage should not be
worry about. However, if the serous
common in wounds after a few hours or
drainage being gets increasingly heavy or
days, and this type of drainage later on may
comes at a rate to regularly soak through
be indicative of trauma to the wound site.
dressings, it may indicate a larger issue, and
the wound should be examined by a
clinician.
Serous drainage
Similar to serous drainage in
• Often described by patients as
thickness, seropurulent
being “milky” in appearance,
drainage is cloudier in its
the purulent drainage is almost
transparency and can be slightly
always a sure sign of infection.
yellow or tan in appearance.
This type of exudate can be
This drainage usually means
green, yellow, brown or white in
that the wound has an infection
color and is a thick liquid.
and will need further treatme
Seropurulent
Often described by patients as
thickness, seropurulent
being “milky” in appearance,
drainage is cloudier in its
the purulent drainage is almost
transparency and can be slightly
always a sure sign of infection.
yellow or tan in appearance.
This type of exudate can be
This drainage usually means
green, yellow, brown or white in
that the wound has an infection
color and is a thick liquid.
Purulent
There is also a lack of smell when the dressing has been removed.
No odoe
An odor is only detectable at close proximity to the patient and when the dressing is removed.
Slight odor
Smell while dressing is on the patient
Moderate odor
This is when an odor is discernible within 6 to 10 feet of the patient and the dressing is removed.
Strong odor
An odor that’s also noticeable within 6 to 10 feet, but the patient’s dressings remain fully intact.
Very strong odor
Sweet smell
Pseudomonas (Antibiotics)
Pressure injuries aka
Pressure ulcers
localized damage to the skin and/or underlying soft
tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.”
Pressure injury
Pressure in combo with
Shear
5 classic locations for pressure injuries
• Sacrum/coccyx
• Greater trochanter
• Ischial tuberosity
• Heel
• Lateral malleolus
Purple or maroon localized area of discolored, in tact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear.
Deep tissue pressure injury
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Stage 1 pressure injury
Partial thickness loss of dermis Presents as a shallow, open ulcer with a red/pink wound bed without slough
Can also present as an intact or open/ruptured serum-filled blister Should not be used to describe skin tears, maceration or excoriation
Stage 2 pressure injury
Full thickness tissue loss Subcutaneous fat may be visible, but bone, muscle or tendon are not. Slough may be present but does not obscure the depth of the tissue loss May include undermining and tunneling, epidermal rolling/ridging/epibole Varies by anatomical location
◦ (bridge of nose, occiput do not have subcutaneous fat
and can have a shallow stage 3) ◦ Areas of high fat tissue content may have very deep
stage 3s
Stage 3
Full thickness tissue loss Exposed bone, tendon or muscle (visible and palpable)
Slough or eschar may be present Often includes undermining and tunneling Depth varies by anatomical location
Stage 4 tissue loss
Full thickness skin loss Base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) or by eschar (tan, brown, black)
Until enough slough/eschar is removed to expose the base of the wound, no stage can be determined Stable, dry, adherent eschar in heels should be left alone
Unstageable
