Integumentary Flashcards
Blanching
Becoming white; paling to the greatest extent
Cellulitis
Bacterial infection of the connective tissue of the skin
Erythema
Redness of the skin caused by increased local vasodilation
Exudate
Fluid accumulation in a wound bed; mixture of high levels of protein and cells
Fibrin
A whitish, nonglobular protein required for blood clotting
Granulation tissue
A gel-like matrix of vascularized connective tissue with “beefy red” epithelial buds in a newly healing wound bed
Hemosiderin staining
The dark purple-brown color of skin caused by a buildup of iron-containing pigment derived from hemoglobin via disintegration of red blood cells.
Induration
Firm Edema with a palpable/definable edge
Infection
Invasion and multiplication of microorganisms capable of tissue destruction accompanied by local or systemic symptoms
Inflammation
Defensive reaction to tissue injury involving increased local blood flow and capillary permeability that facilitates normal wound healing
Lipodermatosclerosis
Progressive changes to the skin
Subcutaneous tissues of the ankle and lower leg in persons with venous insufficiency (fibrotic thickening with hemosiderin staining).
Maceration
Softening of intact skin due to prolonged exposure to fluids
Necrotic
Dead; in a wound, devitalized tissue that often is adhered to the wound bed
Pallor
Lack of color; pale
Purulent Damage
Thick Yellow, green or brown wound drainage that often has a foul odor, typically a sign of infection.
Serous Drainage
Thin fluid that is clear or yellow
Serosanguinous
Combination of serous drainage and blood (serous fluid becomes pink)
Slough
Loose, stringy, necrotic tissue (yellow, white, or tan)
Trophic
Skin changes that occur due to inadequate circulation, including hair loss, thinning of skin, and ridging of nails
Sinus tract
Course pathway that can extend in any direction from a wound surface; results in dead space with potential for abscess formation
Tunneling
Tissue destruction along wound margins in a narrow area that may extend parallel to the skin surface or deeper into the body.
Undermining
Area of tissue under wound edges that becomes eroded; results in a large wound beneath a smaller wound opening
Cyanosis
Bluish tint (fingers and toes); Lips and Tongue (lung disease, heart disease, and hemoglobin abnormalities).
Jaundice
Diffuse yellowing of the skin and sclera (chronic liver disease)
Erythema
Reddish color (blanchable)
Infection, inflammation, allergic reactions or radiation.
Chronic Hyperthryroidism (Screening Inspection of the Skin by texture)
Soft or velvety skin
Chronic hypothyroidism (Screening Inspection of the skin by texture)
Very rough skin
Trauma (Screening inspection of the skin by texture)
Scarring
Scleroderma (Screening inspection of the skin by texture)
Fibrosis or hardening
Anxiety or Hyperhidrosis (Skin Inspection)
Overly Moist
Hypothyroidism/ Chronic Arterial Insufficiency (Skin Inspection)
Very Dry
Turgor Inspection
Measures skin’s elasticity & hydration status
> 3 seconds to return to normal = strong indication of moderately to severely dehydrated
Effusion
Fluid accumulation within a joint capsule or cavity and most often results from injury or inflammation
Edema
Fluid accumulation outside of joint capsules. Two common types of fluid accumulation are pitting and non-pitting.
ABCDE Method for Melanoma
A- Asymmetry
B- Borders
C- Colors
D- Diameter
E- Evolving
Alopecia
Hair loss (as in typical pattern balding in males)
Hypothyroidism (Screening Inspection of the hair)
Sparse & Coarse
Hyperthyroidism (Screening Inspection of the Hair)
Very Fine
Malnutrition (Screening Inspection of the Hair)
Dry, brittle and dull
Anorexia (Screening Inspection of the Hair)
Lanugo (fine, downy, peach fuzz hair on the face and body)
Hormonal Imbalance (in women) (Screening Inspection of the Hair)
Hirsutism (excessive coarse hair on back, face, and chest)
Beau’s Lines: Infection, protein deficiency, metabolic diseases, hypothyroidism, chemotherapy, alcoholism
Lindsay’s Line: Chronic renal failure
Mee’s Line: Chemotherapy, renal failure, arsenic poisoning, recent surgery
Terry’s Line: Cirrhosis of the liver, heart failure, Type 2 Diabetes
Spoon: Iron deficiency, anemia, Vitamin B12 deficiency
Pitting: Psoriasis
Clubbing: Chronic heart disease, cystic fibrosis, oxygen deprivation, chronic pulmonary disease.
Yellow: Chronic bronchitis, liver disorders
What kind of patient’s are at the greatest risk for pressure ulcers?
Hospitalization, Long-term care facilities, spinal cord injuries
Pressure Ulcers
Localized areas of soft tissue necrosis from prolonged pressure over bone
Risk factors for pressure ulcers?
Decreased mobility
Shear forces
Impaired Sensations
Moisture
Malnutrition
Advanced Age
History of previous pressure ulcers
Common locations of pressure ulcers
Sacrum/ coccyx
Greater Trochanter
Ischial Tuberosity
Posterior Calcaneus
Lateral Malleolus
Reactive Hyperemia
After pressure that turns the skin pale is removed, normal color returns to skin.
Erythema
Redness over areas of tissue irritation
Non- blanchable erythema
Areas of redness that do not become pale when pressure is applied
Stage 1 (of Clinical Staging)
Skin is intact, localized non blanchable erythema, At-risk tissues
Stage 2 (of Clinical Staging)
Shallow crater, red/pink wound bed, loss of epidermis & partial thickness of dermis
Stage 3 (of Clinical Staging)
Deep Crater. Undermining or tunneling may be present. Loss of epidermis, dermis & subcutaneous tissue.
Stage 4 (of Clinical Staging)
Deep Crater with extensive necrotic tissue.
Undermining or tunneling present
Full thickness loss of tissue with visible bone, tendon or joint
Unstageable (of Clinical Staging)
Crater with base covered by slough.
Suspected Deep Tissue Injury (of Clinical Staging)
Deep Purple or Maroon area of skin discoloration covered by intact skin. Unable to determine actual tissues involved.
Common cause of neuropathic ulcers
Diabetes Mellitus
Neuropathic ulcers are:
Wounds caused by mechanical stress and have significant sensory loss.
Sensory Diabetic Neuropathy
Damage to small afferent nerve fibers
Most significant risk factor for neuropathic ulcers
Motor Diabetic Neuropathy
Damage to large efferent motor nerve fibers
Atrophy and weakness of intrinsic foot muscles
Autonomic Diabetic Neuropathy
Damage to large efferent autonomic nerve fibers
Deceased sweating & oil production in skin.
0 on Modified Wagner Scale
At-risk foot
1 on Modified Wagner Scale
Superficial, noninfected ulceration
2 on Modified Wagner Scale
Deep ulceration, joint or tendon exposed
3 on Modified Wagner Scale
Extensive ulceration, bone exposed
A on Modified Wagner Scale
Nonischemic
B on Modified Wagner Scale
Ischemia
C on Modified Wagner Scale
Gangrene on part of foot
D on Modified Wagner Scale
Gangrene on entire foot
Superficial burn depth
Epidermis
Red and Dry
Heals within 1 week (minimal to no scarring)
Superficial partial thickness burn depth
Epidermis and top layer of dermis
Blister & moist, blanchable, moderate erythema, very painful
Heals within 2 weeks (minimal scarring)
Deep partial thickness burn depth
Epidermis and dermis
Mottled red & white areas, blanchable skin (slow), very painful
Heals within 3 weeks if area is small (up to several months for larger areas)
May require surgical intervention if wound is large
Results in scarring and permanent pigment changes.
Full thickness burn depth
Epidermis, dermis and hypodermis
Very mottled
Eschar is rigid, dry and leathery.
Little pain.
Sensation to pain, pressure and temperature is lost
Requires greater than 3 weeks to close, requires closure and grafting, permanent pigment changes, may result in contractures depending on location
Subdermal
Epidermis, dermis, and hypodermis and tissues underneath the hypodermis
Skin has dry, charred appearance, deep tissues are exposed
Requires surgical intervention, may require amputation, may result in paralysis of the area, significant scarring and pigment changes.
Total Body Surface Area - Rule of 9’s
- 5% of head
- 5% of back of head
9% of upper chest
9% of upper back
9% of abdomen
9% of lower back
18% of right leg
18% of left leg
9% of right arm
9% of left arm
1% genitalia
