NUR 116 - Week 5 - Tissue Integrity

Question 1

What factors contribute to tissue integrity?

Question 3

What are alterations in skin integrity?

Answer 3

Dermatitis - Irritation when skin is exposed to irritants (ex: feces, urine, stoma effluent)
Maceration - Irritation of epidermis b/c of moisture
Skin tears - Loss of top skin layer by mechanical forces
Pressure injury -
Cellulitis - Infection of superficial layers of the skin

Answer 4

• Erythema - blanchable/non-blanchable
• Edema
  
  • Blanchable (good): Redness that becomes white or pale when pressure is applied, area turns red when pressure is released
  • Non-blanchable (bad): Redness that does not go away when pressure applied; indicates structural damage in vessels
• Temperature: palpate, increase in temp may mean inflammed, low temp may mean decreased blood flow
• Special attention: dark skin, medical devices

Question 5

Types of Wounds to know (for 116)

Answer 5

MASD - Moisture-associated skin damage (pre-disposes to pressure injury formation)
- Form of dermatitis, develops when skin is exposed to irritants (ex: feces, urine, stoma effluent, wound exudates)
- Potential risk factors: Excessive sweating, increased skin temp, abnormal skin pH, deep skin folds

Pressure injury: develop due to prolonged pressure or a combination of pressure + shearing

Question 6

Pressure Injury Risk Factors

Answer 6

Immobility - Will be in same position for prolonged time; decreased circulation
Malnutrition
Reduced Perfusion
Altered Sensation
Decrease Level of Consciousness - May not feel pain,

Question 7

What are the Braden Scale categories?

Answer 7

Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear