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NUR 111 > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

1
Q

What are the layers of skin tissue?

A

Epidermis
Dermis
Subcutaneous

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2
Q

Describe function of skin: protection

A

thickened areas of palms and soles d/t increased trauma

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3
Q

Describe function of skin: Sensation

A

receptors located in skin- sense temperature, pain, light touch and pressure

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4
Q

Describe function of skin: Fluid balance

A

can absorb water if necessary or excrete water as sweat. About 600 mL lost daily in average adult through sweat- known as insensible perspiration

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5
Q

Describe function of skin: Temperature control

A

evaporation of sweat from skin or controlled by blood flow through the skin

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6
Q

Describe function of skin: Vitamin production

A

Vitamin D made w/ melanin

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7
Q

Describe function of skin: Immune Response

A

Langerhans cells facilitated uptake of allergens

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8
Q

Conditions that cause changes in skin integrity

A 
Very thin/very obese
Fluid loss
Excessive moisture
Jaundice: yellowing of skin resulting from bile products and salts in bloodstream; causes pruritis (itching)
Skin disorders
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9
Q

Risk factors for impaired skin integrity

A

Lifestyle variables: smoking
Age
Changes in Health status
Illness: DM2 most common, HIV+ increases risk for sarcomas
Diagnostic procedures: GI Prep for colonoscopy, bedrest on purpose
Therapeutic measures: meds – many causes rashes and/or photosensitivity
Immobility

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10
Q

Categories of Tissue Integrity Impairment

A 
Trauma/Injury
Loss of Perfusion: pressure ulcers, venous stasis
Immunological Disorders: Steven Johnson’s Syndrome – potentially fatal skin condition caused by rxn to medications
Thermal/Radiation: cancer treatment
Infection: 
Bacterial
Fungal
Viral
Infestations
Lesions
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11
Q

Stevens-Johnson Syndrome

A 
potentially fatal skin disorder characterized by:
Widespread erythema
Macule formation
Blistering
Epidermal detachment and sloughing
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12
Q

What is Stevens-Johnson Syndrome typically triggered by?

A

Antibiotics; some anti-seizure meds and NSAIDs

Allopurinol is risk factor: treatment for gout and kidney stone

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13
Q

Treatment for Stevens-Johnson Syndrome

A

Discontinue meds causing reactions

Fluid and electrolyte replenishment

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14
Q

Individuals with this may experience reactions to latex, jewelry, or poison ivy

A

Allergic Contact Dermatitis

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15
Q

Caused by soap, detergents, caustic materials

A

Irritant Contact Dermatitis

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16
Q

Which of the following are bacterial infections? Select all that apply.

a. Cellulitis
b. Impetigo
c. Contact Dermatitis
d. Tinea

A

Cellulitis

Impetigo

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17
Q

Fungal, viral, or bacterial: Candida Albicans

A

Fungal

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18
Q

Fungal, viral, or bacterial: Tinea

A

Fungal

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19
Q

Fungal, viral, or bacterial: Shingles

A

Viral

20
Q

Fungal, viral, or bacterial: Herpes

A

Viral

21
Q

Fungal, viral, or bacterial: Impetigo

A

Bacterial

22
Q

Fungal, viral, or bacterial: Cellulitis

A

Bacterial

23
Q

Fungal, viral, or bacterial: Tinea

A

Fungal

24
Q

List the ABCDE skin lesion rule

A 
Asymmetry
Border irregularity
Color change and variation
Diameter (6mm or more)
Evolving in appearance
25
Q

True or False: Scabies is contagious up to 4 weeks before symptoms appear.

A

True

26
Q

What are pediculosis humanus capitis and​ pediculosis pubis, respectively?

A

Head lice and pubic lice

27
Q

Which of the following are complications of uncontrolled diabetes? Select all that apply.

a. Dermopathy
b. Stasis dermatitis
c. leg and foot ulcers
d. frequent candida albicans infections

A

a. Dermopathy
b. Stasis dermatitis
c. leg and foot ulcers

28
Q

True or False. Karposi’s sarcoma is an AIDS defining illness.

A

True

29
Q

Adequate _____ is essential to wound healing.

A

blood supply

30
Q

Normal healing is promoted when wound is ___________.

A

free from foreign debris

31
Q

What are the types of wounds?

A

Primary intention

Secondary intention

32
Q

Define primary intention wound and provide an example

A

would with little tissue loss; usually done on purpose

ex. surgical incision

33
Q

Define secondary intention wound and provide an example

A

wound with loss of tissue; usually unintended

ex. burn, pressure ulcer, severe laceration

34
Q

True or False. Shock is a phase of wound healing.

A

False. Shock is a state of cellular and tissue hypoxia.

35
Q

Which of the following are phases of wound healing? Select all that apply.

a. Maturation
b. hemostasis
c. Fixation
d. inflammatory
e. proliferation

A

Maturation, hemostasis, inflammatory, proliferation

36
Q

T/ F. An embolus forms during the hemostasis phase of wound healing.

A

False. A clot forms during hemostasis as platelets aggregate at site of injury.

37
Q

True or False. Hemostasis is the last phase of wound healing because the bleeding has stopped.

A

False. Hemostasis is the first phase of wound healing.

38
Q

Choose the correct order of wound healing phases.

a. inflammation, hemostasis, proliferation, maturation
b. inflammation, maturation, proliferation, hemostasis
c. Fixation, inflammation, proliferation, maturation
d. Hemostasis, inflammation, proliferation, maturation

A

d. Hemostasis, inflammation, proliferation, maturation

39
Q

True or False. The inflammatory phase is a local response to injury.

A

False. The inflammatory phase is a systemic response.

40
Q

What is true of the inflammatory phase? Select all that apply.

a. Duration is 4-6 days.
b. Macrophages begin to ingest debris and release growth factors
c. Characterized by the 6 signs of inflammation
d. Fibroblasts begin to secrete collagen.

A

a. Duration is 4-6 days.
b. Macrophages begin to ingest debris and release growth factors

C is incorrect bc there are 5 signs of inflammation.

D is incorrect bc fibroblasts begin to secrete collagen & growth factors in the proliferation phase.

41
Q

What are fibroblasts?

A

sue cells that synthesize and secrete collagen and growth factors.​

42
Q

True or false. Granulation tissue is a sign of skin breakdown that needs to be monitored for infection.

A

False. Granulation tissue- new tissue that is pink/red and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal​

43
Q

True or False. Collagen synthesis peaks in 5-7 days.

A

True

44
Q

True or False. Scar tissue is stronger than normal tissue due to avascular collagen tissue.

A

False. Scar tissue is weaker than normal tissue due to avascular collagen tissue.

45
Q

Shallow wounds involving loss of epidermis & partial loss of dermis​

A

Partial thickness

46
Q

Wounds extends beyond epidermis and into deep layer of dermis​

Dermis does not regenerate; scar formation occurs

A

Full Thickness

47
Q

Select al that apply. Local factors affecting wound repair:

Pressure
Edema
Oxygenation
Bleeding

A

Pressure
Edema
Bleeding

*Oxygenation is systemic

NUR 111 (10 decks)

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