Tissue Integrity Flashcards
How do you acess for dermal ulcers?
Location, size, drainage, condition of surrounding skin and depth.
Exemplar
What is the name of the contagious skin infection that mainly affects children, is caused by the staphylococcus or streptococcus bacteria, and is charecterized by itchy blisters?
Impetigo
What is the name of the contagious fungal infection found in feet (athlete’s foot)? What is it treated with?
Tinea Pedis, antifungal sprays and creams.
Exemplar
What is the name of the yeast infection found in either skin, mouth or vagina? What are treatments?
Candida
Treated with medicated powders or creams for skin form. Nystatin liquid or oral form.
Exemplar
What is the medical term for infestations of human lice that is characterized primarily through pruritus?
Pediculosis
Exemplar
What do shampoos with pyrethrin and piperonyl butoxide treat?
Pediculosis Capitis
Exemplar
What is the name of the autoimmune dermal disorder characterized by scaling patches due to the overproduction of skin cells?
Psoriasis
Exemplar
What skin disorder is treated with topical emollients, keratolytic agents, anthralin, UV therapy or immonosuppresants?
Psoriasis
Pressure Ulcer Stages
What number is the stage characterized by pain, redness and warmth? The wound is not yet opened and affects surface of skin. How long does recovery last?
Stage 1, about 3 days.
Pressure Ulcer Stages
What stage is characterized by partial-thickness (loss of skin) and skin appears to be scraped and may present blisters? How long is recovery?
Stage 2, 3 days to 3 weeks.
Pressure Ulcer Stage
Describe a stage 3 pressure ulcer. How long is recovery?
Ulcer is much deeper within the skin affecting the fatty layer and a crater may form within the skin. Foul odor may be present with draining. 1-4 months
Pressure Ulcer Stage
What stage represents extreme wound depth by showing muscle and bone tissue? Eschar may be present. How long is recovery?
Stage 4, 3 months to 2 years.
Define slough in skin.
Debris that appears tan, yellow, green or brown in color.
Define eschar.
Hard plaque that’s tan, brown or black in color.
Pressure Ulcer Stage
What is the stage characterized by lack of visible wound bed? Usually necrosis is common in this stage.
Unstagable.
What are the phases of wound healing in order?
Hemostasis, Inflammatory, Proliferation, and Maturation.
What happends during Hemostasis phase of wound healing?
Happends immediately after injury
BV constricts, blood clotting begins, pain and edema are present.
What phase of wound healing is characterized by BV constriction, formation of blood clots with pain and edema?
Hemostasis
Describe the inflmmatory phase of wound healing? How long does it typically last?
White blood cells move to wound to destroy bacteria, acute inflammation (pain, heat, redness, swelling and mild temp). Lasts about 2-3 days.
What wound healing phase is characterized by WBC moving toward the wound, acute inflammation that lasts 2-3 days?
Inflammatory phase
Describe proliferation phase. How long does it last?
Building of new tissue and scar tissue. Lasts several weeks.
What phase in wound healing is characterized by fomation of new tissue and scar tissue that lasts for several weeks?
Proliferation phase
Describe maturation phase. How long does it last?
Collagen in wound is remodeled. Begins after 3 wks of injury, may last for years.
What phase in wound healing is characterized by collagen formation that begins 3wks after injury and lasts for years ahead?
Maturation (Remodeling) Phase
Stages of Wound Healing
What are the names for the three stages of wound healing?
Primary, Secondary and Tertiary Intentions.
Stages of Wound Healing
Describe the Primary Intention stage of wound healing?
Minimal tissue loss, approximated edges, most rapid healing, minimal scarring, healing with sutures or staples.
Stages of Wound Healing
What stage of wound healing is characterized by minimal tissue damage, approximated edges, most rapid healing, healed through staples or sutures.
Examples: lacerations or incisions
Primary intention healing.
Stages of Wound Healing
Describe the secondary intention stage of wound healing?
Wound margins are not close together, large wound that requires granulation, scar tissue formation, can present signs of infection and drainage. Takes a little longer to heal.
Stages of Wound Healing
What stage of wound healing is charecterized by: wound margins are not close together, large wound that requires granulation, scar tissue formation, can present signs of infection and drainage. Takes a little longer to heal.
Secondary intention
Stages of Wound Healing
Describe the tertiary stage of wound healing.
Delayed closure, wounds left open to reduce edema and infection and then closed, large infected wound.
Stages of Wound Healing
What stage of wound healing is charecterized by delayed closure, wounds left open to reduce edema and infection and then closed, large infected wound.
Tertiary wound healing.
Define dessication in tissues.
Removal of moisture from the skin or wounds.
Define maceration.
The softening and breaking down of skin resulting from prolonged exposure to moisture.
Define necrosis.
Dead tissue in wound that appears dry, black and leathery. Healing will not take place without removal of dead tissue.
Define evisceration.
Wound that is characterized by portrusion of organs (primarily with abdominal incisions).
If a patient has low serum albumin levels that could cause what?
Delayed tissue repair.
Define dehiscence.
Seperation of wound layers due to excess stress.
Where is a sacral pressure ulcer located?
Lower back where sacrum bone sits.
What are the three types of drainage liquids?
Serous, serosanguinous, and sanguineous.
Describe serous fluid.
Clear, watery plasma.
Example: blister fluid
Describe serosanginous fluid.
Mix between sanguineous and serous fluid. Usually pink in color. Thin watery drainage tinged with blood.
Describe sanguineous fluid.
Bright red, indicates active bleeding. Fresh blood.
