Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Nursing 1st Fall Semester > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

1
Q

What is the largest organ of the body

A

Skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the two layers of skin

A

Epidermis and Dermis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the Dermis

A

Thick, dense, fibroblastic, connective tissue
highly vascularized
Supports and nourishes epidermis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What does the dermis contain

A

Nerves
Sweat Glands
Sebaceous glands
Hair Follicles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the subcutaneous tissue

A

“fat layer”
Is the body’s energy store and also supports blood vessels and nerves
Acts as a cushion to protect from damage and helps protect from the cold.
Channels nutrients and oxygen to the dermis via capillaries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the Fascia

A

White and shiny in appearance
Sheath covering for muscles, nerves and blood vessels.
Acts as a support so that the muscles can act as a single unit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Muscle tissue appearance

A

Pink To Dark Red
Firm
Highly Vascular
Striated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are ligaments

A

A band of strong fibrous tissue that connects two or more bones/cartilage together

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the cartilage

A

Shock absorber
Thin layer of tough tissue that covers the end of bones where they meet in the joint, without causing friction or damage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the Tendon and its appearance

A

Attaches muscle to bone
strong fibrous tissue
Gleaming yellow or white, shiny if healthy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Function of bones

A

Supports and protects internal organs
206 in the body

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is bone marrow

A

Soft spongy tissue in the center of many bones, makes and stores blood vessels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the functions of the skin

A

To protect
Hold the body shape
Prevents loss of fluid
Produces sebum/melanin, Vitamin D
Sensation
Elimination, perspire
Maintains Temp
Immunological response(emotions)
Expression of emotions/psychosocial * Absorption

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the risk factors of wounds

A

Immobility
Inadequate Nutrition (no proteins, fats, carbs)
Fecal and Urinary Incontinence
Decreased mental status
Diminished sensation
Excessive body heat
Chronic Medical Conditions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Describe moisture in wounds

A

Continued exposure causes tissue softening
Skin is more susceptible to shear, pressure and, especially, friction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What parts of the body would you asses for wounds

A

Areas at high risk for skin breakdown:
Those include:
Body folds
Temporal region
Ears
Scapulae
Spinous process * Shoulders
Elbows
Saccrum
Coccyx
Ishial Tuberosities
Femoral Trochanters
Knees
Malleoli
Metatarsals
Heels
Toes
Areas covered by restrictive clothing or equipment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What parts of the body are pressure ulcers more frequent

A

Sacral/coccyx
Greater trochanter
Ischial Tuberosity
Heel
Lateral Malleolus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are some ulcer comorbidities in the cardiovascular system

A

CAD,CHF,PVD,PAD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are some ulcer co morbidities in the respiratory system

A

Pneumonia, COPD, Asthma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are some ulcer co morbidities in the G.I.

A

GI bleeding, Swallowing problems, diarrhea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What are some ulcer co morbidities in the Genitourinary System

A

Urinary Incontinence, Kidney failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are some ulcer co morbidities in the Musculoskeletal System

A

CVA, Arthritis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What are some ulcer co morbidities in the Endocrine

A

Diabetes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What are some ulcer co morbidities in the Hematological

A

Anemia, Fluid and Electrolyte balances

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
What are some ulcer co morbidities in cancer
Radiation treatment, Antineoplastic medication
26
Part of a wound: Describe the wound
Considered the open area only Diameter is edge to edge There are 3 parts to the wound: depth, edges aka the rim and base( the bottom)
27
Parts of a wound: Describe the Periwound
Tissue around the outside of the perimeter of the wound Minimum of 4cm
28
Parts of a wound: Describe tunneling
A channel or a pathway that extends in any direction from the wound through subcutaneous tissue or muscle resulting in dead space with potential for abscess formation
29
What is a fistula
An abnormal passage from an internal organ or vessel to the outside of the body organ to organ, has a tunnel between both of them
30
Parts of a wound: Describe undermining
"lip around the wound" Tissue destruction underlying intact skin along the wound margins is caused by shearing forces against the wound
31
How do you measure an ulcer length
Measure from wound edge to wound edge size is documented in cm consider the wound as a face of a clock 12 o'clock points to the patient's head, 6 o'clock points to the patient's feet therefore length would be 12 to 6
32
How do you measure an ulcer width
Measure from wound edge to wound edge size is documented in cm 3 o'clock to 9 o'clock would be the width of the wound
33
How do you measure ulcer depth
Distance from the visible surface to the deepest part of the wound cotton tipped applicator to the deepest part of the wound measure from tip of applicator If there is no depth, put 0.
34
Tissue types: Describe granulation tissue
Beefy deep pink or red Has an irregular surface puffy or bubbly appearance seen in the wound bed of healing full thickness wounds
35
Tissue types: Describe clean non granulating
Deep pink or red Smooth (nongranular) Striated (when muscle fibers are exposed Is not healing, granulation tissue has to be present to heal
36
Tissue types: Describe Hyper-granulation tissue
Granulation tissue forms above the surface of the surrounding epithelium Delays healing
37
Tissue types: Describe Necrotic Tissue-slough
Yellow, Green or grey Nonviable tissue (dead) Thin Wet stringy
38
Tissue types: Describe Necrotic tissue- eschar
Black brown Dry nonviable tissue (dead) Thick Hard Leathery Do not want to wet this, acts as protection!
39
Tissue types: Describe Epithelial tissue
Deep pink to pearly, light purple or lavender in color In full thickness wounds, new tissue migrates from the wound edges to gradually cover the granulation tissue
40
Exudate of a wound serous, sanguineos, serosanguineoud, purulent
* Serous: thin, watery, clear * Sanguineos: thin, bright red... bleeding, darker red older bleeding * Serosanguineous: thin, watery, pale red to pink * Purulent: thick opaque, tan to yellow,green with offensive
41
Periwound edema, induration, erythmia, crepitus
* Edema: abnormal accumulation of fluid beneath the skin, is it swollen? * Induration: process of the skin “becoming hard” * Erythema: redness may be from infection, irritation from drainage, urine, feces or trauma * Crepitus: an accumulation of air or gas in the tissue. “Rice Krispies” feeling in the skin
42
Describe Pressure in its role in ulcers
Compression or squeezing together a soft tissue caused by weight or tension These forces cause blood vessels to collapse resulting in oxygen deprivation response Blocked blood flow
43
Describe sharing in its role in ulcers
internal opposing motion of tissue layer and bone Caused by gravity & friction forces, elevation of head of bed and from sliding down in chair Result in pressure ulcers in the buttocks and lower back that are deep and oval in shape Tunneling and undermining are caused by shearing
44
Describe friction in its role in ulcers
Force that opposes the movement of one surface to another Epidermal layer of skin is worn away Skin will look like an abrasion or superficial laceration
45
Stage 1 Pressure Ulcer
blister like,Intact skin, usually over bony prominence Area is painful, firm, soft warmer or cooler as compared to adjacent tissue Indicates "at risk" person
46
Stage 2 Pressure Ulcer
Goes from epidermis to the dermis Partial thickness, loss of dermis presenting as a shallow open also with the red pink wound bed ( looks like a blister was popped) Shiny or dry shallow ulcer without slough or bruising
47
Stage 3 Pressure Ulcer
Full thickness loss of skin, adipose tissue present They can be shallow in the nose, ear, occipital and malleolus In other areas, can develop extremely deep ulcers Bone/tendon is not visible or directly palpable Rounded, crater like shapes, has regular edges
48
Stage 4 Pressure Ulcer
Destruction of epidermis, dermis, and subcutaneous or deeper Now shows exposed bone, tendon or muscle Slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling Can extend into muscle or supporting structures and bone/tendon is visible and directly palpable
49
Unstageable ulcer
Full thickness, stable, has eschar( brown covering that serves as natural cover) tissue loss in which the base of the ulcer is covered by yellow tan gray green or brown slough True depth and stage cannot be determined unless enough slough is removed to expose the base of the wound
50
Describe a suspected Deep Tissue Injury
Purple localized area of discolored intact skin or blood-filled blister due to damage from pressure and/or shear. May evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment
51
Reverse staging
Stage 4 cannot become a stage 3,2 or 1 When a stage 4 heals it should be classified as a HEALED stage 4 pressure ulcer not a stage 0 once a stage 4 always a stage 4
52
Nonselective Debridement
mechanical; painful removes viable and non-viable tissue Includes: Scrubbing, Irrigation (4-15 PSI) and then sharp debridement
53
Selective Debridement
Removes non-viable tissue only Autolytic Enzymatic Bio-surgical
54
What does normal healing require
Adaquate Protein, fat, carbs and minerals
55
Topical wound management
Objective is to heal wound in the shortest amount of time possible with minimal discomfort and scaring Dressing, cleanser Pack the wound, has to have some moisture to it
56
Primary dressing type
Therapeutic or protective covering applied directly to the wound or lession
57
Secondary dressing type
Materials that serve therapeutic or protective functions and are needed to secure a primary dressing
58
What are the wound cleansers used
Normal saline is the preferred cleansing agent, doesn't harm tissue and is cost effective Tap water Commercial cleaners
59
What is the purpose of dressings on ulcers
For comfort, prevent or control infection, absorb drainage, maintain moisture, protect from further damage, and to protect the skin surrounding the wound
60
How would you write a treatment for an ulcer
Using generic names of dressing so that another product in that category can be used Include: Wound location Cleaning solution Primary dressing applied Moisture barrier periwound secondary dressing Frequency of dressing change and the expected duration of need
61
What is a Vesicle
Circular free fluid filled up to 1 cm
62
What is a Bulla
Circular free fluid filled Greater then 1 cm
63
What is a Macule
A change in color of the skin Circular flat discoloration Less then 1 cm "freckle"
64
What is a Patch
Same as a macule but larger then 1 cm
65
What is a Papule
Superficial solid Less than 1 cm
66
What is a nodule
Circular and elevated and solid Greater then 1 cm
67
What is a pustule
Circular collection of leukocytes Free fluid filled Varies in size
68
What is a denuded
Looks like skin is peeling off Loss of epidermis caused by exposure to urine, feces, body fluids, affected by some type of moisture
69
What is the Braden Scale
Scale a person on how likely they are to get an ulcer Degree of perception Moisture Activity Mobility Nutrition Friction Shear
70
What are interventions to prevent pressure ulcers
Full change of position every two hours for immobile patients 5 pillow rule Rule of 30
71
What is the 5 pillow rule
1 under legs to elevate heels 2 between ankles 3 between knees 4 behind the back 5 under the head
72
What is the rule of 30
Head of the bed elevated no more than 30 degrees Above 30 friction and shearing occur
73
What are acute wounds
Those without underlying defect and usually occur secondarily to surgery or trauma
74
What are the types of acute wounds
Incision ( paper cut) Contusion (bruise like) Abrasion Puncture (stepped on a nail) Laceration Penetrating wound (gunshot)
75
What are examples of acute wounds
Skin tears Lacerations Cat and dog bites Puncture wounds Gun shot wound Allergic reaction human bites
76
What are the treatment to acute wounds
Control severe bleeding (pressure, eleviation ) Prevent infection Controll swelling Check for rapid, thready pulse and clammy skin of bleeding is severe
77
Explain the healing of acute wounds
Primary intention Surgical incision or no tissue loss Wound edges approximated with staples, sutures, adhesive strips Secondary intention Wound edges remain open Will heal from bottom up Grossly contaminated wounds Tertiary intention Closed with sutures after infection is gone (delayed primary
78
How long do acute wounds heal
Face: 2-5 days Trunk and arms and legs and scalp: 7 days Hands,feet and over joints and on the back: 10-14 days
79
Chronic wound
Keeps growing and doesn't heal, after dressings and cleaning no change is noticed. Have to change what your doing
80
Full thickness wound
When it gets into the subcutaneous, muscle and the bone
81
Intentional wound
Anything you do to the wound intentional Anything that is done, not an accident
82
What is used in healing acute wounds
Adhesive closure strips: reinforce skin closure Staples: close large incisions in timely manner Tissue adhesive: Used in clean, dry linear incisions or lacerations
83
Pale coloring indicates=
Obstruction of arterial supply
84
Cyanotic coloring
Failure of vascular supply

Nursing 1st Fall Semester (41 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions