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Nursing 1st Fall Semester > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

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1
Q

What is the largest organ of the body

A

Skin

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2
Q

What are the two layers of skin

A

Epidermis and Dermis

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3
Q

What is the Dermis

A

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

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4
Q

What does the dermis contain

A

Nerves
Sweat Glands
Sebaceous glands
Hair Follicles

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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

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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

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7
Q

Muscle tissue appearance

A

Pink To Dark Red
Firm
Highly Vascular
Striated

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8
Q

What are ligaments

A

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

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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

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10
Q

What is the Tendon and its appearance

A

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

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11
Q

Function of bones

A

Supports and protects internal organs
206 in the body

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12
Q

What is bone marrow

A

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

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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

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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

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15
Q

Describe moisture in wounds

A

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

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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

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17
Q

What parts of the body are pressure ulcers more frequent

A

Sacral/coccyx
Greater trochanter
Ischial Tuberosity
Heel
Lateral Malleolus

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18
Q

What are some ulcer comorbidities in the cardiovascular system

A

CAD,CHF,PVD,PAD

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19
Q

What are some ulcer co morbidities in the respiratory system

A

Pneumonia, COPD, Asthma

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20
Q

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

A

GI bleeding, Swallowing problems, diarrhea

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21
Q

What are some ulcer co morbidities in the Genitourinary System

A

Urinary Incontinence, Kidney failure

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22
Q

What are some ulcer co morbidities in the Musculoskeletal System

A

CVA, Arthritis

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23
Q

What are some ulcer co morbidities in the Endocrine

A

Diabetes

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24
Q

What are some ulcer co morbidities in the Hematological

A

Anemia, Fluid and Electrolyte balances

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25
Q

What are some ulcer co morbidities in cancer

A

Radiation treatment, Antineoplastic medication

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26
Q

Part of a wound: Describe the wound

A

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)

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27
Q

Parts of a wound: Describe the Periwound

A

Tissue around the outside of the perimeter of the wound
Minimum of 4cm

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28
Q

Parts of a wound: Describe tunneling

A

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

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29
Q

What is a fistula

A

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

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30
Q

Parts of a wound: Describe undermining

A

“lip around the wound”
Tissue destruction underlying intact skin along the wound margins
is caused by shearing forces against the wound

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31
Q

How do you measure an ulcer length

A

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

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32
Q

How do you measure an ulcer width

A

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

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33
Q

How do you measure ulcer depth

A

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.

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34
Q

Tissue types: Describe granulation tissue

A

Beefy deep pink or red
Has an irregular surface
puffy or bubbly appearance
seen in the wound bed of healing full thickness wounds

35
Q

Tissue types: Describe clean non granulating

A

Deep pink or red
Smooth (nongranular)
Striated (when muscle fibers are exposed
Is not healing, granulation tissue has to be present to heal

36
Q

Tissue types: Describe Hyper-granulation tissue

A

Granulation tissue forms above the surface of the surrounding epithelium
Delays healing

37
Q

Tissue types: Describe Necrotic Tissue-slough

A

Yellow, Green or grey
Nonviable tissue (dead)
Thin
Wet stringy

38
Q

Tissue types: Describe Necrotic tissue- eschar

A

Black brown
Dry nonviable tissue (dead)
Thick
Hard
Leathery
Do not want to wet this, acts as protection!

39
Q

Tissue types: Describe Epithelial tissue

A

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
Q

Exudate of a wound
serous, sanguineos, serosanguineoud, purulent

A
  • 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
Q

Periwound
edema, induration, erythmia, crepitus

A
  • 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
Q

Describe Pressure in its role in ulcers

A

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
Q

Describe sharing in its role in ulcers

A

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
Q

Describe friction in its role in ulcers

A

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
Q

Stage 1 Pressure Ulcer

A

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
Q

Stage 2 Pressure Ulcer

A

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
Q

Stage 3 Pressure Ulcer

A

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
Q

Stage 4 Pressure Ulcer

A

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
Q

Unstageable ulcer

A

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
Q

Describe a suspected Deep Tissue Injury

A

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
Q

Reverse staging

A

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
Q

Nonselective Debridement

A

mechanical; painful
removes viable and non-viable tissue
Includes: Scrubbing, Irrigation (4-15 PSI) and then sharp debridement

53
Q

Selective Debridement

A

Removes non-viable tissue only
Autolytic
Enzymatic
Bio-surgical

54
Q

What does normal healing require

A

Adaquate Protein, fat, carbs and minerals

55
Q

Topical wound management

A

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
Q

Primary dressing type

A

Therapeutic or protective covering applied directly to the wound or lession

57
Q

Secondary dressing type

A

Materials that serve therapeutic or protective functions and are needed to secure a primary dressing

58
Q

What are the wound cleansers used

A

Normal saline is the preferred cleansing agent, doesn’t harm tissue and is cost effective
Tap water
Commercial cleaners

59
Q

What is the purpose of dressings on ulcers

A

For comfort, prevent or control infection, absorb drainage, maintain moisture, protect from further damage, and to protect the skin surrounding the wound

60
Q

How would you write a treatment for an ulcer

A

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
Q

What is a Vesicle

A

Circular free fluid filled
up to 1 cm

62
Q

What is a Bulla

A

Circular free fluid filled
Greater then 1 cm

63
Q

What is a Macule

A

A change in color of the skin
Circular flat discoloration
Less then 1 cm
“freckle”

64
Q

What is a Patch

A

Same as a macule but larger then 1 cm

65
Q

What is a Papule

A

Superficial solid
Less than 1 cm

66
Q

What is a nodule

A

Circular and elevated and solid
Greater then 1 cm

67
Q

What is a pustule

A

Circular collection of leukocytes
Free fluid filled
Varies in size

68
Q

What is a denuded

A

Looks like skin is peeling off
Loss of epidermis caused by exposure to urine, feces, body fluids, affected by some type of moisture

69
Q

What is the Braden Scale

A

Scale a person on how likely they are to get an ulcer
Degree of perception
Moisture
Activity
Mobility
Nutrition
Friction
Shear

70
Q

What are interventions to prevent pressure ulcers

A

Full change of position every two hours for immobile patients
5 pillow rule
Rule of 30

71
Q

What is the 5 pillow rule

A

1 under legs to elevate heels
2 between ankles
3 between knees
4 behind the back
5 under the head

72
Q

What is the rule of 30

A

Head of the bed elevated no more than 30 degrees
Above 30 friction and shearing occur

73
Q

What are acute wounds

A

Those without underlying defect and usually occur secondarily to surgery or trauma

74
Q

What are the types of acute wounds

A

Incision ( paper cut)
Contusion (bruise like)
Abrasion
Puncture (stepped on a nail)
Laceration
Penetrating wound (gunshot)

75
Q

What are examples of acute wounds

A

Skin tears
Lacerations
Cat and dog bites
Puncture wounds
Gun shot wound
Allergic reaction
human bites

76
Q

What are the treatment to acute wounds

A

Control severe bleeding (pressure, eleviation )
Prevent infection
Controll swelling
Check for rapid, thready pulse and clammy skin of bleeding is severe

77
Q

Explain the healing of acute wounds

A

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
Q

How long do acute wounds heal

A

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
Q

Chronic wound

A

Keeps growing and doesn’t heal, after dressings and cleaning no change is noticed.
Have to change what your doing

80
Q

Full thickness wound

A

When it gets into the subcutaneous, muscle and the bone

81
Q

Intentional wound

A

Anything you do to the wound intentional
Anything that is done, not an accident

82
Q

What is used in healing acute wounds

A

Adhesive closure strips: reinforce skin closure
Staples: close large incisions in timely manner
Tissue adhesive: Used in clean, dry linear incisions or lacerations

83
Q

Pale coloring indicates=

A

Obstruction of arterial supply

84
Q

Cyanotic coloring

A

Failure of vascular supply

Nursing 1st Fall Semester (41 decks)

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