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NURS120 > Tissue integrity > Flashcards

Tissue integrity Flashcards

1
Q

epiderms contain what types of special cells

A

keratinocytes
melanocytes
merkel cells - light touch
langerhans cells

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2
Q

what’s a part of the dermis

A

CT (collagen and elastic fibers) with capillaries, blood vessels, lymph vessels

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3
Q

what’s subcutaneous tissue have and do

A

have blood vessels and nerves -> thermoregulation, sensation
protec, insulate

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4
Q

maceration

A

irritation of the epidermis caused by moisture

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5
Q

dermatitis

A

red skin irritation that develops when skin is exposed to feces, urine, stoma effluent, and wound secretions

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6
Q

skin tears caused by what

A

loss of top layer of the skin from mechanical forces

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7
Q

most common injuries associated with skin frailty

A

skin tears
pressure injuries
infections (cellulitis)

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8
Q

cellulitis

A

infection of the superficial layers of the skin

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9
Q

decreased skin properties in the elderly

A

less elastic
less subq tissue
less blood supply
less hydrated

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10
Q

changes in skin properties in pts with decreased mobility

A

changes in thermoregulation
loss of collagen
muscle atrophy
impaired sensation
decreased blood flow
incontinence

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11
Q

changes in skin properties in pts that are obese

A

decreased moisture
maceration
increased temperature
decreased blood and lymph flow

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12
Q

radiation in cancer pts can change skin how

A

inflammation
decreased blood supply
skin surface damage

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13
Q

erythema

A

bony prominences; redness of skin from dilation of blood vessels
blanchable or not

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14
Q

blanchable vs. nonblanchable erythema

A

blanchable: temporarily becomes white when pressure is applied
nonblanchable: structural damage in the small vessels supplying blood to the underlying tissues

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15
Q

lacerations

A

tears in the skin; typically from blunt or sharp objects and have an irregular or jagged shape
simple or complicated classification

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16
Q

what type of wounds are considered for surgical ones

A

intentional acute wounds

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17
Q

surgical wounds are classified into what based on cleaniness

A

clean: closed at completion
clean-contaminated: closed at completion
contaminated: left open with long term wound management

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18
Q

surgical wound healing time and characteristics

A

red: 1-4 days
bright pink: 5-14 days
pale pink: 15 days - 1 yr

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19
Q

exudate

A

fluid consisting of plasma that is secreted by the body during the inflammatory phase of healing; resolve by day 5 post surgery

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20
Q

moisture associated skin damage (MASD)

A

form of dermatitis; from sweat, increased local skin temp, abnormal skin pH, deep skin folds

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21
Q

cause of chronic wounds

A

develop over time from disruption of acute wound healing;
conditions that cause alterations to blood flow

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22
Q

3 types of chronic lower extremity wounds

A

venous, arterial, neuropathic disease wounds;
predispose pts to develop pressure injuries

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23
Q

serous exudate

A

thin, watery’ straw colored

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24
Q

serosanguineous exudate

A

thin, watery with blood

25
Q

sanguineous exudate

A

bloody

26
Q

purulent exudate

A

green or yellow

27
Q

shearing

A

forces exerted parallel to the surface of the skin and pulled in opposite directions;
sitting or lying on an incline (high fowler)

28
Q

what risk factors contribute to pressure injury development

A

immobility
malnutrition
reduced perfusion
altered sensation
decreased LOC

29
Q

friction

A

not direct cause to pressure injuries but increases their risk when force created from rubbing

30
Q

purpose of braden scale

A

rates pt risk for alterations in tissue integrity

31
Q

6 categories of braden scale

A

sensory perception
moisture
activity
mobility
nutrition
friction & tear

32
Q

interpretation of Braden scale

A

each category is 0 - 4
adds up
<18 is risk

33
Q

how should a nurse stage pressure injuries

A

nonblanchable erythema
depth and amount of skin and tissue loss
condition, presence of dead tissue
tunneling
undermining

34
Q

undermining

A

open area extending under skin along the edge of the wound

35
Q

benchmarking

A

comparing results and outcomes to toehr sources of similar data; rate pressure injuries stage 1 - 4

36
Q

stage 1 pressure injury

A

non-blanchable erythema

37
Q

stage 2 pressure injury

A

partial thickness skin loss
pink or red tissue in wound bed

38
Q

stage 3 pressure injury

A

full thickness skin loss
visible adipose tissue, granulation tissue: new skin tissue forming
possible death tissue, edge rolled
undermining/tunneling may be present

39
Q

granulation tissue

A

new skin tissue that forms on the surface of the wound

40
Q

stage 4 pressure injury

A

full thickness skin and tissue loss
fascia, muscles, tendons, ligaments, cartilage, and or bone visible
possible dead tissue, tunneling, edges rolled

41
Q

slough

A

yellow, stringy nonviable tissue found in the base of the wound; unstageable pressure injury

42
Q

eschar

A

hard nonviable black/brown tissue; removal shows stage 3 or 4 pressure injury

43
Q

deep tissue pressure injury (DTPI)

A

localized, non-blanchable, deep red, marron, or purple discoloration;
cause of intense and or persistent pressure and shearing force

44
Q

mucosal membrane injury caused by what

A

insertion or placement of a foreign device such as endotracheal tubes, oxygen tubing, feeding tubes, drainage tubes

45
Q

correct position of bed to minimize risk of pressure injuries

A

less than 30 degrees to decrease risk of sliding down

46
Q

wound healing and tissue strengthening nutrients

A

protein
omega3 & 6 fatty acids
vitamins A and C
minerals (Zn)

47
Q

why do steroids prevent wound healing

A

prevent formation of collagen and fibroblasts required for wound healing

48
Q

compare primary, secondary, and tertiary wound healing

A

primary: sutured
secondary: left open
tertiary: left open and then sutured

49
Q

list the 3 stages of wound healing

A

hemostatic/inflammatory phase
proliferative phase
remodeling phase

50
Q

most common cause of surgical site infections and prevention

A

Staph.aureus
chlorhexidine prevent

51
Q

rinse wound culture with what before collecting sample

A

Na Cl cleaning before getting sample

52
Q

dehiscence

A

complete or partial separation of the suture line and underlying tissues; wound fails to heal properly due to poor surgical technique, infection, or foreign particles in wound

53
Q

signs of dehiscence

A

occurs 7-10 days after surgery;
serosanguineous discharge

54
Q

evisceration

A

wound and all layers of tissue under the wound separate resulting in protrusion of intraabdominal organs through the suture line;
sterile saline soaked dressing to cover

55
Q

hemorrhage

A

bleeding that is internal or external

56
Q

hematoma

A

accumulation of blood when clotting mechanisms fail
could lead to wound ischemia; leading to necrosis

57
Q

higher risk pts for getting hematoma

A

anticoagulant medications
obese pts

58
Q

hydrocolloid dressings

A

used in pressure injuries
keep moisture, absorb exudate, protect,

59
Q

what is the PUSH tool

A

pressure ulcer scale for healing
includes: LxW (in cm^2), exudate amount, and tissue type

NURS120 (38 decks)

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