Tissue Integrity Flashcards
The Epidermis is made of what?
Squamous epithelial cells
What cells form the basal layer of the skin?
Keratinocytes
What cells located in the epidermis make melanin?
Melanocytes
What’s melanin?
A pigment that determines the color of the hair and skin
What skin cells absorb radiant energy from the sun and protects the skin from the sun’s harmful UV rays?
Melanocytes
What are Merkel cells?
Receptor cells that are specialized to detect light touch
What cells package and ingest foreign antigens to be presented to lymphocytes?
Langerhans cells
What do Langerhans cells play a role in?
Cutaneous immune system reactions
Cutaneous means?
Relating to the skin
What is the dermis layer of the skin composed of?
Composed primarily of connective tissues, but also has capillaries, blood vessels, and lymph vessels
What does the dermis provide?
Strength and flexibility of the skin
What layer of the skin assists in wound healing?
The dermis
The subcutaneous layer (hypodermis) is composed of what?
Adipose tissue
What does the subcutaneous layer does what?
Insulates the body, absorbs shock, and pads the internal organs + structures
Maceration meaning?
Irritation of the epidermis caused by moisture
Dermatitis meaning?
Red skin irritation that develops whenever the skin is exposed to irritants
What’s a skin tear?
Loss of the top layer of skin caused by mechanical forces and tissue trauma
What is cellulitis?
Infection of the upper layers of the skin
Do collagen and elastic fibers increase or decrease as you age?
Decrease
Erythema meaning
Redness of the skin due to dilation of blood vessels
Blanchable erythema meaning?
Reddened skin that temporarily turns white or pale when light pressure is added. Skin reddens against once pressure is released
Nonblanchable skin
Reddened skin that doesn’t turn pale or white when light pressure is applied
What does nonblanchable skin indicate?
Structural damage has occurred to the small vessels carrying blood to the underlying skin and tissues
Exudate
Fluid secreted by body during the inflammatory stage of healing. Made by plasma
Moisture-associated skin damage (MASD) is a type of what?
Dermatitis
How do chronic wounds develop?
They develop over time because of a disruption in the wound healing process or because of alterations in blood flow
A chronic wound is what kind of wound?
A non-healing wound
What does tunneling mean in skin terminology?
Narrow channel or passage extending in any direction from the base of the wound
Shearing meaning?
Force parallel to the surface of the skin
What is it called whenever the skin and muscles are pulled in opposite directions?
Shear forces
What is hypoperfusion?
Low oxygen levels due to poor blood circulation
What scale is used to check someone’s risk for alterations in tissue integrity?
Braden scale
Undermining meaning?
An open area extending under skin along the edge of a wound
What does benchmarking mean?
Comparing results and outcomes to other sources of similarly retrieved data
How many stages of pressure injury are there?
4
What is the first stage of pressure injury?
Nonblanchable erythema
What is the second stage of pressure injury?
Partial-thickness skin loss
What is the third stage of pressure injury?
Full-thickness skin loss
What is the fourth stage of pressure injury?
Full-thickness skin and tissue loss
What is a unstageable pressure injury?
Obscured full-thickness skin and tissue loss injury
Slough definition?
Yellow, stringy nonviable tissue found in the base of the wound
Eschar definition?
Hard nonviable black/brown tissue found in the wound bed
Deep tissue pressure injury (DTPI) meaning?
Persistent nonblanchable pressure injury that can appear as a maroon, deep red, or purple color
What is a mucosal membrane pressure injury caused by?
The insertion or placement of a foreign device
Debridement meaning?
Surgically removing dead tissue or other debris that can cause infection
What is negative pressure injury therapy used to assist?
The healing and closing of large wounds by reducing edema around the wound and increasing granulation tissue formation
Hematoma meaning?
Accumulation of blood in the body (blood pooling in tissues)
Sedona meaning?
Accumulation of serous fluid
What’s a Penrose drain?
A flat, pliable passive drain that uses gravity to drain accumulated fluids
What’s a Portable Wound Bulb Suction Device?
An active, closed system drain that uses negative suction to drain fluid from the wound
What’s Large Bottle Drainage?
If a large amount of fluid is expected, a higher-pressure, large bottle is used
What’s a circular portable wound suction device?
A special type of wound drainage system that is designed to continuously suction drainage from a wound by providing a low vacuum pressure
Vasoconstriction meaning?
Narrowing of blood vessels due to acute blood loss, pain, and/or low body temp
How many types of wound healing are there?
3
When does primary healing occur?
Occurs in clean lacerations and surgical incisions closed with skin adhesives or sutures
What type of wound healing is fastest?
Primary healing
When does secondary healing occur?
When the wound is left open to heal and granulation tissue forms from the bottom up in the wound bed
When is delayed primary closure?
When the wound is left open for 5 to 10 days before it’s closed with sutures
When should delayed primary closure be used and why?
To decrease the risk the risk of infection. Used when the site isn’t considered clean at the time the injury occurred
What are some of the main essential nutrients for wound healing and tissue strengthening?
Protein, omega-3 and omega-6 fatty acids, and vitamins A and C
If a wound infection is suspected, what do you do to figure out if it is or not?
You do a wound culture collection
What kind of solution is used to rinse a wound when doing a wound culture inspection?
0.9% sodium solution
Why is 0.9% sodium chloride used when collecting a wound culture?
To prevent normal skin micro-organisms from contaminating the culture
Dehiscence meaning?
Complete/partial separation of the suture line and underlying tissues. Occurs when a wound fails to heal properly
Evisceration meaning?
Protrusion of internal organs through a surgical wound which has dehisced or opened
Does a client with a Braden scale score of 23 have a higher risk of a tissue integrity issue than a client with a score of 9?
The higher the score, the less at risk you are for running into a tissue integrity issue
How long does it typically take before you can remove staples?
A week or two
What kind of wound dressing needs a secondary reinforcement?
An alginate dressing
What kind of wound dressing can be used to combat wounds with necrotized tissues and eschars?
Hydrogel
High-Fowler’s position has a downside. What’s the downside?
It increases the risk for shearing and alterations in skin integrity
Is an increased blood glucose level a sign of sepsis?
Yes
What kind of wound dressing is best used for covering superficial wounds that have minimal exudate?
A transparent film
