Tissue Integrity Flashcards
Acrocyanosis
Hands/feet turning blue due to the constriction of an artery (vasospasm).
Normal in newborns 1st 24-48hrs
Arterial ulcer
A deep & painful skin sore in the lower legs or feet. Caused by low blood flow/oxygen in the legs and feet.
Avulsion
When skin or a body part is forcibly torn off. Avulsion fracture: when a small piece of bone is pulled off of the main bone.
Contusion
A bruise
Dehiscence
When a wound doesn’t properly heal, and the wound edges separate.
Evisceration
When a wound doesn’t properly heal, and the wound edges open, allowing tissues or organ to protrude/spill out. Can cut iff blood flow to the squeezed organ
Laceration
A cut that is torn or jagged.
Abrasion
Caused by scraping/friction, where some skin is missing.
Pressure ulcer
AKA a bed sore, pressure injury, or decubitus ulcer
Puncture wound
When the wound goes through the skin and into the tissue. Easily INFECTED
Pruritus
Itching
Venous ulcer
Skin sore in the feet/legs. Caused by venous insufficiency, where blood pools in the legs because the vein valves aren’t able to send all the blood back to the heart.
Turgor
The ability of the skin to return to normal after the skin is pulled up (on the back of the hand or the clavicle). Should be < 2 sec. A sign of dehydration.
Shearing
A force caused by bones moving across tissue while the skin is held in place.
Lesion
Damaged tissue. Broadly includes wounds, ulcers, sore, abscesses, cysts, tumors.
Serum albumin test
Measures the amount of protein in the blood. Low levels indicate malnutrition, malabsorption, kidney disease
increased risk of pressure ulcers.
High levels indicate dehydration.
What does poor perfusion do to skin, short & long-term?
Short-term: pressure ulcers
Long-term: tissue necrosis
Why are the old and young at risk for poor tissue integrity?
Thin skin
Low immune functiin
Rules for safe sun exposure
Sunscreen: SPF 30+, every single day, 30 min before going in the sun. (NOT for infants <6mo).
Some meds increase UV sensitivity.
ABCDE for melanomas
Asymmetry
Border
Color (varying)
Diameter
Evolving
What do we do for dehiscense and evisceration?
Low fowlers position
Cover wound with wet sterile gauze (w/sterile water or saline)
Notify provider
What do we do for an infected wound?
Culture wound.
Start broad-spectrum antibiotics while waiting for lab.
Keep clean and dry.
Contact precautions (gloves & gown).
What can we use to protect the skin from incontinence moisture?
A moisture barrier cream
Abscess vs ulcer
Abscess: pus
Ulcer: necrotic (purple/black, not warm, non-blanching)
