Tissue Integrity

Question 1

Acrocyanosis

Answer 1

Hands/feet turning blue due to the constriction of an artery (vasospasm).

Normal in newborns 1st 24-48hrs

Question 2

Arterial ulcer

Answer 2

A deep & painful skin sore in the lower legs or feet. Caused by low blood flow/oxygen in the legs and feet.

Question 3

Avulsion

Answer 3

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.

Question 4

Contusion

Answer 4

A bruise

Question 5

Dehiscence

Answer 5

When a wound doesn’t properly heal, and the wound edges separate.

Question 6

Evisceration

Answer 6

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

Question 7

Laceration

Answer 7

A cut that is torn or jagged.

Question 8

Abrasion

Answer 8

Caused by scraping/friction, where some skin is missing.

Question 9

Pressure ulcer

Answer 9

AKA a bed sore, pressure injury, or decubitus ulcer

Question 10

Puncture wound

Answer 10

When the wound goes through the skin and into the tissue. Easily INFECTED

Question 11

Pruritus

Answer 11

Itching

Question 12

Venous ulcer

Answer 12

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.

Question 13

Turgor

Answer 13

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.

Question 14

Shearing

Answer 14

A force caused by bones moving across tissue while the skin is held in place.

Question 15

Lesion

Answer 15

Damaged tissue. Broadly includes wounds, ulcers, sore, abscesses, cysts, tumors.

Question 16

Serum albumin test

Answer 16

Measures the amount of protein in the blood. Low levels indicate malnutrition, malabsorption, kidney disease

increased risk of pressure ulcers.
High levels indicate dehydration.

Question 17

What does poor perfusion do to skin, short & long-term?

Answer 17

Short-term: pressure ulcers
Long-term: tissue necrosis

Question 18

Why are the old and young at risk for poor tissue integrity?

Answer 18

Thin skin
Low immune functiin

Question 19

Rules for safe sun exposure

Answer 19

Sunscreen: SPF 30+, every single day, 30 min before going in the sun. (NOT for infants <6mo).
Some meds increase UV sensitivity.

Question 20

ABCDE for melanomas

Answer 20

Asymmetry
Border
Color (varying)
Diameter
Evolving

Question 21

What do we do for dehiscense and evisceration?

Answer 21

Low fowlers position
Cover wound with wet sterile gauze (w/sterile water or saline)
Notify provider

Question 22

What do we do for an infected wound?

Answer 22

Culture wound.
Start broad-spectrum antibiotics while waiting for lab.
Keep clean and dry.
Contact precautions (gloves & gown).

Question 23

What can we use to protect the skin from incontinence moisture?

Answer 23

A moisture barrier cream

Question 24

Abscess vs ulcer

Answer 24

Abscess: pus
Ulcer: necrotic (purple/black, not warm, non-blanching)

Question 25

Solar lentigo

Answer 25

Age spots

Question 26

Melasma

Answer 26

Brown patches on the face, caused by pregnancy.

Question 27

Merkel cells

Answer 27

In the skin, give sensory info

Question 28

Langerhans cells

Answer 28

Link the epidermis to the immune system.

Question 29

Can you reposition an immobile patient by yourself?

Answer 29

No. Need at least 2 people using a draw sheet

Question 30

Urticaria

Answer 30

Same as hives