Tissue Integrity Flashcards
The outer most layer of the skin, made of squamous epithelial cells, which provides a barrier against the external environment.
Epidermis
Cells formed in the basal layer of the skin that function to protect the skin from the external environment.
Keratinocytes
A pigment that determines he color of the hair, skin, and eyes.
Melanin
Receptor cells in the epidermis that are specialized for detection of light touch.
Merkel cells
Cells found in the epidermis that play a role in cutaneous immune system reactions.
Langerhans cells
The layer under the epidermis that is composed mainly of connective tissue and provides strength and flexibility of the skin.
Dermis
An irritation of the epidermis caused by moisture.
Maceration
A red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates.
Dermatitis
Loss of the top skin layer caused by mechanical forces. The severity of a skin tear is defined by the depth of the skin layer loss.
Skin tears
At-risk vulnerable skin
Skin frailty
Localized damage to the skin and/or the soft underlying tissue, which can be caused by prolong contact with a firm surface that interferes with circulation to the area.
Pressure injuries
An infection of the superficial layers of skin.
Cellulitis
redness of the skin due ot dilation of blood vessels.
Erythema
An area of a reddened skin that temporarily turns white or pale when light pressure is applied. The skin then reddens when pressure is relieved.
Blanchable eryhema
Redness of the skin that does not go away when pressure is applied and indicates structural damage has occurred in the small vessels supplying blood to the underlying skin and tissues.
Nonblanchable erythema
Any tearing of the skin, usually caused by blunt or sharp objects
Lacerations
Fluid secreted by the body during the inflammatory stage of healing and is made of plasma.
Exudate
Moisture-associated skin damage
A form of dermatitis; a skin irritation that forms when the skin is exposed to irritants like feces, urine, stoma content, and wound exudates.
Thin, watery wound drainage.
Serous
Thin watery wound drainage mixed with blood.
Serosanguineous
Bloody drainage.
Sanguineous
Blood/yellow wound drainage.
Purulent
A narrow channel or passage way extending it in any direction from the base of the wound.
Tunneling.
A force parallel to the surface of the skin.
Shearing
Imbalance in a client’ s intake, which can include deficiencies or excesses in nutrients, vitamins, or calories.
Malnutrition
Inadequate supply of blood circulation, which results in low oxygen levels in tissues.
Hypoperfusion
An open area extending under skin along the edge of the wound.
Undermining.
Comparing results and outcomes to other sources of similarly retrieved data
Benchmarking
Obscured full-thickness skin and tissue loss injury.
Unstageable pressure injury
New skin tissue that forms on the surface of the wound
Granulation tissue
Obscured full-thickness skin and tissue loss injury.
Unstageable pressure injury
Yellow, stingy nonviable tissue found in the base of the wound.
Slough
Hard nonviable black/brown tissue found in the wound bed.
Eschar
Persistent nonblanchable tissue injury of the skin appearing deep red, maroon, or purple color.
Deep tissue pressure injury.
Injury to a mucous membrane caused by the pressure related to the insertion or placement of a foreign device.
Mucosal membrane pressure injury
The process of surgically removing dead tissue and other debris that can cause infection.
Debridement
Accumulation of blood in the body
Hematoma
Accumulation of serous fluid
Seroma
Death of body tissue as a result of diminished blood flow.
Necrosis
Below the expected level of oxygen in body tissue.
Hypoxia
Vasoconstriction
The narrowing of the blood vessels due to acute blood loss, pain, and/or low body temperature.
What are the universal skin prevention measures utilized in skin care plans? (Enter your response and submit to compare to an expert’s response.)
Hydration, nutrition, hygiene, circulation. The universal plan for skin care includes plans for adequate hydration, nutrition, hygiene, and circulation. Structured prevention plans for hygiene will help with proper maintenance of the skin. The nurse should monitor for signs of dehydration by assessing for skin turgor, weight, urine output, elevated serum sodium levels, and serum osmolality. Good nutrition is a major part of the prevention strategy for maintaining skin integrity. A nutritional assessment is a part of the risk assessment, and the client’s nutrition should be closely monitored to maintain tissue integrity and optimize healing.
What is the correct order of steps in obtaining a wound culture?
Label culture tube.
Remove old dressing.
Rinse wound with 0.9% sodium chloride.
Remove swab from culture tube.
Place sterile swab into the wound bed.
Rotate the swab stick in an area of drainage.
Activate the culture medium.
Note if client has received any recent antibacterial or antifungal therapy
The complete or partial searation of the suture line and underlying tissues that occurs when a wound fails to heal properly.
Dehiscence
What are the risk factors for a Stage 1 Pressure injury?
immobility or limited mobility, older age, poor nutrition, incontinence, decreased sensation, fragile skin, medical conditions affecting blood flow like diabetes or peripheral artery disease, spinal cord injury, obesity, dehydration, and decreased mental awareness
What are the nursing interventions for a stage 1 pressure injury?
Implement effective pressure relief and redistribution strategies.
Optimize wound care and promote healing.
Manage pain and discomfort associated with pressure injuries.
Prevent infection through proper wound hygiene and antimicrobial treatments.
Provide education on self-care and prevention measures.
Address underlying factors contributing to pressure injuries, such as immobility or poor nutrition.
highly absorbent dressing that is used for wounds with moderate to heavy exudate, maintaining a moist environment to promote healing and autolytic debridement
Alginate Dressings
_________ can be used to manage dry wounds for debridement of necrotized tissue and eschar. They work differently than other dressings because they contain water, to provide moisture to or draw moisture away from the wound depending on the needs of the wound.
Hydrogel
How long do staple wounds take to heal?
7-14 days.
Non-blanchable Erythema is a ________ pressure injury
Stage one
Partial-Thickness Skin Loss is a ________ Pressure injury
Stage Two
Full-Thickness Skin Loss with visual adipose tissue is a _________ pressure injury
Stage Three
Full-Thickness Skin and Tissue Loss is a __________ pressure injury
Stage four
