Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Nur 170 Exam 3 12.6.14 > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

1
Q

closed; with the wounds edges touching ea. other

A

approximated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

inadequate blood flow through the arteries

A

arterial insufficiency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

large blister; as seen with burns

A

bulla

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

injury to tissues with skin discoloration from blood seepage just under the skin and without tissue breakage; a bruise

A

Contusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

spontaneous opening of the edges of a surgical wound with partial or total separation of wound layers

A

dehiscence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

area of loss of superficial layers of the skin

A

denuded

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

dehydration of the tissue

A

desiccation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

hemorrhagic spot, or bruise, caused by bleeding under the skin and irregularly formed in a blue or purple or brown patches

A

ecchymosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

reddening of the skin caused by congestion of the capillaries

A

erythema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

severe form of dehiscence where internal viscera protrudes outside the body

A

Evisceration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

material such as fluid with a high content of protein and cellular debris that has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation

A

Exudate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

any abnormal tube like passage in the body

A

fistula

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

localized collection of blood underneath the tissues, appearing as a swelling or mass often characterized by a Bluish discoloration.
-antinflammatory meds can affect hematomas making them worse

A

hematoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

sharply elevated, progressively enlarging scar that does not fade with time

A

keloid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

cut; torn wound

A

laceration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

softening or dissolution of tissue after lengthy exposure to fluid

A

maceration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

spot or thickening of the skin, not raised above the surface

A

macule (freckle?)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

malignant mole or tumor on the skin with atypical melanocytes (pigment-forming cells) in both the epidermis and the dermis and sometimes the subcutaneous cells

A

melanoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

small, solid mass that can be detected by touch

A

nodule

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

small, circumscribed, solid, elevated skin lesion

A

papule

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

condition characterized by various skin manifestations, including hemorrhages into the skin, mucous membranes, internal organs, and other tissues

A

purpura

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

pertaining to serum; thin and watery like serum

A

serous

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

stagnation (stopping) of the flow of body fluid, most commonly used to describe the impaired flow of blood back to the heart from the peripheral circulation (venous stasis)

A

Stasis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

a canal or passageway within the wound bed

A

tunneling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

An overhanging along the edge of the wound bed creating a sac or pocket

A

undermining

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

small blisters that contain liquid

A

vesicle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

smooth, localized, reddened or pale, slightly elevated area on the skin that is either induced via intradermal injection or is typical of allergic reactions

A

wheal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Edges are well approximated (closed)

typically intentional wounds with minimal tissue damage ie. surgical incisions closed with sutures or staples

A

Type of Wound Healing

Primary Intention -

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Edges are not approximated
Typically large open wounds ie. burns, pressure ulcers
some extensive damage

A

Type of Wound Healing

Secondary Intention-

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Wounds that are left open for several days to allow edema or infection to resolve or exudate to drain; later closed with sutures, staples, etc.

A

Type of Wound Healing-

Tertiary Intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Inflammatory Phase
Proliferative Phase
Maturation Phase

A

Phases of Wound Healing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q 
Lasts 3-6 days after injury
Hemostasis occurs (bleeding is ceased)
Fibrin begins to form
Blood clots arrive to area
Scab begins to surface
Dead and dying tissue is removed
Blood supply increases to area
Oxygen and nutrients arrive to area
Macrophages arise
*Client experiences physical symptoms
A

Phases of Wound Healing-

Inflammatory Phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Lasts from day 3 to 4 of injury to up to 21 days
Collagen is produced to strengthen wound
Healing ridge may appear
Capillaries spread wound bed increasing blood supply
Granulation tissue forms
Scab covers wound bed

A

Phases of Wound Healing-

Proliferative Phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Starts at day 21 of injury and can last 1 to 2 years
Collagen fibers re-organize themselves into a structure
Wound is remodeled and contracted
Scar strengthens
Possibility a keloid could develop

A

Phases of Wound Healing-

Maturation Phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

A local collection of blood beneath the skin
Appears as a bruise; Reddish, Blue in color
Swelling may be involved
If really large, can be dangerous

A

Hematoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Also called drainage or discharge
Material is made up of fluid and dead phagocytic cells that escape during the inflammatory phase

Three major types of exudate:
Serous
Purulent
Sanguineous

A

Exudate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

clear drainage

A

serous exudate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

bloody drainage

A

Sanguineous exudate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

clear with blood tinged drainage

A

Serosanguineous Exudate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Pharmacologic therapy:
Could be a variety of treatment options; ointments, antibiotics, analgesics, etc.
Non-pharmacologic therapy:
includes infection prevention, compression bandages, nurtition, VAC therapy, biosurgery, etc

A

Promoting Healing and Preventing Infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q
  • Dead tissue must be removed
  • The wound must be cleaned and dressed regularly
  • Measurements must be taken and documented on a -regular basis
  • Frequent skin assessment necessary
  • Pain needs to be controlled well
  • Support nutrition & hydration
  • Maintain mobility
  • Promote effective elimination
  • Prevent infection
  • Educate client
A

Wound Management

42
Q

-Dr. orders
-Clean technique until it runs clear
-Least contaminated to most contaminated; usually from top to bottom.
-Lay on side for irrigation
Longest to widest to depth (measurements)
Packing:
mechanical packing; 1 piece huge as possible
using wet to moist-promotes healing
ABD pad; then take three pieces

A

Cleaning and Packing Wounds

43
Q

epidermis; surface
dermis; second deeper layer of skin
subcutaneous fatty layer; separate the skin from the underlying tissue

A

3 layers of skin

44
Q

Millions of these wear off ea. day by abrasion. When mature b/come dead cells

A

Kearantinocytes

45
Q

Form a shield that protects the keratinocytes and the nerve endings in the dermis from damaging effects of ultraviolet light.
This activity probably accounts for the difference in skin color in humans

A

Melanin

46
Q

2nd deeper layer of skin; Flexible connective tissue; richly supplied with blood cells, nerve fibers, lymphatic vessels.
-hair follicles, sebaceous glands, sweat glands

A

Dermis

47
Q

hypodermis; lies below dermis.
Layer consists of loose connective tissue and stores roughly 1/2 the fat cells in the body.
Insulator and cushion for the body; stores energy in the form of fat.

A

Subcutaneous Tissue

48
Q

Utero greasy substance containing sebum and shed cells that covers and protects the fetal skin from amniotic fluid and loss of fluids and electrolytes.

A

Vernix Caseosa

49
Q

Observable changes from normal skin structure, may indicate disorder in other systems and organs.
vary in shape, size, color and texture characteristics.

-Macules, patches, papules, nodules, tumors, vesicles, pustles, bullae and wheals.

A

Skin Lesions

50
Q

thickening of the skin

A

lichenification

51
Q

trauma occurs during therapy. ie. operations, venipunctures, removing tumors

A

Intentional wounds

52
Q

accidental. closed or open;

A

Unintentional

53
Q

uninfected; minimal inflammation, respiratory, alimentary, genial and urinary tracts aren’t entered. Primarily closed wounds

A

Clean wounds

54
Q

surgical wounds in which respiratory, alimentary, genital or urinary tract has been entered. These wounds show no sign of infection.

A

Clean contaminated wounds

55
Q

include open, fresh, accidental wounds and surgical wounds that involve a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Shows evidence of inflammation.

A

Contaminated wounds

56
Q

wounds containing dead tissue and wounds with evidence of a clinical infection; ie purulent drainage.

A

Dirty or infected wounds

57
Q

usually seen shortly after an injury (scene of an accident or ER visit)
Guidelines of treatment:
-control severe bleeding; apply pressure elevate the involved extremity
-prevent infection by flushing abrasion/laceration with normal saline and cover wound with a clean dressing.
-wrap wound tightly
apply ice over wound to control swelling and pain

A

Untreated Wounds

58
Q

sharp instrument ie. knife, scalpel; open wound, deep or shallow

A

Incisional wound

59
Q

Blow from a blunt instrument; closed wound, bruising

A

Contusion

60
Q

Surface scrap, either unintensional or intensional; open wound involving the skin

A

Abrasion

61
Q

Tissue torn apart; often from accidents; open wound, edges often jagged

A

laceration

62
Q

Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional; open wound

A

Puncture

63
Q

penetration of the skin & the underlying tissue usually unintentional, ie bullet or metal fragments; open wound

A

Penetrating wound

64
Q

confined to the skin; the dermis and epidermis heal by regenerating

A

Partial thickness

65
Q

Involving the dermis, epidermis, subcutaneous tissue and possibly muscle and bone; required connective tissue repair.

A

Full thickness of the wound by depth

66
Q

epidermolysis bullosa

A

blistering

67
Q

skin thick and scally

A

ichthyosis

68
Q

too little melanin is produced

A

albinism

69
Q

increased growth of coarse hair on the face and trunk is seen in Cushing syndrome, acromegaly, and ovarian dysfunction.

A

Hirsutism

70
Q

Hair loss; maybe related to changes in hormones, chemical or drug treatment, or radiation.

A

Alopecia

71
Q

inflammation of the skin caused by direct contact with an allergen or irritant.

  • damage to the epidermis and dermis
  • red, itch rash, bullae, vesicles, and wheals also could form
A

Contact dermatitis

72
Q

cell-mediated or delayed hypersensitivity to a wide variety of allergens.

A

Allergic contact dermatitis

73
Q

inflammation of the skin from irritants; it is not a hypersensitivity response. ie chemical, soaps, perfumes, poison plants, ie ivy, Latex

A

Irritant contact dermatitis

74
Q

Impaired Skin Integrity r/t contact dermatitis as evidence by pruritus and rash.

A

Nursing Diagnosis

75
Q

Area of loss of the superficial layer of the skin aka denuded area

A

Excoriation

76
Q

Ischemic lesions of the skin and underlying tissues caused by external pressure that impairs the flow of blood and lymph.

A

Pressure Ulcers

77
Q

tissues softened by prolonged wetting and soaking of skin

A

Maceration

78
Q

digestive enzymes in feces, gastric tube drainage, urea in urine contribute. The area of loss of the superficial layers of skin aka denuded area

A

Skin excoriation

79
Q

Non-blanchable erythema of intact skin. could be painful and different temp.
Use a skin prep, hydrocolloid or transparent dressing

A

Stage I pressure ulcer

80
Q

partial-thickness skin loss involving the dermis. Shallow open ulcer. intact or open pus or blood filled blister, shiny or dry without slough.
Treat with Hydrocolloid or Transparent dressing (unless infected)

A

Stage II pressure ulcer

81
Q

Full thickness; skin loss involving damage or necrosis of Subcutaneous tissue; bone, tendon and muscle. Not exposed. Deep crater with or without undermining or tunneling of adjacent tissue; slough may be present

Treat with wet to moist gauze, hydrocolloid or proteolytic enzyme

A

Stage III pressure ulcer

82
Q

Full-thickness with extensive tissue damage and necrosis. -Muscle, tendon, and bone are exposed and directly palpable. Slough or eschar (black) maybe present. Undermining and tunneling are usually present.
-increased likely of osteomyelitis (infected bone)

Treat with wet to moist gauze or VAC therapy; sometiimes surgery is necessary. NEVER use a transparent or hydrocolloid dressing

A

Stage IV pressure ulcer

83
Q

Full-thickness tissue loss with depth completely obscured by slough or eschar in wound bed. Depth cant be determined until slough or eschar are removed.-once removed can be classified as III or IV.

  • Slough or eschar covering 50% of wound.
  • Stable eschar on the heels serves as a natural biological cover and shouldnot be removed.
  • Might need amputation
A

Unstageable

84
Q

Intact skin with Purple or Maroon* discoloration or blood-filled blister. Indicates damage of underlying soft tissue from pressure or shear. Thin blister over a dark wound bed possibly or develop think eschar.

A

Suspected Deep Tissue Injury

85
Q

dressing that contain wound moisture ie hydrocolloid and clear absorbent acrylic dressings, trap the wound drainage against the eschar.
-bodys own enzymes in the drainage break down the necrotic tissue

A

Autolytic debridement

86
Q

alginic acid, an anionic polysaccharide distributed widely in the cell walls of brown algae, where through binding with water forms a viscous gum./gel
-derived from seaweed.
highly absorbent via strong hydrophillic gel formation that minimizes bacteria contaminate. Limits wound secretions

A

Alginate

87
Q 
Under 18 @ risk for pressure ulcers;
sensory perception
moisture
mobility
nutrition
friction/shear
A

Braden Scale 1987

88
Q 
Possible 24 pts
15 or 16 indicators of pressure area risk
1962
activity
mobility
incontinence
addition of meds in 1987
A

Norton Scale 1962

89
Q 
Explores 9 areas
6 general categories
3 special categories for only high risks
general;
build/weight for height
skin type & assessment
sex & age
malnutrition screening
continence
mobility
Primary UK 
1 to 64
A

Waterlow Score 1985

90
Q

blood-tinged drainage seeps (serosanguineous) from wounds healed by
thick grey, fibrinous tissue-converts to dense scar tissue

A

secondary intention

91
Q

is the partial or total rupture of a surgical wound. -usually abdominal wound. Layers below also separate. “something has given way”

A

Dehiscence

92
Q 
Protrusion of the internal viscera through an incision. 
Obesity
Poor nutrition
multiple trauma 
failure of suturing
excessive coughing
vomiting
dehydration
all heightens clients risk of 
4-5 days post-op
A

Evisceration

93
Q

purulent exudate; thicker than serous, lg quantity of cell and necrotic cells; can vary in color depending on bacteria. blue, green, yellow, brown, black; depends on microb.

A

Pyogenic bacteria.

94
Q

helps to strengthen the skin to prevent breakdown

A

skin prep

95
Q

permeable to air and water vapor so aids in preventing the growth of anaerobic organisms

A

Hydocolloid (duoderm) dressing

96
Q

allows oxygen and moisture permeability but prevents moisture and bacteria entry

A

transparent dressing Tagederm dressing

97
Q

aids in debridement of necrotic tissue from wound bed no longer practiced; wet to moist perferred

A

Wet to dry gauze dressing

98
Q

aid in debridement for infected wounds with dead tissue

A

Proteolytic enzymes

99
Q

provides negative pressure environment to help reduce edema, increases blood supply, O2 to area, promotes moist environment, decreases bacterial agents and helps with formation of granulation tissue

A

Vacuum-assisted closure VAC therapy

100
Q

when snthetic skin or skin forms a healthy area of the client is removed and placed over the non-healing wound and sutured

A

skin grafting

101
Q

COPA

Color of wound bed and drainage
Odor
Consistency of drainage
Amount of drainage

Measurements

Size
LxWxDiameter
Sterile cotton swab
Tunneling/undermining
Sterile Cotton Swab
Use Clock as a frame of reference
A

Wound Description

Nur 170 Exam 3 12.6.14 (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions