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Fundamentals Exam 1 > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

1
Q

Epidermis

A
  • surface or outermost part of the skin
  • consists of epithelial cells
  • 4 or 5 layers, depending on location
  • -5 layers over the palms of the hands and soles of the feet
  • -4 layers over the rest of the body
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2
Q

Dermis

A
  • second, deeper layer of skin
  • flexible connective tissue
  • richly supplied with blood cells, nerve fibers, and lymphatic vessels
  • most hair follicles, sebaceous glands, and sweat glands are located in the dermis
  • papillary and reticular layer
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3
Q

SubQ tissue

A

aka hypodermis

  • lies below the dermis
  • loose connective tissue
  • stores roughly half the fat cells of the body
  • serves as insulator and cushion for the body
  • stores energy from the fat
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4
Q

Keratin

A
  • fibrous, water-repellent protein

- gives epidermis its tough, protective quality

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5
Q

Melanin

A
  • forms a shield that protects the keratinocytes and the nerve endings in the dermis from the damaging effects of ultraviolet light
  • accounts for the difference in skin color
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6
Q

Sebum

A

an oily secretion of the sebaceous glands.

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7
Q

Vernix caseosa

A

a greasy deposit covering the skin of a baby at birth.

-cheese like protectant

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8
Q

Pruritis

A

severe itching of the skin, as a symptom of various ailments.

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9
Q

functions of skin

A
  • protection
  • sensation
  • temp regulation
  • secretion
  • excretion
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10
Q

Newborn

A
  • thin skin
  • less subQ fat
  • increased absorption of topical meds
  • decreased ability to shiver
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11
Q

Eldery

A
  • decreased thickness and collagen
  • decreased elasticity
  • decreased subQ
  • decreased sensation
  • decreased thermoregulation
  • increased healing time
  • increased skin tearing
  • decreased melanin
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12
Q

Dark skin

A
  • increased susceptibility to inflammatory processes and keloids
  • post-inflammatory hypo- or hyperpigment action
  • increased sebum production and sweat due to larger pores
  • prone to scarring after acne
  • age slower
  • produces more melanin than light skin
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13
Q

Asians

A
  • less protective

- more sensitive

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14
Q

culturally and ethnically diverse patients may…

A

use home remedies for hair and skin

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15
Q

intact skin

A

normal skin and skin layers uninterrupted by wounds

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16
Q

3 types of skin disorders

A

infectious

Inflammatory
neoplastic

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17
Q

infectious skin disorder

A

caused by microorganisms

-bacteria, virus, fungi, or parasite

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18
Q

inflammatory skin disorder

A

caused by pathologies

-acne, burns, eczema

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19
Q

neoplastic skin disorder

A

caused by skin cancers

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20
Q

primary lesions

A

arise from healthy skin (papules, macules, vesicles)

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21
Q

secondary lesions

A

result from a change in a primary lesion (scar, keloid)

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22
Q

Skin Assessment

A
  • inspect for color, lesions, scars, tattoos
  • inspect for alterations in integrity (redness, tears)
  • inspect skin surrounding tubes, pins, caths, stomas
  • note any odors
  • palpate for temp, turgor, edema
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23
Q

turgor

A

checking for hydration status

good/brisk: if it is elastic and returns quickly

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24
Q

Risk factors for compromised skin integrity

A
  • immobilization
  • reduced sensation
  • poor nutrition and/or hydration
  • secretions/excretions
  • altered cognition
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25
Q

Hair/scalp assessment

A
  • inspect for hair distribution
  • inspect for hair texture
  • inspect for lesions
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26
Q

Nail assessment

A
  • nail curvature
  • nail color even
  • not too thick
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27
Q

90% of African Americans have

A

pigmented bands

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28
Q

yellow nail

A

fungal; psoriasis

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29
Q

trauma to nail

A

turns dark color

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30
Q

normal nail curvature

A

160 degrees

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31
Q

clubbing

A

180 degrees

  • CHD in children
  • lack of oxygen or long term smoking in adults
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32
Q

tinea unguium

A

yellow, thick nail

  • fungal, hard to treat
  • oral antifungal
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33
Q

melanonychia

A

dark pigmented band in nail

common in His/Afr.Amer./Asians
Whites: could be melanoma, get checked immediately

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34
Q

Types of diagnostic tests for skin integrity

A
  1. biopsy
  2. culture
  3. wood lamp
  4. patch/scratch
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35
Q

biopsy

A

pathology

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36
Q

culture

A

infection; not prevention

-what is growing??

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37
Q

wood lamp

A

fungal skin infections

38
Q

patch/scratch test

A

allergies

39
Q

Wounds can be…

A
  • intentional or unintentional

- open or closed

40
Q

intentional

A

surgical incision

41
Q

unintentional

A

road rash

42
Q

open

A

papercut

43
Q

closed

A

hematoma

44
Q

clean

A

closed wounds

45
Q

clean contaminated

A

surgical wounds

46
Q

contaminated

A

fresh, accidental wounds

47
Q

dirty or infected

A

dead tissue, w/ evidence of infection

48
Q

incision

A

scapel, knife

49
Q

contusion

A

bruise, sharp blow

50
Q

abrasion

A

surface scrape

51
Q

puncture

A

penetration of skin and underlying tissues, sharp instrument

-can be intentional or unintentional

52
Q

laceration

A

tissues torn apart; often accidents

53
Q

penetrating

A

penetration of skin and underlying tissues

usually unintentional

54
Q

Untreated wounds

A
  • control bleeding
  • prevent infection
  • control swelling and pain
  • assess for signs of shock related to bleeding
55
Q

signs of shock related to bleeding

A
  • rapid, thready pulse
  • cold and pale skin
  • low BP
56
Q

Treated wounds

A
  • observe healing
  • observe for signs of infection
  • document

-if covered; assess dressing and document

57
Q

C/D/I

A

clean/dry/intact

58
Q

Types of wound drainage

A

serous
sanguineous
sero-sanguineous
purulent

59
Q

serous

A

thin, watery, clear

60
Q

sanguineous

A

thin, bright red (bloody)

61
Q

sero-sanguineous

A

thin, watery, pale red to pink

bloody and serous fluid

62
Q

purulent

A

thick or think, color may be tan to yellow or green; may have offensive odor

-infectious looking

63
Q

Wounds by depth

A

partial thickness
full thickness

64
Q

partial thickness

A

heals on its own by regeneration

-contained in epidermis and dermis

65
Q

full thickness

A

needs help healing through connective tissue repair

-involves, epidermis, dermis, subQ (hypodermis), muscle and bone possibly

66
Q

dehiscence

A

see tissue underneath; partial or total rupture of sutured wound; usually involves abdominal wound

67
Q

evisceration

A

protrusion of internal viscera through an incision

-usually abdominal contents showing or coming out

68
Q

Pressure Ulcers

A
  • develop over bony prominences
  • external pressure impairs blood flow and lymph
  • worsens with friction and shearing
69
Q

event timeline of PU

A

ischemia–>necrosis–>pressure ulcer

70
Q

ischemia

A

inadequate blood supply to an organ or part of the body

71
Q

shearing

A

when moving patient in bed and bones move opposite of skin or skin stays put; skin tears

72
Q

Risk of factors for pressure ulcers

A
  • immobility
  • poor nutrition
  • incontinence
  • decreased mental status
  • decreased sensation
  • increased temp of skin
  • increased age
73
Q

______ is key for PU

A

prevention

74
Q

Prevention of Pressure Ulcers

A
  • assess the skin!!!!!
  • relieve pressure on body areas
  • Q 2hr turning
  • airflow beds
  • provide nutrition
  • maintain skin hygiene
  • promote ROM/OOB/Mobility
75
Q

Nutrition

A
  • supplemental nutrition to increase calories, protein, vitamins, and iron
  • monitor hemoglobin, albumin
  • monitor weight
  • monitor intake and output (I&Os)
76
Q

Stage 1 Pressure Ulcer

A

non-blanchable
erythema of intact skin
can be painful, soft, firm, warm or cool

77
Q

Stage 2 Pressure Ulcer

A

partial thickness skin loss (abrasion, blister, shallow crater)
involves epidermis and possibly dermis
Skin NOT intact

78
Q

Stage 3 Pressure Ulcer

A

full thickness skin loss involving subQ tissue (deep crater)

-may have undermining or tunneling

79
Q

Stage 4 Pressure Ulcer

A

full thickness skin loss, tissue necrosis or damage to muscle, bone, or supporting structures (tendon or joint capsule)

-typically wheelchair bound patients

80
Q

Unstageable Pressure Ulcer

A

full thickness tissue loss where the base of the ulcer cannot be seen

  • covered by yellow, tan, brown, or black tissue
  • not sure how deep the ulcer goes
81
Q

Deep tissue injury

A

pressure-related deep tissue injury under intact skin

-purple or maroon localized area of discolored intact skin or blood-filled blister

82
Q

Pressure Ulcer Treatment

A
  • collaborative/interdisciplinary
  • depends on stage
  • wound management
  • debridement, dressing
  • surgical flap
  • wound vacs
  • drains, irrigation
  • nutrition
  • antibiotics
  • maggots
83
Q

Topical Corticosteroids

A

relieves inflammation and pruritus

  • apply thin layer to avoid toxicity
  • No more than 7 to 14 days
  • assess for atrophy and hypo-/hyperpigmentation
84
Q

Antiacne

A

gets worse before gets better

minimize sun exposure

85
Q

antibacterials/antibiotics

A

monitor for signs of allergic rxn

86
Q

antifungals

A

monitor for allergic rxn

87
Q

antivirals

A

may take several weeks
herpes not cured
teach standard precautions

88
Q

anesthetics

A

avoid applying in large areas

avoid eyes

89
Q

antihistamines

A

avoid taking both oral and topical simultaneously

avoid applying over large areas or broken skin

90
Q

topicals are applied as…

A

creams
lotions
ointments

91
Q

Braden scale

A

assess risk for pressure ulcer

-most commonly used assessment tool in US for predicting pressure sore risk

92
Q

6 categories of Braden scale

A 
sensory perception
moisture
activity
mobility
nutrition
friction and shear

total of 23 pts possible

Fundamentals Exam 1 (8 decks)

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