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Nur 111 - Unit 3 Exam > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

1
Q

Includes integumentary, mucous membrane, corneal, and/or subcutaneous tissues uninterrupted by wounds

A

Tissue Integrity

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2
Q

What is the normal presentation of the skin in order from the most superficial layer to the most inner layer?

A
  1. epidermis
  2. dermis
  3. subcutaneous tissue
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3
Q

What are some factors affecting tissue integrity?

A 
Genetics
Age 
Underlying health
Activity
Health
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4
Q

What are the steps for an assessment in regards to tissue integrity?

A 
inspect
palpate
turgor assessment
edema assessment 
inspect scalp and hair distribution
inspect nails and color and curvature
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5
Q

open wound; deep and shallow; once the edges have been sealed together as a part of treatment of healing, the ______ becomes a closed wound (caused by a sharp instrument)

A

Incision

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6
Q

closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels. caused by blow from a blunt instrument

A

Contusion

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7
Q

open wound involving the skin, caused by a surface scrape either unintentional or intentional

A

Abrasion

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8
Q

open wound caused by penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional.

A

Puncture

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9
Q

Open wound; edges are often jagged; caused by tissues being torn apart, often from accidents

A

Laceration

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10
Q

Open wound caused by penetration of the skin and the underlying tissues, usually unintentional

A

Penetration wound

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11
Q

What are the diagnostics tests used to associate with tissue integrity?

A

Skin biopsy
Skin culture
Allergy Test
Wound Culture

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12
Q

At risk for the skin being adversely altered or the altered stated of the epidermis and/or dermis

A

Impaired skin integrity

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13
Q

Damage to mucous membranes, corneal, integumenatry, or subcutaneous tissue

A

Impaired tissue integrity

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14
Q

What are the independent interventions for tissue integrity?

A 
Hygiene education
Infection prevention measures
Teach signs and symptoms of infection
Physical activity
Nutrition
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15
Q

What are the collaborative interventions for tissue integrity?

A

Medications

- oral medications 
- topcial medications
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16
Q

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

A

contact dermatitis

17
Q

Ischemic lesions of the skin and underlying tissue that impairs blood flow (perfusion) of blood and lymph. Caused by external pressures that compresses blood vessels, and friction and shear that tears and injures vessels.

A

Pressure Injury

18
Q

What are the common sites for development of pressure injury?

A

Elbow, inner knees, back of head and ears, shoulder, lower back and buttocks, hip and heel

19
Q

What are the common sites for friction and shear injury ?

A

head, shoulder, sacrum, buttock and heel

20
Q

What are the risk factors of pressure injuries?

A 
immobility
poor nutrition
incontinence
decreased mental status
diminished sensation
excessive body heat
chronic medical conditions
21
Q

What can be done to prevent pressure injuries?

A

provide nutrition
maintain skin hygiene
avoid skin trauma
provide support

22
Q

What are the things you need to look for during an assessment specifically for a pressure injury?

A

location, size (width, length and depth), undermining, stage, condition of wound bed, condition of wound edges, clinical signs of infection, pain or discomfort at site of wound

23
Q

The Braden scale is used to predict the risk for a pressure injury. What score should cause concern and initiate precautions to soothe a pressure injury?

A

18 or less

24
Q

What stage of a pressure injury is an ulceration of the epidermis and dermis and potential partial thickness skin loss

A

stage 2

25
Q

What stage of a pressure injury involves full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia?

A

stage 3

26
Q

What stage of a pressure injury involved full thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule.

A

stage 4

27
Q

What stage of pressure injury is classified by the inability to identity the root of the injury ?

A

un-stageable pressure injury

28
Q

pressure injury classified by purple or maroon area that is discolored intact skin but there is damage of the underlying soft tissue

A

Deep Tissue Pressure Injury

29
Q

What are some treatments and prevention of pressure injuries

A 
Positioning
nutrition and hydration
prevent infection
specialty surfaces 
dressing changes
irrigation
soaks
30
Q

What are the three phases of wound healing ?

A

inflammatory phase
proliferative phase (granulation tissue)
maturation (scar formation)

Nur 111 - Unit 3 Exam (4 decks)

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