Tissue Integrity Flashcards
Includes integumentary, mucous membrane, corneal, and/or subcutaneous tissues uninterrupted by wounds
Tissue Integrity
What is the normal presentation of the skin in order from the most superficial layer to the most inner layer?
- epidermis
- dermis
- subcutaneous tissue
What are some factors affecting tissue integrity?
Genetics Age Underlying health Activity Health
What are the steps for an assessment in regards to tissue integrity?
inspect palpate turgor assessment edema assessment inspect scalp and hair distribution inspect nails and color and curvature
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)
Incision
closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels. caused by blow from a blunt instrument
Contusion
open wound involving the skin, caused by a surface scrape either unintentional or intentional
Abrasion
open wound caused by penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional.
Puncture
Open wound; edges are often jagged; caused by tissues being torn apart, often from accidents
Laceration
Open wound caused by penetration of the skin and the underlying tissues, usually unintentional
Penetration wound
What are the diagnostics tests used to associate with tissue integrity?
Skin biopsy
Skin culture
Allergy Test
Wound Culture
At risk for the skin being adversely altered or the altered stated of the epidermis and/or dermis
Impaired skin integrity
Damage to mucous membranes, corneal, integumenatry, or subcutaneous tissue
Impaired tissue integrity
What are the independent interventions for tissue integrity?
Hygiene education Infection prevention measures Teach signs and symptoms of infection Physical activity Nutrition
What are the collaborative interventions for tissue integrity?
Medications
- oral medications - topcial medications