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
an inflammation of the skin caused by direct contact with an allergen or irritant
contact dermatitis
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.
Pressure Injury
What are the common sites for development of pressure injury?
Elbow, inner knees, back of head and ears, shoulder, lower back and buttocks, hip and heel
What are the common sites for friction and shear injury ?
head, shoulder, sacrum, buttock and heel
What are the risk factors of pressure injuries?
immobility poor nutrition incontinence decreased mental status diminished sensation excessive body heat chronic medical conditions
What can be done to prevent pressure injuries?
provide nutrition
maintain skin hygiene
avoid skin trauma
provide support
What are the things you need to look for during an assessment specifically for a pressure injury?
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
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?
18 or less
What stage of a pressure injury is an ulceration of the epidermis and dermis and potential partial thickness skin loss
stage 2
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?
stage 3
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.
stage 4
What stage of pressure injury is classified by the inability to identity the root of the injury ?
un-stageable pressure injury
pressure injury classified by purple or maroon area that is discolored intact skin but there is damage of the underlying soft tissue
Deep Tissue Pressure Injury
What are some treatments and prevention of pressure injuries
Positioning nutrition and hydration prevent infection specialty surfaces dressing changes irrigation soaks
What are the three phases of wound healing ?
inflammatory phase
proliferative phase (granulation tissue)
maturation (scar formation)
