Unit IV (Physical Integrity) Flashcards
A lesion that appears as the initial result of changes in the skin is termed:
Primary Lesion
Lesions that do not appear initially as a result to the change of the skin are termed:
Secondary Lesion
How are secondary lesions formed?
Result from trauma or infection of the primary lesion.
True/False:
All lesions are external.
False, lesions may be external or internal.
A break in the continuity of the skin is termed:
wound.
What does the nurse assess a wound for?
shape, size, depth, location, presence of drainage, odor.
The patient has a surgical incision. The nurse identifies this type of wound to be:
Intentional.
The patient has a wound from a car accident. The nurse identifies this type of wound to be:
Unintentional.
What type of wound is an ecchymosis?
Closed wound.
Define a closed wound.
Skin does not open, but trauma is present to underlying tissues.
Results of a force, blow, or strain
The patient has a pin-point wound on their skin from accupuncture. Is this wound type intentional or unintentional?
Intentional.
What is another term for ecchymosis?
Bruise
A primary wound that results from cutting with an instrument is termed:
Incision
A superficial wound resulting from scraping or rubbing is termed:
abrasion
Skin that has torn with irregular and ragged edges is termed:
laceration.
What chemical is primarily responsible for skin tone?
Melanin
The nurse notes the patient to be pale. How is this charted?
Pallor
The nurse receives report that the patients skin is flush. What does the nurse expect to see? What causes flushing?
Redness of the skin, associated wit increased body temperatures. Caused by vasodilation.
What skin condition/coloration would the nurse expect to see in a patient who has extremely inadequate tissue perfusion?
Cyanosis
This skin condition/discoloration is caused by an increase of bilirubin in the blood.
Jaundice.
Other than increased bilirubin in the blood, what does jaundice indicate is happening in the patients body?
Liver disease or blocked bile ducts.
What assessment scale is used to assess pressure ulcers?
Braden Scale
What six aspects does the Braden Scale assess?
Sensory Perception Moisture Activity Mobility Nutrition Friction/Shearing
What Braden Scale score indicates risk for pressure sores?
A score less than 18 is considered at risk for pressure sores. (Lower the number, the higher the risk)
