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)
What causes pressure ulcers?
Unrelieved pressure that leads to decreased circulation and damage of tissues.
What factors relate to the development of pressure ulcers? (Not Braden Scale)
Pressure Intensity
Pressure duration
Tissue Tolerance
The nurse assess the patients shoulder to have non-blanching reddness, and the skin is entirely intact. What stage is this?
Stage 1
The nurse assesses the patients leg to have partial skin loss involving the epidermis and dermis. What stage is this?
Stage 2 (looks like abrasion, blister, or shallow crater caused by rubbing or scrapping)
The nurse notes extensive loss of skin, and tissue necrosis. Muscle and bone is visible. What stage is this?
Stage 4
The nurse notes the patients skin to look like a deep crater involving loss, damage, or necrosis of subcutaneous tissue. What stage is this?
Stage 3
Name 4 skin conditions noted for geriatric patients. Define each condition.
Keratosis- overgrowth and thickening of epithelium
Lentigo Senilus- Age Spots (brown macula)
Skin Tags- flesh colored, raised areas
Skin Tears- Thin layer of skin in elderly is easily damaged.
What increases in regards to hair for geriatric pyhsical integrity changes?
Graying/whiting
Thinning
Eyebrow, ear and nasal hair coarser and longer.
Coarse facial hair in women.
A wound in which a sharp instrument penetrates the skin and underlying tissue
Puncture
Normal ranges of skin color
Pinkish white-shades of brown
Jaundice is primarily seen where on the body
Skin
Sclera of eye
Define tissue ischemia
Localized absence of blood and oxygen to tissue cells
A wound in which a sharp instrument penetrates the skin and underlying tissue
Puncture
Normal ranges of skin color
Pinkish white-shades of brown
Jaundice is primarily seen where on the body
Skin
Sclera of eye
Define tissue ischemia
Localized absence of blood and oxygen to tissue cells
