Week 6: Tissue Integrity, Peripheral Perfusion, H2T Assessment Flashcards
How does the nurse perform an assessment of the integumentary system?
this is not completed as a separate step of the health assessment but integrated throughout the complete examination of the patient
focuses on inspection and palpation (from IPPA)
what are the physiological and embody (social) functions of skin?
Physiological Functions
Protection
Prevention of penetration
Temperature regulation
Wound repair
Absorption and excretion
Production of vitamin D
Embody (Social) Functions
Perception - sensory
Communication - blushes, startled
Identification - culturally
what is the subjective data - integumentary system?
- Previous history of skin disease (allergies, hives, psoriasis, or eczema)
- Change in pigmentation
- Change in mole (size or colour)
- Excessive dryness or moisture
- Pruritus
- Excessive bruising
- Rash or lesion
- Medications
- Hair loss
- Change in nails
- Environmental or occupational hazards
- Self-care behaviours
what is the objective data - integumentary system?
(A) Consider the colour of the patient’s skin:
Widespread colour change:
Pallor (white)
Erythema (red)
Cyanosis (blue)
Jaundice (yellow)
if darker - look at palms and feet (less pigment)
Areas of lighter pigmentation (vitiligo – absence of melanin pigment)
what follows under clinical context: widespread colour change?
pallor - clinical term for pale (under eyeballs
Jaundice - yellowish skin (enlarged belly) alcoholism - liver disease
what are objective assessments that can be done on the integumentary system?
consider the thickness of the patients skin - Are there any calloused areas? Is the skin thin or shiny?
What does general survey, head-to-toe assessment and system/focused assessment?
general survey is for safety and immediate concern
Head to Toe assessment - is or baseline, ( how is this individual doing, clinical manifestations)
system/focused assessment - in-depth focus on specific system ( focusing it and narrowing it)
Tissue integrity : When would a nurse prioritize an in-depth focused assessment of a patient’s skin?
burns, lesions, rash, and any obvious signs
who are the most prone for skin breakdown?
older client ( bed ridden)
From the following what are the integumentary system : subjective data ?
a. previous history of skin disease
b.change in pigmentation
c.change in mole
d.erythema
e.jaundice
a b c
true or false. Excessive dryness or moisture, excessive bruising and hairloss and pallor are a part of subjective data of integumentary.
false, although excessive dryness or moisture, excessive brusing, and hair loss is, pallor is not this is objective
integumentary System: objective data
what do you have to consider?
A) YOU HAVE TO CONSIDER the patient’s skin
areas of darker pigmentation ( freckles, moles, birthmarks)
areas of lighter pigmentation ( vitiligo- absence of melanin pigment)
B) Palpate the temperature of the patient’s skin
- Hypothermia or hyperthermia ?
- Use the back of your hand
C) Consider the moisture of the patient’s skin?
- diaphoresis or profuse perspiration
-dryness
-dehydration - oral mucous membranes
D) Consider the texture of the patient’s skin
- smooth, firm , with an even surface
Integumentary System : Objective data . true or false. widespread colour change can be a clinical manifestations to lead something is wrong with this patient?
true
What are the widespread colour change ?
1) pallor
2) erythema
3) cyanosis
4) jaundice
What color do these indicate?
Pallor
erythema
cyanosis
jaundice
white
red
blue
yellow
what are some indications of these terms :
pallor ( white )
erythema ( red )
cyanosis ( blue )
jaundice ( yellow )
anemia, not enough blood
fever, infection, C02 poisoning
not enough oxygen
not enough oxygen
something is wrong with the liver
If somebody has a darker skin tone ? what could be a big sign of a widespread colour change ( where in the body could we see this)?
mouth ( oral( or lips
palm of the hands
looking for cellular differences
when doing an integumentary system: objective assessment, what do we have to consider?
a) consider the thickness of the patient’s skin
- are they any calloused areas?
-is the skin thin or shiny?
b) Palpate the patient’s skin for edema
- unilateral edema: local or peripheral cause
-bilateral edema or generalized edema ( anarsaca) : central problem
Nonpitting or brawny edema
Pitting Edema
What are the ranges for pitting edema ?
1+ = mild pitting, slight indentation, no perceptible swelling of the leg
2+ = moderate pitting, indentation subsides rapidly
3+ = deep pitting, indentation remains for a short time, swelling of leg
4+ = very deep pitting, indentation lasts a long time, gross swelling and distortion of leg
what else do we have to consider when it comes to integumentary system : objective assessments?
re-call :
- consider the thickness of the patient’s skin
-palpate the patient’s skin for edema
what else?
palpate the mobility and turgor of the patient’s skin
inspect vascularity and bruising
note the presence of any rashes or lessions
Go into further details about these objective assessments when it comes to integumentary system
palpating the mobility and turgor of the patient’s skin
inspect vascularity and bruising
note the presence of any rashes and lessions
-pinch up a large fold of skin on the anterior aspect of the chest under the patient’s clavicle
-mobility = skin’s ease of rising
-turgor = skin’s ability to promptly return to place
Cause of any bruises ?
signs of recreational IV drug use ( track marks)
Types of lessions, how to describe
focuses on :
1) different types of lessions what’s the first you wanna know
(feel them)
aute and chronic
notice what we can observe
Abnormal Finding : Lesions
what are the two things we should categorize?
1) Type
- Primary
-Secondary
2) Assessment
- health history
-inspection
-palpation
Abnormal Findings: Lesions
1. Type
Primary and Secondary
Go in depth with this ?
Primary : when a lesion develops an unaltered skin
Secondary : When a lesion changes over time ( scratching/itching)
True or false. Health history links to pain, healing, cause, when/where did it start spreading, contagious, environmental, itching fever, stress
true
true or false. Inspection links to colour, elevation, pattern or shape, size, location, and distribution on the body, any excaudate
true
True or false. Palpitation links to depth, pain, temperature, easily removed ‘brushed off’ - cause of bleeding> blanch with pressure?
true
Types ( Structure ) of Lesions
Primary Skin Lesions are what kind?
macule & patch
papule & plaque
nodule & tumour
wheal & urticaria ( hives )
vesicle & bulla
cyst pustule
Types ( Structure ) of Lesions Secondary skin lesions
crust
scale
fissure (tear)
erosion
ulcer ( pressure sore)
excoriation ( scratch or abrasion)
scar
atrophic scar
keloid
lichentication
Skin terminology : lesions and wounds
Common shapes and configurations
annular
confluent
discrete
grouped
gyrate
target
linear
polycyclic
zosteriform
circular
merged, multi shaped
distinct, separate
cluster
snakelike, coiled
iris, bullseye
scratch, streak
annular grow together
along nerve route
what is configurations?
pattern of the body ( the shapes)
true or false. closely monitor mole (can become malignant cancer –> skin cancer)
true
How do you assess moles ?
ABCDE characteristics
Asymmetry
Border irregularity
Colour variation
Diameter > 6mm
Evolution
Rapidly changing
The ugly duckling sign
Integumentary System : objective assessment
when assessing the nail beds for any abnormalities and hygiene ( name the examples )
clubbing, discoloration
When is a good time to check the patient’s oral cavity ?
by checking their temperature ( orally)
As nurses we are obligated to inspect the patient’s cavity, when we are doing our integumentary system subjective assessment?
false. Yes as nurse we are obligated to inspect their cavity, however it is not subjective but rather OBJECTIVE
name the examples of inspection we are looking for when inspecting a patient’s oral cavity.
moist mucous membranes
any lessions
halitosis
furrowed tongue
condition of the teeth ( broken, clean, bleeding gums)
what is clubbing associated with ?
could be associated with lung disease
true or false. when doing an integumentary system, objective assessments. We palpate and inspect the scalp.
true
What do we look for when palpating and inspecting the patient’s scalp?
tenderness
sores/lessions
infestations ( head lice )
Tissue Integrity - Laboratory Assessment
what are the assessment?
wound cultures
albumin
biopsy
True or false. Protein in the blood is important for the healing?
True, it is important.
True or false. If someone has a really bad wound, it is recommended to eat high protein and high calories.
true
name the biopsy methods
curettage
shave
punch biopsy
excisional
incisional
If you have low albumin and you have a big wound, what happens?
if the albumin is low, there’s not enough to heal for the wound–> takes longer
What are the 4 types of tissue
muscle
neural
connective
epithelial
What is the scope of tissue integrity ?
intact skin tissue
damaged skin tissue ( partial thickness injury and fullness thickness injury)
what are ways how a cell can die ?
( causes of lethal cell injury )
cellular ischemia ( doesn’t have enough oxygen)
physical damage
- heat, cold, radiation, electrothermal, mechanical
microbial injury
-bacteria can come ( like a pimple etc.)
immunological injury
- damage caused by body’s own immune system
normal substances with unintended contact
- gastric acid leads into abdominal cavity
neoplastic growth ( benign or cancer)
True or false. Normal substances with unintended contact ( e.g gastric acid leads into abdominal cavity) . This can cause a leakage and cause cellular injury or death.
true
Cell Death: Necrosis : What does this mean?
uncontrollable passive pathological process of cell death ; occurs when cells are exposed to extreme conditions
causes swell and rupture, leading to inflammation and damage of surrounding tissue
True or false. When having a heart attack, the heart cells looks normal but it’s actually dead.
True
What are the terms we need to know that undergoes cell death : necrosis
coagulative
liquefactive
caseous
gangrene
- dry gangrene
-wet gangrene
when describing the term coagulative , what does it mean?
caused by ischemia, free radical, still looks like a cell for a while
what is liquefactive, identify the term
caused by the body releasing enzymes to kill bacteria, causes damage ( liquefy) of neighbouring cells ( abscess)
what does caseous mean ?
a distinctive from coagulative necrosis, where tissue no longer recognizable, cheese-like appearance. caused by mycobacterial infections ( tuberculosis) or tumor necrosis.
what does gangrene mean ?
build up decomposing dead tissue, usually refers to appendage/limb /with ischemic necrosis
what are the two types of gangrene ?
dry and wet gangrene
what is a dry gangrene
chronic/slow caused by degenerative diseases ( atherosclerosis. diabetes) may auto-amputate
what is wet gangrene
acute/quick, caused by sudden elimination of blood flow ( severe burn or traumatic crush injury) possible bacteria
Pressure Ulcers
Etiology :
Pressure- Skin and soft tissue compressed
shearing force- skin stationary, tissue below moves
Friction - Surfaces rub the skin
Excessive moisture
Pressure Ulcers
Risk Factors :
loss of mobility
confusion
poor nutritional status
dehydration
True or false. Sitting all day in that bony premises ( cutting circulation in that issue) initially getting a cellular injury cutting off that perfusion= leading to cellular death.
true
Who is more prominent for pressure ulcers ?
underweight, ( but both under and over weight could be )
True or false. Shearing forces pulling skin layers away from the deeper tissue.
true
The skin is “ bunched up “ against the back of the mattress while the rest of the bone and muscle in the area presses download on the lower part of the mattress. This is called =
shearing
define if this is true. Shearing forces pulling skin layers away from the deeper tissue. The skin “ bunched up “ against the back of the mattress while the rest of the bone and muscle in the area presses downward on the lower part of the mattress. Blood vessels become kinked, obstructing circulation and leading to tissue death.
true
ISTAP skin tear classficiation
1) no skin loss
2) partial flap floss
3) total flap loss
what category is this in? Linear or Flap tear which can be repositioned
no skin loss
what category is this in ? Total flap loss exposing entire wound bed
total flap loss
what category is this in? cannot be repositioned to cover the wound bed
partial flap loss
true or false.When doing a skin assessment, notice it’s red ( see if it’s latching lighting) telling me you’re still perfusion there ( red spot and it doesn’t launch) not getting perfusion = stage 1 ulcer
true
what is stage II of ulcers?
artial thickness loss of dermis presenting as a shallow open ulcer with a red pink moist wound bed, without slough. May also present as
an intact or open/ruptured serum-filled blister.
What stage of ulcers is this?
Full thickness tissue loss with exposed bone, tendon or muscle.
stage IV
what stage of ulcers is this?
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
Stage III
what is the unstageable stage of ulcers?
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
what is a Suspected Deep Tissue Injury? (ulcer)
A purple or maroon localized area of discolored intact skin or blood- filled blister due to damage of underlying soft tissue from pressure and/ or shear
what are the four types of wound drainage or exudate?
Serous
Serosanguineous
Sanguineous
Purulent
what is a serous wound drainage?
Clear, watery plasma
WNL – expected with wound healing
What is a Serosanguineous wound drainage?
Pale, red, watery: mixture of clear and red fluid
WNL – expected with wound healing
what is Sanguineous wound drainage?
Bright red
Active bleeding
What is a purulent wound drainage?
Thick, yellow, green, tan, or brown
Possible infection
what is wound healing - primary intention?
incision with blood clot - edges approx. with suture - fine scar
what is wound healing - secondary intention?
irregular large wound with blood clot - granulation - large scar
what is wound healing - tertiary intention?
contaminated wound - granulation tissue - delayed closure with suture
what does wound healing involve?
Inflammatory response - involved in the healing of wounds
Partial thickness wound (damage to epidermis and upper dermal layers)
- Re-ephithelization – production of new skin cells by undamaged dermal layer
- Occurs in 5-7 days (hydrated, well-oxygenated, few microorganisms)
Full thickness wounds (lower layers of dermis and subcut tissue)
- Granulation – gap in tissue filled by scar tissue
- Contraction – gap in tissue fibroblasts pull wound edges inward
what is granulation? what is contraction (full thickness wounds) ?
Granulation – gap in tissue filled by scar tissue
Contraction – gap in tissue fibroblasts pull wound edges inward
What stage do we want to have early intervention?
stage 1 these are early signs, and prevent from getting worse.
When someone sitting on a wheelchair all the time. Causing friction and shearing What stage is this occurring?
Stage 1 pressure ulcers
What is this : we now have broken skin ( still in the dermis) , seeing that skin opening up
stage II
With through the epidermis and through the dermis, and all the way through that tissue ( see that underline subcutaneous tissue)
stage III
this is all the way to the skin, and subcutaneous tissue ( underlying tissue, bones, tissues, muscles)
this is starting to get that slough ( wet greene)
Stage IV
True or false. Nutrition is a big thing ( component) in a long term care home ( dealing with a skin tissue ) –> can be seen in all stages
true
This is when we still don’t see the top layer breaking down ( but is swollen and darkening in colour ) what stage is this ?
Staging of Pressure Ulcers: Suspected Deep Tissue Injury
What type of wound healing is this?
heals by generating new cells, new baby skin cells to fill in that wound left with a large scar
secondary intention
what type of wound healing is this?
this is a cut to bone to heal
take a structure and sew it back together ( closed the wood and it’s healed) -> fine scar
primary intention
what type of wound healing is this?
this is when someone goes for surgery ( and there is infection in there, not going to close it immediately.Leave it open and clean the tissue is infected, we do that by giving them antibiotics)
tertiary intention
In terms of wound healing: what type of response is this ? Help form clot ( and form a clot and clot has been formed, the wound heals itself, has chemical mediators so it can start healing itself)
inflammatory response
In terms of creating skin cells and starting to generate skin cells what type of wound healing is this ?
partial thickness wounds
How does the nurse perform an assessment of the PVS ? ( peripheral vascular system)
assessing the peripheral vascular system involves inspecting and palpating the patient’s arms and legs
informs the nurse about the patient’s peripheral perfusion, or the body’s ability to circulate blood to and from extremities
arteries and veins in the leg
located on the top of our foot ( and behind our ankle) fetal pulses
Peripheral Vascular Assessment : subjective data
leg pain or cramps
skin changes on arm or legs r/t PVD (peripheral vascular disease)
swelling in arms or legs r/t PVD
(peripheral vascular disease)
lymph node enlargement
medications
Peripheral Vascular Assessment : objective data , name the three things we should look at
A) palpate/compare the color, warmth, sensation, movement
Colour
Warmth
Sensation
Movement
Palpate the oulses
True or false. Peripheral Vascular Assessment : objective data
should we assess the capillary refill of the fingers and toes .
- depress the nail edge to cause blanching, and then release
-note the return of colour brisk vs. sluggish
true
what is brisk ? and what is sluggish ?
brisk >3-5
sluggish < 3-5 sec
what are the different pulses that we can find in our body ?
carotoid
temporal
brachial
radial
femoral
popliteal
posterior tibial
dorsalis pedis
Peripheral Vascular Assessment : objective data. True or False. Colour changes : suspected arterial deficit
we lift the patient’s leg under the table, and ask the patient to make their leg still and hold it for one minute to drain venous blood
have patient stand out - assess how long for colour to return
false.
lift the patient’s legs above the table, ask the patient to move their feet, hold for 30 seconds to drain venous blood
have patient sit up legs over bed- assess how long for colour to return ( normal is < 10 seconds)
what is the scope of perfusion?
Optimal perfusion
Impaired perfusion
no perfusion
what are the four stages of peripheral arterial disease?
stage 1: Asymptomatic
stage 2: Claudication
stage 3: Rest Pain
Stage 4: Necrosis/Gangrene
In the following option, which one goes away from out heart to our arteries, and which goes back into our arteries into the heart ?
oxygenated
dexygenated
what is stage 1: asymptomatic?
No claudication (pain in thigh, calf or buttocks)
Bruit or aneurysm may be present
Pedal pulses are decreased or absent
Blood that flows through arteries and capillaries to target tissues
tissue perfusion
what is tissue perfusion?
blood that flows through arteries and capillaries to target tissues
what are the three categories under tissue perfusion
-blood that flows through arteries and capillaries to target issues
-arterial blood pressure
-venous blood pressure
what is stage 2: Claudication?
Muscle pain, cramping, burning occurs with exercise
* Relieved with rest
Symptoms are reproducible with exercise
what is Step 3: Rest Pain?
Pain while resting commonly awakens the patient at night
Pain described as numbing, burning, toothache-type pain
Pain usually in distal part of extremity
Pain is relieved by placing the extremity in a dependent position
go more in depth for arterial blood pressure under tissue perfusion
determined by CO and SVR
ventricular contraction creates pressure pushes blood through arteries, capillaries into intersial spaces
Delivers oxygen, fluid and nutrients to the cells
Blood pressure is maintained by constricting or dilating arteries and arterioles in response to stimuli
what is stage 4: Necrosis/Gangrene
Ulcers and blackened tissue occur on the toes, forefoot, heel Distinctive gangrenous odor
what are the clinical manifestations of peripheral arterial disease?
loss of hair on lower calf/ankle/foot
Dry, scaly/dusky pale or mottled skin
thickened toenails
decreased or absent pulses
pain at rest, leads to or worsening at night
Cold and cyanotic or darkened skin (pallor with elevation, dependent rubber when lowered)
Muscle atrophy with chronic cases
ulcers to toes, metatarsal heads, and lateral ankle (ulcers = ale ischemic base, well defined edges, no bleeding)
go more in depth by venous blood pressure under tissue perfusion
blood is returned through veins and venules ( less sturdy than arteries and arterioles)
more stretchy lower pressure than arteries
veins contain valves to keep blood flowing forward to the heart
complications of peripheral arterial disease?
infection, gangrene
delayed-/non-healing, amputations
what is the impaired perfusion risk factors ( who are at risk).
Who are at populations at risk ?
Who are individuals at risk ?
populations at risk - older adults, and social determinants of health
Individual risk factors-
genetics, lifestyle, immobility
how to calculate ankle brachial index?
ABI = Ankle Pressure/Branchial Pressure
Normal = 1.00 - 1.40
what is peripheral venous disease?
Prolonged venous hypertension that stretches veins and damages valves
includes:
Backup of blood leads to edema and decreased tissue perfusion
Standing/sitting for prolonged periods
Obesity
Hypercoagulable states/Vein trauma/Thrombus formation Incompetent valves (varicose veins)
true or false. Peripheral vascular Disease are perfusion risk factors which includes peripheral arterial disease and chronic venous insufficiency.
true
what are the stages of peripheral arterial disease
1) asymptomatic
2) claudication
3) rest pain
4) necrosis/gangrene
what does Peripheral Venous Disease (CVI) lead to?
Venous stasis ulcers Swelling
Cellulitis
what are the clinical manifestations of PVD/CVI
Edema
Stasis dermatitis: reddish-brown discolouration
- extending up calf
stasis ulcers
- from edema/minor injury
- often above medial malleolus
- Irregular borders
- Difficult to heal
Stages of peripheral arterial disease is a problem with
arteries
what are designed to get nutrients to our extremities ?
arteries
if we lose nutrients and are not getting enough perfusion, what do we get?
peripheral arterial disease
true or false. Peripheral arterial disease must be catch and carry on ( they get weaker by clotting formation)
true
what would the location be for arterial and venous?
Deep muscle pain, usually in calf
Calf, lower leg
what would the character be for arterial and venous?
intermittent claudication (cramping, numbness)
Aching, tiredness, feeling of fullness
what would the onset and duration be for arterial and venous?
chronic, onset gradual after exertion
chronic, increases at end of day
GO in depth with the information of stages of peripheral arterial disease.
1) asymptomatic
- no claudition
- bruit or aneurysm may be present
- pedal pulses are decreased or absent
2) claudication
- muscle pain, cramping, burning occurs with exercise
=relieved with rest
- symptoms are reproducible with exercise
3) Rest Pain
- Pain while resting commonly awakens the patient at night
-Pain described as numbing, burning, tootache-type pain
-Pain usually in distal part of extremity
-Pain is relieved by placing the extremity in a dependant position
4) Necrosis/Gangrene
- ulcers and blackened tissue occur on the toes, forefoot, heel
-distinctive gangerenous odor
what would the Aggravating Factors be for arterial and venous?
Activity (walking, stairs), Elevation (rest pain indicates severe involvement)
Prolonged standing, sitting
what would the relieveing factors be for arterial and venous?
Rest (usually within 2 min [e.g., standing]) Dangling (severe involvement)
Elevation, lying, walking
what would the associated symptoms be for arterial and venous?
Cool, pale skin
Edema, varicosities, weeping ulcers at ankles
what would the population at risk be for arterial and venous?
Older adults; history of hypertension, smoking, diabetes, hypercholesterolemia, obesity, vascular disease
Prolonged standing or sitting; obesity; prolonged bed rest; varicosities, or thrombophlebitis; veins crushed by trauma or surgery
what major arteries can be found in the arm?
radial, ulnar and brachial
what major arteries can be found in the leg?
femoral, popliteal and posterior tibial
what major veins are found in the leg?
great saphenous, small saphenous, femoral, anterior tibial
