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Clinical Assessment 1 > Integumentary > Flashcards

Integumentary Flashcards

1
Q

Blanching

A

Becoming white; paling to the greatest extent

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2
Q

Cellulitis

A

Bacterial infection of the connective tissue of the skin

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3
Q

Erythema

A

Redness of the skin caused by increased local vasodilation

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4
Q

Exudate

A

Fluid accumulation in a wound bed; mixture of high levels of protein and cells

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5
Q

Fibrin

A

A whitish, nonglobular protein required for blood clotting

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6
Q

Granulation tissue

A

A gel-like matrix of vascularized connective tissue with “beefy red” epithelial buds in a newly healing wound bed

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7
Q

Hemosiderin staining

A

The dark purple-brown color of skin caused by a buildup of iron-containing pigment derived from hemoglobin via disintegration of red blood cells.

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8
Q

Induration

A

Firm Edema with a palpable/definable edge

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9
Q

Infection

A

Invasion and multiplication of microorganisms capable of tissue destruction accompanied by local or systemic symptoms

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10
Q

Inflammation

A

Defensive reaction to tissue injury involving increased local blood flow and capillary permeability that facilitates normal wound healing

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11
Q

Lipodermatosclerosis

A

Progressive changes to the skin

Subcutaneous tissues of the ankle and lower leg in persons with venous insufficiency (fibrotic thickening with hemosiderin staining).

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12
Q

Maceration

A

Softening of intact skin due to prolonged exposure to fluids

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13
Q

Necrotic

A

Dead; in a wound, devitalized tissue that often is adhered to the wound bed

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14
Q

Pallor

A

Lack of color; pale

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15
Q

Purulent Damage

A

Thick Yellow, green or brown wound drainage that often has a foul odor, typically a sign of infection.

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16
Q

Serous Drainage

A

Thin fluid that is clear or yellow

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17
Q

Serosanguinous

A

Combination of serous drainage and blood (serous fluid becomes pink)

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18
Q

Slough

A

Loose, stringy, necrotic tissue (yellow, white, or tan)

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19
Q

Trophic

A

Skin changes that occur due to inadequate circulation, including hair loss, thinning of skin, and ridging of nails

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20
Q

Sinus tract

A

Course pathway that can extend in any direction from a wound surface; results in dead space with potential for abscess formation

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21
Q

Tunneling

A

Tissue destruction along wound margins in a narrow area that may extend parallel to the skin surface or deeper into the body.

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22
Q

Undermining

A

Area of tissue under wound edges that becomes eroded; results in a large wound beneath a smaller wound opening

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23
Q

Cyanosis

A

Bluish tint (fingers and toes); Lips and Tongue (lung disease, heart disease, and hemoglobin abnormalities).

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24
Q

Jaundice

A

Diffuse yellowing of the skin and sclera (chronic liver disease)

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25
Erythema
Reddish color (blanchable) Infection, inflammation, allergic reactions or radiation.
26
Chronic Hyperthryroidism (Screening Inspection of the Skin by texture)
Soft or velvety skin
27
Chronic hypothyroidism (Screening Inspection of the skin by texture)
Very rough skin
28
Trauma (Screening inspection of the skin by texture)
Scarring
29
Scleroderma (Screening inspection of the skin by texture)
Fibrosis or hardening
30
Anxiety or Hyperhidrosis (Skin Inspection)
Overly Moist
31
Hypothyroidism/ Chronic Arterial Insufficiency (Skin Inspection)
Very Dry
32
Turgor Inspection
Measures skin's elasticity & hydration status \> 3 seconds to return to normal = strong indication of moderately to severely dehydrated
33
Effusion
Fluid accumulation within a joint capsule or cavity and most often results from injury or inflammation
34
Edema
Fluid accumulation outside of joint capsules. Two common types of fluid accumulation are pitting and non-pitting.
35
ABCDE Method for Melanoma
A- Asymmetry B- Borders C- Colors D- Diameter E- Evolving
36
Alopecia
Hair loss (as in typical pattern balding in males)
37
Hypothyroidism (Screening Inspection of the hair)
Sparse & Coarse
38
Hyperthyroidism (Screening Inspection of the Hair)
Very Fine
39
Malnutrition (Screening Inspection of the Hair)
Dry, brittle and dull
40
Anorexia (Screening Inspection of the Hair)
Lanugo (fine, downy, peach fuzz hair on the face and body)
41
Hormonal Imbalance (in women) (Screening Inspection of the Hair)
Hirsutism (excessive coarse hair on back, face, and chest)
42
Beau's Lines: Infection, protein deficiency, metabolic diseases, hypothyroidism, chemotherapy, alcoholism
43
Lindsay's Line: Chronic renal failure
44
Mee's Line: Chemotherapy, renal failure, arsenic poisoning, recent surgery
45
Terry's Line: Cirrhosis of the liver, heart failure, Type 2 Diabetes
46
Spoon: Iron deficiency, anemia, Vitamin B12 deficiency
47
Pitting: Psoriasis
48
Clubbing: Chronic heart disease, cystic fibrosis, oxygen deprivation, chronic pulmonary disease.
49
Yellow: Chronic bronchitis, liver disorders
50
What kind of patient's are at the greatest risk for pressure ulcers?
Hospitalization, Long-term care facilities, spinal cord injuries
51
Pressure Ulcers
Localized areas of soft tissue necrosis from prolonged pressure over bone
52
Risk factors for pressure ulcers?
Decreased mobility Shear forces Impaired Sensations Moisture Malnutrition Advanced Age History of previous pressure ulcers
53
Common locations of pressure ulcers
Sacrum/ coccyx Greater Trochanter Ischial Tuberosity Posterior Calcaneus Lateral Malleolus
54
Reactive Hyperemia
After pressure that turns the skin pale is removed, normal color returns to skin.
55
Erythema
Redness over areas of tissue irritation
56
Non- blanchable erythema
Areas of redness that do not become pale when pressure is applied
57
Stage 1 (of Clinical Staging)
Skin is intact, localized non blanchable erythema, At-risk tissues
58
Stage 2 (of Clinical Staging)
Shallow crater, red/pink wound bed, loss of epidermis & partial thickness of dermis
59
Stage 3 (of Clinical Staging)
Deep Crater. Undermining or tunneling may be present. Loss of epidermis, dermis & subcutaneous tissue.
60
Stage 4 (of Clinical Staging)
Deep Crater with extensive necrotic tissue. Undermining or tunneling present Full thickness loss of tissue with visible bone, tendon or joint
61
Unstageable (of Clinical Staging)
Crater with base covered by slough.
62
Suspected Deep Tissue Injury (of Clinical Staging)
Deep Purple or Maroon area of skin discoloration covered by intact skin. Unable to determine actual tissues involved.
63
Common cause of neuropathic ulcers
Diabetes Mellitus
64
Neuropathic ulcers are:
Wounds caused by mechanical stress and have significant sensory loss.
65
Sensory Diabetic Neuropathy
Damage to small afferent nerve fibers Most significant risk factor for neuropathic ulcers
66
Motor Diabetic Neuropathy
Damage to large efferent motor nerve fibers Atrophy and weakness of intrinsic foot muscles
67
Autonomic Diabetic Neuropathy
Damage to large efferent autonomic nerve fibers Deceased sweating & oil production in skin.
68
0 on Modified Wagner Scale
At-risk foot
69
1 on Modified Wagner Scale
Superficial, noninfected ulceration
70
2 on Modified Wagner Scale
Deep ulceration, joint or tendon exposed
71
3 on Modified Wagner Scale
Extensive ulceration, bone exposed
72
A on Modified Wagner Scale
Nonischemic
73
B on Modified Wagner Scale
Ischemia
74
C on Modified Wagner Scale
Gangrene on part of foot
75
D on Modified Wagner Scale
Gangrene on entire foot
76
Superficial burn depth
Epidermis Red and Dry Heals within 1 week (minimal to no scarring)
77
Superficial partial thickness burn depth
Epidermis and top layer of dermis Blister & moist, blanchable, moderate erythema, very painful Heals within 2 weeks (minimal scarring)
78
Deep partial thickness burn depth
Epidermis and dermis Mottled red & white areas, blanchable skin (slow), very painful Heals within 3 weeks if area is small (up to several months for larger areas) May require surgical intervention if wound is large Results in scarring and permanent pigment changes.
79
Full thickness burn depth
Epidermis, dermis and hypodermis Very mottled Eschar is rigid, dry and leathery. Little pain. Sensation to pain, pressure and temperature is lost Requires greater than 3 weeks to close, requires closure and grafting, permanent pigment changes, may result in contractures depending on location
80
Subdermal
Epidermis, dermis, and hypodermis and tissues underneath the hypodermis Skin has dry, charred appearance, deep tissues are exposed Requires surgical intervention, may require amputation, may result in paralysis of the area, significant scarring and pigment changes.
81
Total Body Surface Area - Rule of 9's
4. 5% of head 4. 5% of back of head 9% of upper chest 9% of upper back 9% of abdomen 9% of lower back 18% of right leg 18% of left leg 9% of right arm 9% of left arm 1% genitalia

Clinical Assessment 1 (13 decks)

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