Integumentary System Flashcards

Question

# Wound closure What is tertiary intention?

Answer 1

"delayed primary" meaning the secondary intention fails then has to be surgically closed - when delay is purposeful = infection - once healed = closure happens

Answer 2

- change in color and ordor - persistent edema - necrotic tissue formation - tunneling or undermining - infection - wound edge builds up a ridge that curls under itself - hypertrophic scarring or keloid

Answer 3

Color - normal Pain - none to aching (dependent to position) Color - normal or cyanotic (may see dark pigmentation) Temp - normal Edema - often marked skin changes: - pigmentation - statis dermatitis - skin gets thick as scarring develops ulceration - may develop medially - wet with large amount of exudate gangrene - absent

Answer 4

Pulses - poor or absent pain - often severe - intermittent claudication - progressing to pain at rest color - pale on elevation - dusky rubor on dependency temp - cool edema - usually absent skin changes - trophic changes - loss of hair on foot and toes - nails thicken ulceration - on toes or feet - can be deep gangrene - black gangrenous skin adjacent to ulcer can develop

Answer 5

Pulses - may be present or diminished pain - typically not painful - sensory loss usually present ulceration - may develop due to trauma to insensitive skin gangrene - may develop if left untreated

Answer 6

pain - can be painful if sensation is intact color - red - brown/black - yellow temp - may be warm if localized infection is present skin changes - inflammatory response with necrotic tissue ulceration - typically occurs over bony prominences gangrene - may develop if left untreated

Answer 7

* sensory perception * moisture * activity * mobility * nutrition * friction and shear

Answer 8

intact skin with non-blanchable redness over a localized area over a bony prominence dark pigmented skin may not be seen its color may differ according to the area can be painful, firm, soft, warmer or color than adjacent skin warning signs for at-risk patients

Answer 9

partial thickness loss of dermis that shows as a shallow open ulcer with a red-pink wound bed with sloough can be present as in intact or open/ruptured serum-filled blister

Answer 10

full thickness tissue loss subcutaneous fat may be visible but the fascia and structures beneat the fascia are not exposed slough may be present but does not obscure the depth of tissue loss can include undermining and tunneling

Answer 11

Full thickness tissue loss with exposed bone, tendon or muscle slough or eschar may be present on some parts of the wound bed often includes undermining and tunneling

Answer 12

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 area may be preceded by tissue that is painful, firm, mushy, bogggy, warmer or coolr as compared to adjacent tissue

Answer 13

Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed

Answer 14

foot tissues - poor footwear - foot deformities - trauma to the foot noncompliance with disease management lack of protective sensation skin changes - dry, red, shiny skin, previous ulcers history of: - amputation - alcohol/tobacco use - immobile - increased age - weak immune system - vascular disease

Answer 15

no open lesion may have pre-ulcerative lesions (healed ulcers or presence of bony deformity)

Answer 16

Superficial ulcer - does not involve any subcutaneous tissue

Answer 17

deep ulcer - penetrating through subcutaneous tissue - has potential to expose bone, tendon, ligament, joint capsule

Answer 18

Deep ulcer - with osteitis, abscess or osteomytelitis

Answer 19

Gangrene - likely requiring amputation

Answer 20

Gangrene - suspected deep tissue injury - requiring amputation