Skin, Wound, & PICC Flashcards
(55 cards)
What is tissue integrity ?
state of structurally intact and physiolocially functioning epithelial tissues such as integument and mucous membranes
What is the ideal way we describe tissue integrity ?
pink, warm, dry, and intact
What are some characteristics of the epidermis ?
- outermost layer
- cells are flattened and dead
- protects underlying cells and tissues from dehydration
- prevents entrance of certain chemical agents
- allows evaporation of water from the skin
- permits absorption of certain topical medications
What are some characteristics of the dermis ?
- inner, middle layer
- provides tensile strength
- mechanical support
- protection to the underlying muscles, bones and organs
- contains mostly connective tissue and few skin cells
What are pressure injuries ?
localized injury to the skin and other underlying tissue as a result of pressure or pressure + shear and/or friction
What is tissue ischemia ?
longer you lay on a part of body and the capillaries/vessels are being compressed which reduces blood flow
- start of pressure injury
- blanching
What is shear ?
sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary
- vessels gets stretched
What is friction ?
force of 2 surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens
How do we prevent friction ?
use draw sheet
- when pulling pt ensure you have someone to assist
How does moisture affect the skin ?
it softens the skin makes it easier to damage
What does HAPIS stand for ?
hospital acquired pressure injuries
- as RN’s we don’t diagnose these PI’s (pressure injuries)
What are some characteristics of a stage 1 pressure injury ?
nonblanchable redness of intact skin
- discoloration of skin, warmth, edema, hardness or pain may also be present
What are some characteristics of stage 2 pressure injuries ?
partial-thickness skin loss or blister
- shallow open ulcer with red-pink wound bed without slough
- blister may be serum/fluid filled (don’t burst)
- involves epidermis, dermis or both
What are some characteristics of stage 3 pressure injuries ?
full thickness skin loss (fat visible)
- subcutaneous fat may be visible: but bone, tendon, or muscle is not exposed
- slough may be present
- may include undermining and tunneling
What is undermining ?
an area of tissue injury beneath intact skin around the margins of a wound
What is tunnelling ?
tract of injury occurring in any direction from surface or edge of wound
- starts to migrate and branch out that forms “tunnels”
What are some characteristics of stage IV (4) pressure injuries ?
full-thickness tissue loss with muscle/bone visible
- slough or eschar may be present
- often includes undermining and tunneling
What are some characteristics of a unstageable pressure injury ?
full-thickness tissue loss in which the depth of the ulcer is completely obscured by slough/eschar
- base of wound can’t be visualized
- is either stage 3 or 4
What is special about any eschar on the heel ?
it serves as a “natural (biological) cover of the body” and SHOULD NOT be removed
What are some characteristics of deep tissue injuries ?
full-thickness skin or tissue loss with depth unknown
- purple or maroon localized area of discolored intact skin
- stable (dry, adherent, intact without erythema)
- may also present as a blood filled blister
- caused by pressure or shear
What is granulation tissue ?
soft, pink, fleshy HEALTHY tissue
What is slough ?
stringy substance attached to wound bed
What is eschar ?
thick layer of dead, dry tissue that covers a wound bed
What is exudate ?
fluid, cells, or other substances that have been discharged from cells or blood vessels (think drainage from wound)
