Tissue Integrity Flashcards
(21 cards)
in order for the patient to have no issues with tissue integrity, they should have the antecedents :
good nutrition
lack of external trauma
adequate perfusion
limited pressure on site
from birth to death
the ability of the body tissues to regenerate and or repair to maintain normal physiological processes
tissue integrity
tool for assessing and predicting pressure ulcer
Braden scale
largest organ of the body
skin
the edge of the wound lines up and is well approximated
primary intention of wound healing
granulation tissue fills the gap to close the wound ex: scab covering a wound
secondary intention of wound healing
long term healing, under direct supervision, wound care management team. a wound that is closed much later.
ex: patient has surgery but the wound becomes infected and has to be reopened.
tertiary intention of wound healing
skin hygiene
adequate nutrition
avoidance of excessive sun exposure
burn safety precautions
dermal ulcer prevention
clinical management
primary prevention
Abcde for skin lesion
asymmetry
border
color
diameter
evolving
FYI: teach the patient to do this monthly
nurse role to assess patient
nurses responsibilities
assessment
skin hygiene
wound care
medication administration
patient teaching
EX: teach diabetics to dry their feet in between the toes, potential for injury.
Which of the following are characteristics of the dermis layer of the skin?
✅ a. Contains blood vessels, hair follicles, and nerve endings
✅ c. Composed of thick fibrous connective tissue
You are assessing the texture of a client’s skin. Which of the following findings require additional investigation?
Smooth, velvety skin
Which of the following findings are associated with a possible malignant lesion?
✅ a. Several colors within a single mole
✅ c. A mole that is larger than a pencil eraser
✅ d. A report of a mole being itchy
✅ e. Occasional bloody drainage from a mole
✅ f. A mole that becomes elevated
You are assessing a client and note a pressure injury on the client’s sacrum. The lesion is a deep depression below the level of the skin and subcutaneous fat is visible. What stage of pressure injury would you document for this wound?
stage 3
The nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration. In which of the following locations should the nurse perform the assessment? Lateral to the umbilicus? inferior to the collarbone? dorsal side of the hand? anterior aspect of the neck?
inferior to the collarbone
A nurse is examining a lesion on a client’s back. Which of the following characteristics should the nurse identify as a possible indication of a malignant skin lesion?
Smooth defined border
uniform color
greater than 6mm in diameter
symmetrical appearance
greater than 6mm in diameter
A nurse is assessing the client’s skin color. Which of the following areas should the nurse check to determine the presence of paler?
Anterior chest
palms of the hand
auricle of the ear
mucous membranes.
mucous membrane
A nurse is providing teaching to a client who reports acne on their face and chest. Which of the following client statements indicates an understanding of the teaching?
wash the areas frequently with warm water
A nurse is palpating a client’s extremities and notes that the lower left leg is cooler to the touch than the client’s right leg or arms. How should the nurse interpret this finding?
client may have a blood clot
A nurse is caring for a client who has a stage 1 pressure injury. Which of the following information should the nurse include when documenting the characteristics of the wound? Select all that apply. Location of the pressure injury. Size of the injury in centimeters. Depth of the injury in centimeters. Color and odor of drainage from the wound. Integrity of the skin surrounding the wound.
✅ Location of the pressure injury
✅ Size of the injury in centimeters
✅ Integrity of the skin surrounding the wound
A nurse is examining the texture of an older adult client’s skin. Which of the following findings should the nurse report to the provider? Thin skin, hyperpigmentation on the back of the hands, silver-white depressed scars on the abdomen, velvety skin,
velvety skin
