Tissue Integrity Part 1 Flashcards
Name the three distinct layers of the skin.
the epidermis, the dermis, and a fatty subcutaneous layer of adipose tissue.
the ability of the human body to regenerate and maintain normal physiologic functioning
tissue integrity
The skin, cornea, subcutaneous tissue, and mucous membranes act as __________ mechanisms for the body.
defense
What is the largest organ system of the body?
skin
What is the main function of the skin?
protection, providing a barrier from injury, infection, ultraviolet radiation (UV), and heat
What layer of skin is composed mainly of keratinocytes and other ypcells, such as melanocytes, Merkel cells and Langerhans cells?
Epidermis
What is the largest portion of the skin that consists of blood vessels, nerves, and hair roots?
dermis
What type of injury is classified according to how much tissue loss is observed in the wound and how many levels are there to the classification scale?
Pressure, 4 levels
What mnemonic is a good reminder for how pressure injury should be described in the nurse notes?
T - Tissue Integrity. I - Inflammation or infection. M - Moisture. E - Edge of wound.
The skin participates in the production of what vitamins?
vitamins A and D
Factors affecting wound healing can be remembered easily by what mnemonic?
DIDN’T HEAL ( Diabetes, infection, drugs, nutritional problems, tissue necrosis, hypoxia, extensive tension, another wound, and low temperatures
What are the 3 stages of wound healing?
Hemostasis or inflammatory, proliferative, and remodeling
Following an operation, a patients would is left open for 5 days and then closed using sutures. What type of wound healing has occurred?
delayed primary closure
A 62-year-old male presents to the ER with a open wound on the sole of the left foot. He reports that the wound first presented 2 weeks prior. He has expressed difficulty walking due to the wound. He has a hx of diabetes. How would this wound be classified?
chronic wound
An irritation of the epidermis caused by moisture present during infancy and early childhood.
maceration
A red skin irritation that develops in infancy and early childhood when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound secretions
dermatitis
Redness of the skin that temporarily becomes white or pale when pressure is applied; the area returns to red when the pressure is released.
blanchable erythema
Redness of the skin that does not go away when pressure is applied.
non- blanchable erythema
Green/yellow wound drainage
purulent
Bloody wound drainage
sanguineous
Thin, watery wound drainage mixed with blood
serosanguineous
Thin, watery wound drainage
serous
Inadequate supply of blood circulation, which results in low oxygen levels in tissues
hypoperfusion
