Integumentary
System
System
What is skin pallor?
A pale or lighter than normal skin tone that could indicate poor circulation or anemia.
What is the first white blood cell to arrive during a cellular response to cell injury?
Neutrophils (within 6 to 12 hours).
What is dehiscence versus evisceration?
Dehiscence: Partial or complete separation of would edges.
Evisceration: Protrusion of internal organs through an open wound.
What does a stage 1 pressure ulcer look like on darker skin tones?
Petechiae: Pinpoint hemorrhages less than 2mm.
Purpura: Non-blanching purple spots between 2mm to 1cm.
Ecchymosis: Bruises that are larger than 1cm caused by blood leaking into the skin.
What are some local and systemic responses to infection? List at least three.
Local: Redness, heat, pain swelling, loss of function
Systemic: Elevated WBC, nausea, tachycardia, tachypnea, malaise (fatigue), fever
What are some contributing factors of delayed wound healing? Give at least three examples.
Nutritional deficiencies, inadequate blood supply, corticosteroid medications, infection, smoking, mechanical friction on wound, advanced age, obesity, diabetes mellitus, poor general health, and anemia.
What are some prevention strategies to decrease the risk of pressure ulcers? Give three examples.
Remove excessive moisture, avoid massage over bony prominences, frequent turning (q 1-2 hours), use lift sheets, increase mobility (most important).
Identify risk using the Braden Scale.
What does A, B, C, D, E stand for when assessing for melanoma?
A: Asymmetry
B: Border irregularity
C: Color variation
D: Diameter, greater than 1/4 of an inch (6 mm)
E: Evolving characteristics
What occurs during the vascular response of cell injury?
Cell injury/death leads to release of chemical mediators (histamine, kinins, prostaglandins) vasodilation, hyperemia (redness, warmth), increased capillary permeability, local edema.
What is tertiary intention? Give some examples.
Delayed primary intention due to delayed suturing of the wound. Occurs when a contaminated would is left and sutured closed after the infection is controlled. Closure with a wide scar.
Examples: Bite marks, traumatic injuries, etc.
Describe the difference between a stage II and stage III pressure ulcer.
Stage III: Full thickness skin loss with visible fat and involving damage or necrosis to SQ tissue, may extend down to but not through underlying fascia.