Exam (elaborations)
PN 144 -TISSUE INTEGRITY STUDY SET
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PN 144 -TISSUE INTEGRITY STUDY SET...
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EpidermisThe outer layer of the skin
Dermis
middle layer of skin; contains nerves, lymph and blood vessels, hair glands
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subcutaneous tissue
Fatty tissue found beneath the dermis
Intentional Wound
a wound that is the result of a planned surgical or medical intervention
Unintentional Wound
are accidental; occur from unexpected trauma
Open Wound
an injury in which the skin is interrupted, exposing the tissue beneath
Closed Wound
a type of wound in which the skin's surface is not broken
, Pressure Ulcer
chronic, open wounds caused by localized ischemia due to pressure, friction, and/or
shearing
Risk Factors for Pressure Ulcer Formation
- immobility + inactivity
- inadequate nutrition
- fecal + urinary incontinence
- decreased mental status
- diminished sensation
- excessive body heat
- advanced age
- presence of certain chronic conditions
Stage 1
nonblanchable erythema of intact skin
Stage 2
partial thickness skin loss with exposed dermis
Stage 3
full thickness skin loss with visible sub q fat
Stage 4
Full-thickness tissue loss with exposed bone, muscle, or tendon
Unstageable
full thickness tissue loss in which the base of the ulcer is covered by slough and/or
eschar
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