NUR 326 exam 1
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1. tissue integrity: state of structurally intact and physiologically functioning epithelial tissues
2. tissue integrity risk factors: infants: thin skin, weak immune system, mostly immobile, dehydration,
incontinent, less SC tissue
children: injury prone
older adults: less mobile, less SC tissue, thin skin
health conditions, exposure to irritants, tissue trauma
3. granulation: CT that forms on surface of healing wound
4. primary intention: wound margins well approximated, lacerations + surgical incisions, the most rapid
healing
5. secondary intention: wound margins not well approximated, larger wound area requires formation of
granulation tissue to fill gap, longer healing
6. tertiary intention: would healing delayed and occurs when wound previously open is now closed, usually
associated with large infected/contaminated wounds
7. tissue integrity inspection: general color/condition of skin
lesions: location, size, shape, color, pattern, characteristics
8. tissue integrity palpation: feel skin for surface characteristics, temp, texture
skin turgot
9. tissue integrity assessment: acute/chronic
location
size
color
cleanliness
odor
drainage
staging
10. stage 1 pressure injury: non-blanchable erythema of intact skin
11. stage 2 pressure injury: partial thickness skin loss with exposed dermis
12. stage 3 pressure injury: full thickness tissue loss with visible fat
13. stage 4 pressure injury: full thickness skin and tissue loss
14. unstageable pressure injury: obsured full thickness skin and tissue loss
15. tissue integrity primary prevention: skin hygiene, adequate nutrition + hydration, avoidance of
excessive sun exposure, burn safety precautions, dermal ulcer prevention, activity restriction
, NUR 326 exam 1
Study online at https://quizlet.com/_irwje8
16. tissue integrity secondary prevention: screening, ABCDE
17. tissue integrity collaborative interventions: Pharmacotherapy - antibiotics, steroids, emol-
lients, chemotherapy agents
Wound Care - cleansing, dressings
Phototherapy
Surgical Treatment - excisions, debridement, skin grafts, nutrition (paraenteral or enteral)
18. peripheral artery disease (PAD): involves progressive narrowing + degeneration of arteries of upper
+ lower extremities (atherosclerosis is leading cause)
19. PAD risk factors: tobaccos use, atherosclerosis, diabetes, hypertension, high cholesterol, age greater than
60, male
20. PAD symptoms occur when: arteries are 60-75% blocked
21. PAD patho: gradual thickening of intima + media due to cholesterol + lipid deposits, inflammation + endothe-
lial injury play major role
22. PAD manifestations: paresthesia, thin/shiny/taut skin, loss of hair on lower legs, diminished/absent
pedal/popliteal/femoral pulses, intermittent claudication, pallor of foot w leg elevation, reactive hyperemia of foot with
dependent position, rest pain
23. paresthesia: abnormal sensation of numbness and tingling, produces loss of pressure + deep pain sensa-
tions
24. arterial ulcer appearance: tips of toes, foot, lateral malleolus, rounded, smooth, looks "punched out",
minimal drainage, black eschar/pale pink granulation
25. PAD ulcer complications: atrophy of skin + underlying muscles, delayed healing/infection, tissue
necrosis, amputation
26. PAD ulcer interventions: cessation of risk factor habit
med management
surgical/radiographic interventions
diagnostic needs
education
27. Peripheral Venous Disease (PVD): damage, defects or blockage in the veins that carry blood from
the hands and feet to the heart
28. PVD patho: veins + valves fail to move, venous hypertension, varicosities, venous thromboembolism, painful
debilitating ulcers
Study online at https://quizlet.com/_irwje8
1. tissue integrity: state of structurally intact and physiologically functioning epithelial tissues
2. tissue integrity risk factors: infants: thin skin, weak immune system, mostly immobile, dehydration,
incontinent, less SC tissue
children: injury prone
older adults: less mobile, less SC tissue, thin skin
health conditions, exposure to irritants, tissue trauma
3. granulation: CT that forms on surface of healing wound
4. primary intention: wound margins well approximated, lacerations + surgical incisions, the most rapid
healing
5. secondary intention: wound margins not well approximated, larger wound area requires formation of
granulation tissue to fill gap, longer healing
6. tertiary intention: would healing delayed and occurs when wound previously open is now closed, usually
associated with large infected/contaminated wounds
7. tissue integrity inspection: general color/condition of skin
lesions: location, size, shape, color, pattern, characteristics
8. tissue integrity palpation: feel skin for surface characteristics, temp, texture
skin turgot
9. tissue integrity assessment: acute/chronic
location
size
color
cleanliness
odor
drainage
staging
10. stage 1 pressure injury: non-blanchable erythema of intact skin
11. stage 2 pressure injury: partial thickness skin loss with exposed dermis
12. stage 3 pressure injury: full thickness tissue loss with visible fat
13. stage 4 pressure injury: full thickness skin and tissue loss
14. unstageable pressure injury: obsured full thickness skin and tissue loss
15. tissue integrity primary prevention: skin hygiene, adequate nutrition + hydration, avoidance of
excessive sun exposure, burn safety precautions, dermal ulcer prevention, activity restriction
, NUR 326 exam 1
Study online at https://quizlet.com/_irwje8
16. tissue integrity secondary prevention: screening, ABCDE
17. tissue integrity collaborative interventions: Pharmacotherapy - antibiotics, steroids, emol-
lients, chemotherapy agents
Wound Care - cleansing, dressings
Phototherapy
Surgical Treatment - excisions, debridement, skin grafts, nutrition (paraenteral or enteral)
18. peripheral artery disease (PAD): involves progressive narrowing + degeneration of arteries of upper
+ lower extremities (atherosclerosis is leading cause)
19. PAD risk factors: tobaccos use, atherosclerosis, diabetes, hypertension, high cholesterol, age greater than
60, male
20. PAD symptoms occur when: arteries are 60-75% blocked
21. PAD patho: gradual thickening of intima + media due to cholesterol + lipid deposits, inflammation + endothe-
lial injury play major role
22. PAD manifestations: paresthesia, thin/shiny/taut skin, loss of hair on lower legs, diminished/absent
pedal/popliteal/femoral pulses, intermittent claudication, pallor of foot w leg elevation, reactive hyperemia of foot with
dependent position, rest pain
23. paresthesia: abnormal sensation of numbness and tingling, produces loss of pressure + deep pain sensa-
tions
24. arterial ulcer appearance: tips of toes, foot, lateral malleolus, rounded, smooth, looks "punched out",
minimal drainage, black eschar/pale pink granulation
25. PAD ulcer complications: atrophy of skin + underlying muscles, delayed healing/infection, tissue
necrosis, amputation
26. PAD ulcer interventions: cessation of risk factor habit
med management
surgical/radiographic interventions
diagnostic needs
education
27. Peripheral Venous Disease (PVD): damage, defects or blockage in the veins that carry blood from
the hands and feet to the heart
28. PVD patho: veins + valves fail to move, venous hypertension, varicosities, venous thromboembolism, painful
debilitating ulcers
