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Foundations: Fundamentals of Nursing, Chapter 48 Skin Integrity and Wound Care

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Skin integrity and wound care

Grade levels:
College: Third year

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1

Abnormal reactive hyperemia

Excessive vasodilation and induration, skin is bright pink to red, no blanching with fingertip pressure, can last 1 hour to 2 weeks, stage I pressure ulcer;

2

Abrasion

Superficial wound with little bleeding, considered a partial-thickness wound. Often appears "weepy" because of plasma leaking from damaged capillaries;

3

Approximated

Closed;

4

Blanching

When normal red tones of light skinned patients are absent as when pressing a patient's fingertips to test capillary refill - blanching of the skin does not occur in darkly pigmented skin;

5

Collagen

A tough fibrous protein;

6

Darkly pigmented skin

Skin that remains unchanged (does not blanch) when pressure is applied on a bony prominence;

7

Debridement

Removal of nonviable, necrotic tissue;

8

Dehiscence

Partial or total separation of wound layers - this happens when wounds fail to heal properly - occurs before collagen formation;

9

Drainage evacuators

Convenient, portable units that connect to tubular drains lying down within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage;

10

Epithelialization

The natural act of healing by secondary intention, the proliferation, or rapid reproduction, of new epithelium into an area devoid of it but that naturally is covered by it;

11

Eschar

Black or brown necrotic tissue - has to be removed before healing can occur;

12

Evisceration

Protrusion of visceral organs through a wound opening;

13

Exudate

Amount, color, consistency, and odor of wound drainage;

14

Fibrin

Provides a framework for cellular repair. Protein involved in the clotting of blood form a "mesh" that forms a hemostatic plug or clot in conjunction with platelets over a wound site;

15

Fistula

Abnormal passage between two organs or between an organ and the outside of the body - caused by diseases, radiation, and trauma that prevents tissue layers from closing properly allowing a fistula tract to form. Increase risk of infection and fluid and electrolyte imbalances from fluid loss. Chronic drainage of fluids through a fistula all predispose a person to skin breakdown.;

16

Friction

Occurs when skin is dragged across a coarse surface, such as bed linens, usually affecting the top layer of epidermis of skin.;

17

Granulation Tissue

Red, moist tissue composed of new blood vessels which indicated progression toward healing;

18

Hematoma

Localized collection of blood underneath the tissues;

19

Hemorrhage

Bleeding from a wound site;

20

Hemostasis

Injured blood vessel constrict and platelets gather to stop bleeding;

21

Induration

Abnormal firmness or hardness of tissue with margins as a result of edema or inflammation;

22

Laceration

A break or opening in the skin that may be smooth or jagged. Bleed more depending on location and depth.;

23

Normal reactive hyperemia

Redness-localized vasodilation, blanching with fingertip pressure; lasts less than 1 hour;

24

Pressure ulcer

Impaired skin integrity related to unrelieved prolonged pressure;

25

Primary intention

Wound healing with skin edges that are approximated, or closed, risk of infection is low, healing occurs quickly with minimal scar formation as long as infection and secondary breakdown is prevented; similar to a surgical wound;

26

Puncture

Caused by an object piercing the skin and creating a hole, bleeding determined by depth and size, primary dangers are internal bleeding and infection;

27

Purulent exudate

Thick, yellow, green, tan or brown pus or drainage;

28

Sanguineous

Bright red which indicates active bleeding;

29

Secondary intention

Wound is left open until it fills with scar tissue, wound healing takes longer and chance of infection is greater. If scarring s severe often a permanent loss of tissue function occurs, usually burns, pressure ulcers, or severe lacerations;

30

Serosanguineous exudate

Pale, red, watery; mixture of clear and red fluid;

31

Serous exudate

Clear, watery, plasma;

32

Shearing force

Force exerted parallel to skin resulting from both gravity pushing down on the body and resistance, or friction, between the client and a surface. Example: when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of friction with the bed.;

33

Slough

String substance attached to a wound bed - has to be removed before wound can heal properly;

34

Sutures

Threads or metal used to sew body tissues together;

35

Tissue ischemia

When living tissue is deprived of oxygen - depriving tissue of adequate blood flow is the same as depriving tissue of oxygen;

36

Vacuum Assisted Closure (VAC)

Device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together;

37

Wound

Disruption of the integrity and function of tissues in the body;

38

Wound contraction

The shrinkage and spontaneous closure of open skin wounds. Begins almost concurrently with collagen synthesis centripetal movement of wound edges that facilitates closure of a wound, maximal 5 - 15 days after injury;

39

Abnormal reactive hyperemia

Excessive vasodilation and induration, skin is bright pink to red, no blanching with fingertip pressure, can last 1 hour to 2 weeks; stage I pressure ulcer;

40

Abrasion

Superficial wound with little bleeding, considered a partial-thickness wound. Often appears "weepy" because of plasma leaking from damaged capillaries;

41

Approximated

Closed;

42

Blanching

When normal red tones of light skinned patients are absent as when pressing a patient's fingertips to test capillary refill - blanching of the skin does not occur in darkly pigmented skin;

43

Collagen

A tough fibrous protein;

44

Darkly pigmented skin

Skin that remains unchanged (does not blanch) when pressure is applied on a bony prominence;

45

Debridement

Removal of nonviable, necrotic tissue;

46

Dehiscence

Partial or total separation of wound layers - this happens when wounds fail to heal properly - occurs before collagen formation;

47

Drainage evacuators

Convenient, portable units that connect to tubular drains lying down within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage;

48

Epithelialization

The natural act of healing by secondary intention, the proliferation, or rapid reproduction, of new epithelium into an area devoid of it but that naturally is covered by it;

49

Eschar

Black or brown necrotic tissue - has to be removed before healing can occur;

50

Evisceration

Protrusion of visceral organs through a wound opening;

51

Exudate

Amount, color, consistency, and odor of wound drainage;

52

Fibrin

Provides a framework for cellular repair. Protein involved in the clotting of blood form a "mesh" that forms a hemostatic plug or clot in conjunction with platelets over a wound site;

53

Fistula

Abnormal passage between two organs or between an organ and the outside of the body - caused by diseases, radiation, and trauma that prevents tissue layers from closing properly allowing a fistula tract to form. Increase risk of infection and fluid and electrolyte imbalances from fluid loss. Chronic drainage of fluids through a fistula all predispose a person to skin breakdown.;

54

Friction

Occurs when skin is dragged across a coarse surface, such as bed linens, usually affecting the top layer of epidermis of skin.;

55

Granulation Tissue

Red, moist tissue composed of new blood vessels which indicated progression toward healing;

56

Hematoma

Localized collection of blood underneath the tissues;

57

Hemorrhage

Bleeding from a wound site;

58

Hemostasis

Injured blood vessel constrict and platelets gather to stop bleeding;

59

Induration

Abnormal firmness or hardness of tissue with margins as a result of edema or inflammation;

60

Laceration

A break or opening in the skin that may be smooth or jagged. Bleed more depending on location and depth.;

61

Normal reactive hyperemia

Redness-localized vasodilation, blanching with fingertip pressure; lasts less than 1 hour;

62

Pressure ulcer

Impaired skin integrity related to unrelieved prolonged pressure;

63

Primary intention

Wound healing with skin edges that are approximated, or closed, risk of infection is low, healing occurs quickly with minimal scar formation as long as infection and secondary breakdown is prevented, similar to a surgical wound;

64

Puncture

Caused by an object piercing the skin and creating a hole, bleeding determined by depth and size, primary dangers are internal bleeding and infection;

65

Purulent exudate

Thick, yellow, green, tan or brown pus or drainage;

66

Sanguineous

Bright red which indicates active bleeding;

67

Secondary intention

Wound is left open until it fills with scar tissue, wound healing takes longer and chance of infection is greater. If scarring s severe often a permanent loss of tissue function occurs; usually burns, pressure ulcers, or severe lacerations;

68

Serosanguineous exudate

Pale, red, watery, mixture of clear and red fluid;

69

Serous exudate

Clear, watery, plasma;

70

Shearing force

Force exerted parallel to skin resulting from both gravity pushing down on the body and resistance, or friction, between the client and a surface. Example: when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of friction with the bed.;

71

Slough

String substance attached to a wound bed - has to be removed before wound can heal properly;

72

Sutures

Threads or metal used to sew body tissues together;

73

Tissue ischemia

When living tissue is deprived of oxygen - depriving tissue of adequate blood flow is the same as depriving tissue of oxygen;

74

Vacuum Assisted Closure (VAC)

Device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together;

75

Wound

Disruption of the integrity and function of tissues in the body;

76

Wound contraction

The shrinkage and spontaneous closure of open skin wounds. Begins almost concurrently with collagen synthesis centripetal movement of wound edges that facilitates closure of a wound, maximal 5 - 15 days after injury;


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