 | Term | Definition |
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dermis |
function is to support and nourish the epidermis. contains capillary ends, nerve endings, sweat and sebaceous glands, hair follicles, collagen and elastin |
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subcutaneous tissue |
mostly adipose and connective tissue. contains lymphatics and blood supple. yellowish in color. functions to nourish the dermis |
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fascia |
shiny white sheath-like tough covering over muscle, blood vessels, and nerves. Function is to support muscle fibers and keep them together |
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ligament |
a fibrous band or sheet. connect bone and cartilage. They have poor vascularity and are yellowish/white. |
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tendon |
a white, shiny, cord-like, elastic, fibrous tissue. high tensile strength and poor vascularity |
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bone |
bright white, solid, distinct sound/feeling. consists of the periosteum and cortical layers |
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blood vessels |
bright red or maroon/purple. observe for pulsing of structure |
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adipose |
yellow, globular, slippery, and will recoil when you touch it. |
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primary intention |
full thickness wound repair, surgical repair, edges are approximating, decreased risk of infection, involves little tissue loss, and heals with minimal scarring |
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secondary intention |
full or partial thickness wound repair, chronic wounds, edges are not approxiamated, greater tissue loss, higher risk of infection, and londer healthing times. |
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tertiary intention |
a surgical wound left open until ready to close, provides time to decrease edema or infection. aka delayed primary intention |
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healing ridge |
induration beneath the skin under the suture line. about 1 cm on each side of th incision line. observed in 5-9 days. if absent....possible risk of infection, risk of dehiscence. |
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dehiscence |
reopening of the incision line |
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drainage, dehiscence, fistula, infection; change in skin color, induration, temp and unresolved pain |
incision line complications |
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evisceration |
internal contents come through the opening |
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drains |
these are used to remove fluid to prevent buildup and decrease risk of infection. either passive or active. |
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Penrose |
a passive drain that works by gravity and is placed by surgeon. |
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hemovac, Jackson pratt, Stryker Constavac |
active drains that are active, battery powered, suction force to remove fluid |
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partial thickness |
skin loss through the epidermis but not completely through the dermis. no dead tissue is present and no granualtion tissue (formation of collagen as it grows back). |
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inflammatory, proliferative, maturation |
the phases of healing of full thickness ulcer repair. these phases can overlap |
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inflammatory phase |
the first phase of full thickness ulcer repair. at time of injury...edema, erythema, heat, pain. lasts 4-6 days normally. can last weeks or months if chronic, necrotic, or infected. leukocytes and macrophages remove debris |
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proliferatuve phase |
the second phase of full thickness ulcer repair. granulation tissue fills, margins contract and pull together, and is covered with epithelial tissue |
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granulation tissue |
new tissue made during the proliferative phase that is beefy red, shiny granular. the macrophages and fibroblasts stumulate collagen (tensil strength and structure), and blood vessels. Beefy red to pale red bulbs...due to capillary bed formation. |
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maturation phase |
the final phase of full thickness ulcer repair. lasts 21 days-2 years. collagen fibers reorganize, remodel, mature, contracts, increases in tensile strength |
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age, nutrition, medications, tussue perfusion and oxygenation, infection, bacterial imbalance |
systemic factors that affect wound care |
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corticosteroids |
meds that interfere with epidermal regeneration |
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tissue hypoxia |
this condition causes impaired collagen synthesis, decrease epithelial proliferation and migration, and there is reduced tissue resistance to infection |
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osteomyelitis |
a bacterial infection in the bone. a portion of the bone may need to be removed. |
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silent infection |
an infection which shows no normal signs and symptoms of bacterial infection. failure for wounds to thrive |
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contamination, colonization, critical colonization, infection |
bacteria present within a wound can be divided into four distinct categories. |
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antiseptics |
a broad spectrum antimicrobial agent. an end date must be in order. Dakin's, acetic acid, betadine. less than 14 days |
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antibiotics |
antimicrobial agents that target specific bacteria...like laser guide missels. topical, oral, IV. Polysparin and vancomycin |
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oral antibiotics |
used only if infection extends beyond the ulcer margin |
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diabetes mellitus |
patients with this disease have slower healing process, reduced collagen synthesis, impaired wound contraction, delayed epidermal migration, blood sugars must be in control |
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pressure ulcers |
the cost of treating these in the US is approx $8.5 billion. treatmennt for each one can cost from $5,000-$60,000. |
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gravity, pressure, shearing, friction, maceration |
mechanical factors that contribute to pressure ulcers |
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shearing |
friction +pressure. when sliding in a chair...internal tissue goes down, external tissue goes up -->strangulation of tissue, and is easy to occlude |
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maceration |
continued exposure to moisture. this leaves the skin more susceptible to forces of shear pressure and friction |
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epidermal stripping |
removal of epidermis by mechanical forces....ex. tape removal. this is why tape needs to be applied without tension |
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Stage I pressure ulcer |
skin is still intact with non-blanchable redness of a localized area....usually over a bony prominence. may be painful, "mushy", and abnormally warm/cool prepared to adjacent tissue. |
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stage II pressure ulcer |
parital thickness ulcer with loss of dermis as a shallow open ilcer with a red or pink wound bed without slough. or a intact/ruptured serum-filled blister. Present as a shiny/dry shallow ulcer without slough or bruising. no granulation tissue. PINK, PARTIAL, and PAINFUL |
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stage III pressure ulcer |
full thickness tussue loss. subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. slough may be present. may include undermining and tunneling. depth of this stage varies with anatomical position |
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stage IV pressure ulcer |
full thickness tissue loss which exposes bone, tendons, or muscle. slough/eschar may be present. often includes undermining and tunneling. the depth varies by anatomical location |
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deep tissue injury |
purple or maroon localized area of discolored intact or blood-filled blister due to damage of underlying soft tissue from pressure and/or shearing. may be difficult to detect in darker skin tones. these are able to heal without ulceration |
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unstageable |
full thickness tissue loss which the base of the ulcer is covered by slough (yello, tan, gray, green, or brown) and or eschar (tan, brown, black) in the wound bed. until enough sloguh and/or eschar are removed to expose the base of the wound, the true depth, and therefore the true stage. |
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braiden and norton plus |
tools that assess the risk of pressure ulcers and their staging |
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turning and repositioning |
any individual "at risk" should be repositioned at least q 2 hr if consistent with overall patient goals. needs to be at least 30 degrees to safely relieve pressure from that side |
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seating intervention |
weight should be shifted every 15 min. if unable to reposition self, readjust q 1 hr. if pressure ulcer present, no more than 1 hour in a chair....sitting decreases blood flow |
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chronic wound |
wound that has been around longer than 12 weeks. it failed to health orderly. |
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full thickness |
wound resulting in the loss of tisue extending through the dermis into the subcutaneous or deeper tissues |
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wound measurement |
record measurement in cm. always measure LxWxD. measure and document the depth and direction of tunneling and undermining. |
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epithelial tissue |
pink to pale pink, pearly....new cells often look slimey. |
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eschar |
dry, blac, or brown necrotic tissue. |
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slough |
yellow or white, wet, stringy or adherent necrotic tussue. |
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serous |
exudate that is thin, clear, watery, plasma |
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sanguinous |
type of exudate that is bloody, "fresh bleeding" |
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serosanguinous |
type of exudate that is thin, watery, pale red to pink, plasma with RBC's |
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purulent |
type of eudate that is thick, opaque tan, yellow, green or brown color. viscous and stinky |
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none |
when classifying the amount of exudate....this is when the wound is dry, scabbed, and crusted |
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scant |
when classifying the amount of exudate, this is when the wound tissue is moist and has no measurable drainage |
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small |
when classifying the amount of exudate this is when the wound tissues are very moist and cover less than 25% of the bandage. |
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moderate |
when classifying the amount of exudate this is when the wound tissues are wet and 25-75% of the bandage is covered. |
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large or copious |
when classifying the amount of exudate this is when the tissues are filled with fluid, and more than 75% of the bandage are covered |
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defined/undefined, attached/unattached, epiboly |
wound edges |
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epiboly |
edgees of top layer of the epidermis have rolled down to cover lower edge of epidermis, therefore epithelial cells cannot migrate from wound edges |
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tunneling |
a course or pathway that can extend in any direction from the wound resulting in dead space. caused by shearing forces and doesn't need to have 2 openings |
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undermining |
tussue destruction underlying intact skin along the wound margins. caused by shearing |
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induration |
a raised, hardened mass surrounding the tissue |
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erythema, edema, induration, maceration |
tissue surrounding the peri-wound |
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Dr. George Winter |
the an whi in 1962 did tests on pigsand realized that skin heals 2x fasterwhen using MOIST WOUND HEALING |
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selective debridement |
debridement that removes only nonviable tissue |
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non-selective debridement |
debridement that removes viable and non-viable tissue. |
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autolytic debridement |
the body's way of tissue debriding. selective, little or no pain, slow. not recommended for infected wounds....maintain moist wound base. Semi/Occlusice dressings used |
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mechanical debridement |
non-selective, can be painful (whirpool, scrubbing, high pressure irrigation). gauze dressings (dry/moistened) are substandard for optimal wound care. |
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enzymatic debridement |
selective, not harmful to healthy tussue, fast. daily application, prescription product, can be used in combination with other methods. |
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bio-surgical debridement |
second fastest method of debridement. leave in for 48 hours. usually in 2-6 cycles. aka maggot/larval therapy. maggots liquify necrotic tissue and ingest it. |
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alginates |
dressing made of seaweed. rope, sheet, conformable. great for high exudate dressing, without adequate drainage it drys the wound out. requires a 2nd dressing. frequency of dressing change is dependent on the amount of drainage. |
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semi-permeable film |
Tegaderm, Opsite, Polyskin. polyurethane film with adhesive back. use skin sealants to protect skin and increase wear time. Change every 3-7 days. good visual monitoring, permeability to O2 and moisture vapor. water and bacteria barrier. not recommended for sweaty areas or infectedwounds. cautious of skin when removing |
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semi-permeable foam |
allevyn, curafoam, flexzan, polymem. made of polyurethane foam. waterproof outer layers. change q 3 days or as dictacted by drainage. good exudate drainage, good O2 and moisture vapor transmission. decrease pain at wound site. poor wound visualization. can be used on infected wounds. can dehydrate wounds. |
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Hydrogels |
add fluid to the wound. vigilon, intrasite, and carrigauze. 90% water in gel base; sheet, gel, or impregnated gauze. softens eschar, autolyti debridement, moist wound healthing. use every dressing change. PTW, FTW, Stage 2-4, burns. great for dry wounds. good permeability, can fill in dead space, can be used on infected cells. Provides poor bacterial barrier |
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hydrocolloids |
encourage autolytic debridement. duoderm, replicare, restore. hydrophillic colloidal particles in an adhesive compound laminated on to a flexible water resistant outer layer.. prevents oxygen, bacteria, or fluids from getting in, change q 3-7 days. fair-good exudate absorption. requires intact periwound, cannot be used on infected wounds. |
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composites |
combination of 2 or more physically distinct products manufactured as a single dressing. Telpha island, alldress, covaderm. autolytic debridement, allow exchange of moisture vapor. PTW, FTW, min-heavy drainage, clean or necrotic tussue. Require intact periwound, can be expensive. |
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specialty absorptives |
aqacel, exu-dry, combiderm. moist healing, absorb exudate, autolytic debridement. can hold up to 60x their weight in fluid. non-adherent, can use with infected wounds. Not recommended for dry wounds, can be costly. |
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collagens |
dressings that promote collagen growth. contraindicated for tertiary intention wound repair. fibracol, woundres, medfil pads. available as freeze dried sheets, gels, pastes. great for minimal-heavy drainage, non-adherent, used on infected wounds....cannot be used on 3rd degree burns |
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wound fillers |
dressings used to fill dead space. iodoflex, flexigel, multidex powder. available in granules, beads, powders, gels, and pastes. allow moist healing, absorb exudate, autolytic debridement. not recommended for dry wounds, requires secondary dressing |
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cleanse, reassess, skin protectants, keep dressing approx 1-2 in larger than the wound. |
basic dresssing application guidelines |
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diapedesis |
the WBCs capability to squeeze between the epithelial cells during inflammation. |
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regeneration |
replacement of the injured tussue with parenchymal cells of the same type. results in restoration of original structure and physiologic function. epithelial cells of skin, mucus membranes, GI tract, and liver cells. |
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connective tissue repair |
replacement of injured tissue with scar tissue. occurs if these is more extensive damage. |
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reconstructive, maturation |
phases of connective tissue repair |
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reconstructive phase |
fibroblasts proliferate and synthesize collagen and other connective tissue proteins to cover the wound with granulation tissue. collagen formation requires adequate iron, vit C, and O2. epithelial cells grow into the wound from surrounding helathy tissue and slowly move inward over the collagens matrix. wound contracts with the help of myofibroblasts, specialized cells which pull on neighboring cells. a healing ridge is evident. aka the fibroblastic, proliferative, or connective tissue phase |
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maturation phase |
about 2-3 weeks after the initial tissue injury and may take a few years to complete. scat issue is remodeled (protease enzymes), capillaries disappear from the scar, collagen fibers reorganize. scar tissue is not as strong or as elastic as the original tissue. |
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keloid |
excessive scar tissue caused by an imbalance between collagen formation vs. collagen degradation....extends beyond the original wound boundaries. |
