Upgrade to remove ads
Only $35.99/year

chapter 31 skin integrity and wound care

Terms in this set (67)

bandage
: piece of gauze or other material used to cover a wound
biofilm
a thick grouping of microorganisms
débridement
cleaning away devitalized tissue and foreign matter from a wound
dehiscence
separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound
dermis
layer of the skin below the epidermis
desiccation
: dehydration; the process of being rendered free from moisture
epithelialization
stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of "ground glass" to pink
dressing
protective covering placed over a wound
epidermis
superficial layer of the skin
eschar
a thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur
evisceration
protrusion of viscera through an incision
exudate
fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells
fistula
an abnormal passage from an internal organ to the skin or from one internal organ to another
friction
occurs when two surfaces rub against each other; the resulting injury resembles an abrasion and can also damage superficial blood vessels directly under the skin
granulation tissue
new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal
ischemia
deficiency of blood in a particular area
maceration
softening through liquid; overhydration
necrosis
death of cells and tissue
negative-pressure wound therapy (NPWT)
activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid
pressure ulcer
any lesion caused by unrelieved pressure that results in damage to underlying tissue
purulent drainage
comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria
sanguineous drainage
mixture of serum and red blood cells
scar
mixture of serum and red blood cells
serosanguineous drainage
mixture of serum and red blood cells
serous drainage
composed of clear, serous portion of the blood and from serous membranes
shear
...
sinus tract
a cavity or channel underneath the wound that has the potential for infection
subcutaneous tissue
underlying layer that anchors the skin layers to the underlying tissues of the body
wound
injury that results in a disruption in the normal continuity of a body tissue
integumentary system
Consists of the skin, mucous membranes, hair, and nail
factors affecting skin integrity
-Age
-Mobility status
-Nutrition/hydration
-Sensation level
-Impaired circulation
-Medications
-Moisture
-Fever
-Infection
-Lifestyle
wound
a break or disruption in the normal integrity of the skin and tissues
wound classification
Intentional or unintentional
Open or closed
Acute or chronic
Partial thickness, full thickness, complex
intentional
planned from surgery or invasive therapy, purposely created, controlled
unintentional
accidental
open
intentional / unintentional - skin surface is broken
closed
blow , force, strain, - skin is not broken, soft tissue is damaged
acute
surgical incisions, edges are well approximated
chronic
do not progress through normal sequence of repair, healing time increased, risk of infection, remain in inflammatory phase of healing
wound healing
Process of tissue response to injury where impaired tissues are repaired by physiologic mechanisms that regenerate functioning cells and replace connective tissue cells with scar tissue.
primary intention
Well approximated, minimal tissue loss, and approximated edges
secondary intention
edges not approximated , large wounds
tertiary intention
The wound is purposely left open due to heavy infection or contamination
initially cleaned, debrided and observed
(Tissue Graft, Stage 4 Pressure ulcer with necrotic tissue and infection)
phases of wound healing
hemostasis, inflammatory phase, proliferation phase, maturation phase
hemostasis
immediately after injury, vessels constrict, blood clots begin, after constriction reopen allowing blood into affected area
inflammatory phase
the initial phase of wound healing in which bleeding is reduced as blood vessels in the affected area constrict
proliferation phase
The second phase of wound healing, in which new tissue forms, closing off the wound.
maturation phase
the third phase of wound healing, in which scar tissue forms
factors affecting wound healing
local: pressure, desiccation, maceration, trauma, edema, infection, necrosis
local factors
occurring local to wound
pressure
disrupts blood supply to wound : delays healing
maceration
softening of tissue and breakdown of skin from prolonged moisture
trauma
repeated trauma causes delay
edema
interferes with blood supply
infection
bacteria in wound increases stress on body
excessive bleeding
large clots increase the amount of space that must be filled during healing and interferes with oxygen diffusion to the tissue
necrosis
dead tissue present in wound - slough , moist, yellow stringy tissue,
wound complications
Infection
Hemorrhage
Dehiscence and evisceration
Fistula formation
Dehiscence
Bursting open of a wound, especially a surgical abdominal wound
evisceration
wound separation with protrusion of organs
pressure ulcers
tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period; tissue ischemia that leads to necrosis
factors in pressure ulcer development
1. external pressure - compresses blood vessels & causes friction
2. friction & shear - tear & injure blood vessels
risk for pressure ulcer development
Impaired sensory perception, impaired mobility, alteration in level of consciousness, shear, friction, and moisture, nutrition / hydration , mental status , age
pressure ulcer staging
Stage I: intact skin, change in skin color, temp, stiffness or sensation,
Stage II: partial thickness skin loss that involves epidermis and/or dermis. superficial and presents as an abrasion, blister or shallow crater.
Stage III: full thickness skin loss involving damage or necrosis of subcutaneous tissue that may go down to underlying fascia.
Stage IV: full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures.
psychological effects of wounds and pressure ulcers
emotional as well as physical adaption
pain
anxiety and fear
ADL
changes in body image
Heat and Cold Therapy
-heat causes vasodilation when you want inflammation to begin healing.
-Cold causes vasoconstriction to limit bleeding. Use cold within first 48 hours.
-Must apply heat and cold every 20 minutes
pressure ulcer
wound with a localized area of injury to the skin and/or underlying tissue. Most pressure ulcers develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction.
Sets found in the same folder