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57 terms

MTC Nur 101 Skin and Wound care

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approximated wound edges
edges of a wound that are lightly pulled together, epithelialization of wound margins, edges touch, wound is closed
debridement
removal of deviatlized tissue and foreign material from a wound
dehiscence
accidental separation of wound edges, especially a surgical wound
ecchymosis
discoloration of an area resulting from infiltration of blood into the subcutaneous tissue
edema
accumulation of fluid in the interstitial tissues
epithelialization
stage of wound healing in which epithelial cells move across the surface of a wound margin; tissue color ranges from the color of a ground glass to pink
erythema
redness or inflammation of an area as a result of dilaton and congestion of capillaries
eschar
a thick leathery scab or dry crust composed of dead cells and dried plasma
exudate
fluid that accumulates in a wound, may contain serum, cellular debris, bacteria, and white blood cells
granulation tissue
new tissue that is deep pink/red and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal. characterized by irregular surface like raspberries
hypothermia
condition characterized by a body temperature below 96.8
ischemia
insufficient blood supply to a body part due to obstruction of circulation
jaundice
condition characterized by yellowness of the skin, whites of eyes, mucous membranes, and body fluids as a result of deposition of bile pigment resulting from excess bilirubin in the blood
maceration
softening of tissue due to excessive moisture overhydration related to urinary and fecal incontinence, related to moisture, ph changes, and overgrowth of bacteria and infection of the skin and erosion of skin from friction
necrosis
localized tissue death
nonsterile technique
strategies used in patient care to reduce overall number of microorganisms or to prevent or reduce overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one pace to another. Involves meticulous hand washing, maintaining a clean environment by preparing a clean filed, using clean gloves and sterile instruments and preventing direct contamination of materials and supplies
nosocomial infection
infection acquired while receiving healthcare
pathogens
microorganisms that can harm humans
personal protective equipment
equipment and supplies necessary to minimize or prevent exposure to infectious material, including gloves, gowns, masks, and protective eye gear.
pressure ulcer
lesion caused by unrelieved pressure that results in damage to underlying tissue, can be acute or chronic
occur in older adults due to aging skin, chronic illnesses, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness
other at risk groups - spinal cord injuries, traumatic brain injuries, or neuoromuscular disorders

2 mechanisms contribute - external pressure and friction and shearing forces
sinus tract
cavity or channel underneath a wound that has the potential for infection
sterile technique
strategies used in patinet care to reduce exposure to microorganisms and maintain objects and areas as free from microorganism as possible. Involves meticulous hand washing, use of a sterile field, use of sterile gloves for application of a sterile dressing and use of sterile instruments
surgical staples
stainless-steel wire shapled like a staple used to close a surgical wound
surgical sutures
thread or wire used to hold tissue and skin together
tunneling
passageway or opening that may be visible at skin level but with most of the tunnel under the surface of the skin
undermining
areas of tissue destruction underneath intact skin along the margins of a wound; associated with Stage 3 or 4 pressure ulcers
vasoconstriction
narrowing of the lumen of a blood vessel
vasodilation
an increase in the diameter of a blood vessel
wound
disruption in the normal integrity and function of the skin and underlying tissues
figure eight bandage
overlap evenly and by 1/2 to 2/3 the width of the bandage. oblique overlapping turns that ascend and descend alternately. used around the knee, elbow, ankle, and wrist
evisceration
wound completely separates with protrusion of viscera through the incisional area
fistula
abnormal passage from an internal organ to the outside of the body or from one internal organ to another
friction
two surfaces rub against each other resembles an abrasion
NPWT
negative-pressure wound therapy, promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria, and removal of excess wound fluid while providing a moist environment. used to treat acute or chronic, heavy drainage. failing to heal or healing slowly
purulent drainage
white blood cells, liquefied dead tissue debris and both dead and live bacteria. thick with musty or foul odor and varies in color such as dark yellow or green depending on organism.
sanguineous drainage
large numbers of red blood cells and looks like blood, bright-red sanguineous drainage is indicative of fresh bleeding darker indicates older bleeding.
scar
s
serosanguineous drainage
mixture of serum and red blood cells, light pink to blood tinged
serous drainage
clear, serous portion of the blood and from serous membranes, clear and watery
shear
one layer of tissue slides over another layer. spearates skin from udnerlying tissues
integumentary system
made up of skin, subcutaneous layer under the skin and appendages of the skin including glands, blood vessels nerves and sensory organs of the skin. 2 layers epidermis and dermis
functions as - protections, temperature regulation, psychosocial, sensation, vit d production, immunological, absorption, elimination
age -related skin changes
subcutaneous and dermal tissue become thin, sebaceous and sweat gland decreases, cell renewal is shorter delaying healing, melanocytes decline in number, collagen fiber is less organized causing loss of elasticity.
4 stages repair injury
hemostasis - occurs immediately, vessel constriction and blood clotting, exudate occurs with swelling and pain., heat and redness

inflammation - lasts 4-6 days, leukocytes and macrophages move in. the macrophages ingest debris and release growth factors to attract fibroblasts, patient generalized body response with elevated temp, leukocytosis and generalized malaise

proliferation- fibroblastic, regenerative or connective tissue. synthesize and secret collagen and induce blood vessel formation as increasing endothelial cells , granulation tissue forms the foundation for scar tissue

maturation 3 weeks after injury remodeling
first intention
well approximated wound edges, intentional wounds with minimal tissue loss heal this way
secondary intention
not well approximated large, open wounds -burns or major trauma and often contaminated, Infected primary intention wounds heal by secondary takes longer and forms more scar tissue
tertiary intention
left open for several days to allow edema or infection to resolve or exudate to drain and then closed.
desiccation
process of drying up , causes a crust to form over the wound site and delays healing
factors affecting wound healing
local - pressure, desiccation, maceration, trauma, edema, infection, necrosis,

systemic factors - age, circulation and oxygenation, nutritional status, wound condition, medications and health status, immunosuppression,
wound complications
infection, hemorrhage, dehiscence, evisceration,and fistula
risks for pressure ulcer dev
immobility, nutrition and hydration, moisture, dehydration, incontinence, skin hygiene, diabetes, diminished pain, fractures, corticosteroid therapy, immunosuppression, poor circulation, significant obesity or thinness
stages of pressure ulcer
suspected deep-tissue - purple or maroon localized area of dicolored intact kin or blood-filled blister due to damage of underlying soft tissue - painful, mushy, firm, boggy, warmer, or cooler area

Stage I - defined area of intact skin with nonblanchable redness of localized area over a bony prominence

Stage II partial thickness loss of dermis, shallow open ulcer with a red pink wound bed without slough, shiny or dry without bruising., or intact or open rupture serum-filled blister.

Stage III full thickness tissue loss but no bone, tendon, or muscle is exposed. SLough, undermining and tunneling may be present.

Stage IV full thickness loss with exposed bone, tendon, or muscle, slough or eschar present.

Unstageable when covered with slough, and/or eschar.
Braden Scale
pressure ulcer risk scale
19-23 no risk, 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, 9 or lower very high risk
open drainage system
empties into absorptive dressing material, passive drainage, no sutures. steril large safety pin attached to outer portion to prevent drain from slipping back into incised area. Penrose drain.
closed drainage system
drainage tube that may be connected to an electrical suction device or have portable built-in reservoir to maintain constant low suction. Jackson-Pratt tubes and Hemovacs sutured to the skin. prevents microorganisms from entering the wound. accurate measurement of drainage. must be emptied and suction reestablished .
additional wound healing techniques
fibrin sealants, NPWT, growth factors, oxygen therapy, heat and cold therapy, or perhaps surgery.
dry sterile dressing
administer pain meds if appropriate
clean gloves to loosen tape on old dressing, remove and assess of drainage on dressing
remove gloves, inspect wound, use sterile technique, open cleaning solution, apply sterile gloves, clean the wound, dry the wound, apply dressing gauze, second layer, surgical or ABD pad, remove gloves, apply clean gloves, tape dressing in place
saline-moistened dressing
clean gloves, remove dressing, assess dressing, assess the wound, remove gloves and go tot sterile technique, prepare solution for dressing, apply sterile gloves, clean the wound, dry the area, apply skin protectant, fluff and squeeze gauze, pack wound loosely, apply dry sterile gauze pads. apply ABD pad, remove gloves, reglove with clean and tape.