Term
|
Definition
Skin color varies prom person to person and body part to body part according to race. Skin color is derived from three sources
1- mainly from the brown pigment melanin and
2- also from the yellow orange tones of the pigmented carotene
3- from the red purple tones in the underlying vascular bed. The relative proportion of the shades affects the prevailing color. Skin color is further modified by the thickness of the skin and by the presence of edema |
|
|
Term
|
Definition
Pigmentation – skin color
Vitiligo- Complete absence of melanin
Hypopigmentation – loss of color
Hyperpigmentation-increase in color.
Generalized change suggests systemic illness: pallor, jaundice, cyanosis |
|
|
Term
|
Definition
| Erythema-Redness, usually from irritation or inflammation |
|
|
Term
|
Definition
| Pallor skin color that may appear pale with hypoxia and anemia |
|
|
Term
|
Definition
| Jaundice- a yellowish skin color indicates rising amount of bilirubin in the blood. Jaundice is first noted in the junction at the hard and soft palate in the mouth and in the Sclera. The Scleral yellow of jaundice extends up to the edge of the iris. As levels of Bilirubin rise, jaundice is evident in the skin over the rest of the body. Light or clay colored stools and dark golden urine accompany jaundice in both light and dark skinned people |
|
|
Term
|
Definition
Cyanosis – a bluish mottled color that signifies decreased perfusion; the tissues do not have enough oxygenated blood. Cyanosis indicates hypoxemia and occurs with shock, heart failure, chronic bronchitis, and congenital heart disease.
Other clinical signs such as changes in levels of consciousness and signs of respiraTory distress |
|
|
Term
|
Definition
| Ecchymosis- a purplish patch resulting from extravasation of blood into the skin,>3mm in diameter |
|
|
Term
|
Definition
Moles (Nevus or Nevi)
•A asymmetry-Not regularly round or oval, to have sublation do not look the same.
•B border -irregularity Notching, scalloping, ragged edges, poorly defined margins
•C color- Variation. Areas of brown, tan, black, blue, red, white, or combination
•D diameter-Greater than 6mm
•E evolution and/or elevation- enlargement
Any change in a mole suggests neo-plasma in pigmented nevus.
Mole-A proliferation of melanocytes flat or raise characterized by their symmetry, small size, smooth borders, and single uniform pigmentation. |
|
|
Term
|
Definition
Skin Palpation:
•Temperature/moisture
•Texture
•Edema
• 1 mild pitting
• 2 moderate pitting
• 3 deep pitting
• very deep pitting
•Brawny
Turgor |
|
|
Term
|
Definition
Lesions-Involve the loss of structure or function of normal tissue. Described by their shape, arrangement, and distribution
•Primary-Arise in previously normal skin
•Secondary-Develope from primary lesions ex: Scales, crusts, and fissures. In the acute form of dermatitis, vesicles develop, burst, and ooze, and Crusts for
If any lesions present note:
1. Color
2. Elevation: Flat, raised, or pedunculated.
3. Pattern or shape: The grouping or distinctness of each lesion. Pattern maybe characteristic of a certain disease
4. Size in cm: use ruler
5. Location and distribution on the body: generalized or localized
6. Any exudate: No color and any odor |
|
|
Term
|
Definition
Macule - flat area of color 1mm -1 cm (i.e. freckle)
Papule- Circular elevated area less than 1 cm in size (i.e. pimple, wart)
Nodule-Solid mass, knot like, collection of tissue deeper in skin layer than papule (i.e. fibroma) |
|
|
Term
|
Definition
Wheal
•Swelling, slightly elevated red, uticaria rash, irregular shape (i.e. hive)
Superficial, raised, transient And erythematous;slightly irregular shaped due to Adema |
|
|
Term
|
Definition
Vesicle
•Small, sac-like serous fluid filled (i.e. blister, herpes) |
|
|
Term
|
Definition
Secondary Lesions
•Scale- thickened epidermal cell cells (i.e. psoriasis)
•Ulcer- tissue erosion of eroded area of skin, can be very deep
•Scar- collection of connective tissue after healed wound
•Excoriation- scratch, abrasions, torn skin usually in epidermis |
|
|
Term
|
Definition
Assessment
•Location
•Size in mm or cm
•Color of wound (surrounding skin, layers, base)
•Elevation
•Distribution
•Configuration
•Exudate – color, consistency, amount, odor |
|
|
Term
|
Definition
Hair Inspection
•Color
•Distribution
•Infestations |
|
|
Term
|
Definition
Hair Palpation
•Texture
•Lesions (scalp) |
|
|
Term
|
Definition
•Color-brown linear streaks are abnormal in light-skinned people but not dark skinned people- may indicate melanoma. Cyanosis or marked pallor is also abnormal
•Shape- 160° angle for normal or curved, clubbing nail has 180° angle between cuticle and nail
•Consistency-Smooth and regular, not brittle or splitting. Pitting, transverse grooves, or lines may indicate a nutritional deficiency or accompany acute illness |
|
|
Term
|
Definition
Nail Palpation
•Capillary Refill (blanch test)-Depressed the nail edge to blanch and then release, noting the return of color. Normally color return is instant, or at least within a few seconds in a cold environment. This indicates the status of the peripheral circulation. A sluggish color return takes longer than one or two seconds. Inspect the toenails. Separate toes and note the smooth skin in between. Cyanotic nailbeds or sluggish color return: consider cardiovascular or respiratory dysfunction
•Texture: Nails Thickness is uniform nail firmly adheres to nailbed and nail base is firm to palpation |
|
|
Term
|
Definition
| Approximated – the edges of the primary wound are approximated or lately pulled together. Granulation tissue is not visible, and scarring is usually minimum. |
|
|
Term
|
Definition
Debridement is the removal of material or dead tissue from wound to discourage the growth of microorganisms and to promote wound healing. There are four main types of debridement: surgical, enzymatic, autolytic, and mechanical:
-Surgical debridement Refers to the use of sharp instruments to debride the wound is done during surgery or at the bedside.
-Enzymatic debridement Refers to the process of placing chemical products within the wound to help break down the necrotic debris
-Autolytic debridement Is the process of removing debris and necrotic tissue using the bodies own fluids and cells. Occurs when an occlusive dressing or hydrogel is applied over a wound and left in place while wound exudates, containing endogenous enzymes, buildup. The wound exudate softens the. Nonviable tissue, making it easier to remove, and, in some cases, totally dissolved and debris so that I can be irrigated from the wound during the subsequent dressing change
-Mechanical debridement removes necrotic tissue using mechanical force. Effective in removing the necrotic tissue and debris but it is not selective and likely will remove healthy granulated tissue as well. Example wet-dry-dressing. A wound that is filled with saline moistened gauze. Dressing, allowed to dry, and then removed. Wound debris including the necrotic tissue, Is trapped in the gauze dressing and removed along with the dressing. Removal of the dry dressing is often painful for the patient |
|
|
Term
|
Definition
Dehiscence is a total or partial disruption of wound
Edges. Wound separation, is synonymous with dehiscence, skin has separated but underlining subcutaneous tissue has not parted. As woundedges separate, an increase in drainage usually occurs. Most commonly occurs before collagen formation is complete in high-risk patients. Obesity, poor nutritional status, and increased stress on the incisional area increased the risk of dehiscence. Occur if sutures are staples are removed before wound is healed |
|
|
Term
|
Definition
| Evisceration – protrusion of internal organs through an open wound |
|
|
Term
|
Definition
A fistulas is an abnormal tubelike passageway that forms between two organs or from one organ to the outside of the body. Results of poor wound healing after surgery, or illness.
Name of Fistula designates the site of the abnormal Communication ex:rectovaginal fistula |
|
|
Term
|
Definition
| A full thickness wound extends through the dermis to involve subcutaneous tissue and possibly muscle and bone |
|
|
Term
|
Definition
Granulation tissue – soft, pink, highly vascularized connective tissue formed during wound repair. In full-thickness wound proliferation phase starts with development of GT. Consists of a matrix of collagen and embedded with macrophages, fibroblasts, and capillary beds. As it is produced, it fills The Wound
With connective tissue. Open full thickness wounds undergo contracture and epithelialization during this phase of healing. |
|
|
Term
|
Definition
| A bruise you can feel. A hematoma is a localize collection of blood. It appears as a swelling or mass underneath the skin surface, often with a bluish color. Large hematomas may take weeks to reabsorb, creating dead space and dead cells that inhibits healing. may require a evacuation or surgically removal. |
|
|
Term
|
Definition
Laceration-open wound or cut in the skin; wound edges maybe jagged or smooth; depth may be shallow or deep; object possibly contaminated, infection risk.
-Most affect only the upper layers of skin and subcutaneous you underneath. Permanent damage may result , however, if injury occurs to internal structure such as muscles tendons blood vessels or nerves. |
|
|
Term
|
Definition
| Maceration softening of the skin tissue due to excessive moisture. Tissue appears wrinkled and is lighter in appearance than healthy tissue. Fecal and urinary incontinence increase an individuals risk for maceration. Diaphoresis or inadequate drying after hygiene, especially in the skin folds, can increase moisture and encourage the growth of yeast, leading to rashes |
|
|
Term
|
Definition
| Partial thickness wound Involves the loss of epidermis and possibly partial loss of the dermis |
|
|
Term
|
Definition
| Purulent-drainage contains white cells and microrganisms and occurs when infection is present. It is thick and Opaque and can vary from pale yellow to green or tan, depending on the offending organism . |
|
|
Term
|
Definition
| Sanguinous drainage is bloody, as from an acute laceration |
|
|
Term
|
Definition
| Serous drainage is pale yellow, watery, and like fluid from blisters. |
|
|
Term
|
Definition
| Serosanguineous drainage is pale pink-yellow, thin and contains Plasma and red cells |
|
|
Term
|
Definition
Wounds heal through a systematic four phase process:
Hemostasis, inflammatory phase, proliferative phase, and maturation. This process begins installment of injury and under normal condition is completed and 12 to 24 months. |
|
|
Term
|
Definition
| The first phase in wound healing, hemostasis, begins immediately upon wounding with the onset of vasoconstriction, platelet aggregation, and clot formation. |
|
|
Term
|
Definition
| The second phase of wound healing Inflammation last up to about three days. This phase is marked by vasodilation and phagocytosis as the body works to clean out the Wound to begin the repair process |
|
|
Term
|
Definition
| Proliferation- epithelialization (epithelial cells replicate, cell layers increase, granulation tissue, contracture of wound edges, angiogenesis |
|
|
Term
|
Definition
Maturation (remodeling)- collagen stabilizes wound, scar occurs.
-Maturation is the final stage of full thickness wound healing. It begins about three weeks after injury and may last as long as two years. The number of fibroblast decreases, collagen synthesis stabilizes, and collagen and fibrils become increasingly organized, resulting in greater tensile strength of the wound. Tissue usually reaches max strength in 10 to 12 weeks but Even after full healing only 70 to 80% of the original strength can be expected |
|
|
Term
|
Definition
Types of Wound Healing
•Primary– wounds with minimal tissue loss, heal by primary intention. The edges of the primary Wound are approximated or lightly pulled together. Granulation tissue is not visible, and scarring usually minimal. Ex: clean surgical incision or shallow sutured wounds. Infection risk is lower when they clean surgical wound heals by primary intention.
•Secondary-wounds Wesfall thickness tissue loss such as deep lacerations, burns, and pressure ulcers, have edges that do not readily approximate. They heal by secondary intention. The open wound gradually fills with granulation Tissue. Eventually epithelial cells migrate across the granulation base, completing the cycle. Scarring is more prevalent. Because the wound is open for a longer time, it becomes colonized with microorganisms that may lead to infection.
•Tertiary-Healing by tertiary intention occurs when the delay ensues between injury and wound closure also referred to as delayed primary closure. It may happen when a deep wound is not sutured immediately or is purposefully left open until there is no sign of infection and then closed with sutures. When a wound heals by secondary or tertiary intention, a deeper and wider Scar is common |
|
|
Term
|
Definition
Types of Wounds
•Trauma- accidental,
Surgical. Any trauma to the skin such as a wound, creates a risk for altered function.
•Exposure – burns. Excessive heat, electricity, caustic chemicals, or radiation can result in tissue damage and burns. Degree of damage depends on the type of burn, it's extent and depth, and the patient state of health before the burn.
•Mechanical – pressure, shearing, friction. Forces applied to the skin causing damage
Shear-force occurs when tissue layers move on each other causing blood vessels to stretch as they pass through the subcutaneous tissue. Most commonly, this occurs when patients slide down in bed or are pulled up in bed |
|
|
Term
| Factors effecting wound healing |
|
Definition
Factors Affecting Wound Healing
•Age
•Immune status
•Medications
•Stress
•Lifestyle
•Nutrition and Fluid Status
•Weight
•Type of injury
•Presence of infection
•General state of health, disease processes
-Circulation, oxygenation, immune function, smoking history, obesity, drug therapy, and local factors like the nature and location of the injury, infection, and the type of wound dressing used. |
|
|
Term
| Complications of wound healing |
|
Definition
Complications of Wounds
•Infection
•Hematoma
•Dehiscence
•Evisceration
•Hemorrhage |
|
|
Term
|
Definition
Wound Assessment
•General Appearance – location, size in mm or cm (length, width, depth), shape, signs |
|
|
Term
|
Definition
•Effects of Heat - Vasodilation, increases blood flow, oxygen and nutrients to the area. Creates muscle relaxation and promotes healing. Hastens phagocytosis and removal of waste and decreases inflammation
- promoted wound healing and suppuration, decreases inflammation by accelerating inflammatory process. Decreases musculoskeletal skeletal discomfort
•Uses - many ( muscles spasms, arthritic and menstrual pain, infected wounds)
•Types - Warm soaks, warm compresses, heating pads |
|
|
Term
|
Definition
•Effects of Cold - Vasoconstriction, limits blood flow and nerve conduction to an area
-controls bleeding,deceases Adema, relieves pain
•Uses - many (sprains, fractures, sports injuries, control bleeding |
|
|
Term
| Safety precautions for hot |
|
Definition
•Assess patient prior to application (age, skin, mental status, circulatory status). Note contraindications.
•Follow specific guidelines and procedure for therapy (length of time, frequency of application, temperature, skin protection, equipment use)
•Therapy can cause local and adverse effects .
•Assess client closely throughout therapy.
for adverse effects (macerated skin, burns, freezing) |
|
|
Term
|
Definition
| * Turgor-Normally skin has been elasticity, rapidly returning to its normal shape when pinched between thumb and forefinger this quality is called skin turgor. as person ages skin turgor normally decreased also caused by dehydration |
|
|
Term
|
Definition
| An abrasion results when skin rubs against a hard surface. Friction scrapes away the epithelial later, Exposing the epidermal or dermal layer. Falls on hands knees or elbows cause abrasions. |
|
|
Term
|
Definition
| Puncture-Intentional or unintentional penetrating trauma by sharp pointed instrument that penetrates skin and underlying tissue |
|
|
Term
|
Definition
| Contusion-Closed wound; bleeding in underlying tissues from blunt blow; bruising |
|
|
Term
| Classification of surgical wounds |
|
Definition
Surgical wounds :
-Clean- closed surgical wound that did not enter gastrointestinal, respiratory, or genitorinary systems, low infection risk.
-Clean/contaminated- wound entering gastrointestinal, respiratory or genitourinary systems; infection risk
-Contaminated- open, traumatic wound; surgical wound with break in asepsis; high infection risk.
-Infected- wound site with pathogens present;signs of infection |
|
|
Term
|
Definition
| Stoma- artificially created opening to bowel on the abdominal skin surface |
|
|
Term
|
Definition
| Ostomies are surgical openings in the abdominal wall that allow part of an organ to open onto the skin |
|
|
Term
|
Definition
Pressure ulcer-Is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressuring combination with sheer and/or friction.
-Pressure decreases the blood flow, and impairing supply of nutrients and oxygen to skin and underlying tissues. Cells die and decompose, and ulcer forms. Pressure ulcers usually occur over bony prominences such as coccyx ischial tuberosities, heels, and trochanters.
-Pressure ulcers are classified based on their death of tissue destruction using staging system. -Decreased mobility, decreased activity, and decreased sensory/perceptual ability increase the risk of pressure ulcers.
-Decreased mobility, decreased activity, decreased sensory/perceptual ability increase the risk of pressure ulcers. And individual who cannot move independently or who will be immobilized at an increased risk. Patients with neuropathy or paralysis are at increased risk because unpaired sensation.
-Extrinsic factors that decreased tissue tolerance and increase the likelihood of pressure ulcer development includes moisture, friction, and sheering forces. Other contributing factors are malnutrition, age, and low arteriolar pressure.
-impaired nutritional status increases the risk of pressure ulcer development. Nutritionally to depleted patient's capillaries become more fragile, and as they break, blood flow to the skin can be impaired. Patients who are malnourished may have weight loss, decreased sebum proteins, and reduced immune function. Loss of subQ tissue and muscle mass effect sebum of protective padding between skin and bone and increases the risk of pressure ulcers.
-risk assessment tools are Braden scale and norton scale providing numeric score to rate individual patients level of risk |
|
|
Term
|
Definition
| Epithelialization-Process in which epidermal cells, which appear pink in color, reproduce and migrate across the surface of the partial thickness wound |
|
|
Term
|
Definition
| Contracture can be identified by its effective pulling the want Inlet, into decreasing depth and dimension of the world |
|
|
Term
|
Definition
A dressing is a protective covering placed on a wound to provide an environment to promote wound healing. Type used depends on type of wound, location, status, and personal preference.
-dressings used to:
-absorb drainage
-prevent contamination
-prevent mechanical injury to the wound
-help maintain pressure so that excessive bleeding is avoided
- provide a moist wound environment
-provide comfort for the patient |
|
|
Term
|
Definition
Dressings:
Transparent films-Adhesive semipermeable film dressings.
Foams-Hydrophilic polyurethane used for partial and full thickness wounds with small to moderate drainage; foams provide absorption and protection
Hydrocolloids – hydrophilic colloid particles attached to a backing
Hydrogels – used to encourage granulation within full thickness wounds; to provide comfort in tender, partial thickness wounds; to assistant autolytic debridement of necrotic tissue in full thickness wounds
Alginate- used for absorption; indicated for deep or moderate draining wounds
Collagen- contains collagen, a major protein I. The body used for partial and full- thickness wounds.
Composites- dressings that combine two or more products to facilitate application and use
Contact layers- non adherent dressings that will not stick to wound surface; minimize disruption of cells
Silver dressings- anti microbial dressings used for infected wounds |
|
|
Term
|
Definition
| Undermining- is an area of tissue destruction under the edge of the wound opening. Filling wound including undermining portions allows for healing from base to surface, helping prevent abscess formation. Gauze or absorptive products like calcium align area can be used to fill wound. |
|
|
Term
|
Definition
Seborrhea-oily
Xerosis-dry |
|
|
