Term
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Definition
| ones in which the surface of the skin or mucous membrane is no longer intact |
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Term
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Definition
| when there is no opening in the skin or mucous membrane, occur more often from blunt trauma or pressure |
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Term
| the three sequential phases of wound repair are |
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Definition
1. inflammation
2. proliferation
3. remodeling
-Inflammatory: first 3 days after trauma; attempts to control bleeding with clot formation; deliver oxygen, WBCs, and nutrients to area via blood
-Proliferative: 3-24 days: replacing lost tissue with connective/granulated tissue; contracting wound edges; resurfacing new epithelial cells
-Maturation/Remodeling: can take more than a year: strengthening collagen scar and restoring normal appearance |
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Term
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Definition
| the physiological defense immediately after tissue injury lasts approximately 2 to 5 days |
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Term
| the three purposes of inflammation are to |
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Definition
1. limit the local damage
2. remove injured cells and debris
3. prepare the wound for healing |
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Term
| the first stages of inflammation is |
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Definition
* immediately following an injury, blood vessels constrict to control blood loss and confine damage
*then blood vessels dilate to deliver platelets that form a loose clot
*the membranes of damaged cells become more permeable, causing release of plasma and chemical substances that transmit a sensation of discomfort |
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Term
| signs and symptoms of inflammation are |
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Definition
| * swelling, redness, warmth, pain and decreased function |
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Term
| second stage of inflammation is when |
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Definition
| leukocytes and macrophages migrate to the site of injury, and the body produces more and more white blood cells to take their place |
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Term
| leukocytes and macrophages are |
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Definition
| types of white blood cells |
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Term
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Definition
| increased production of white blood cells is confirmed and monitored by counting the number and type of white blood cells in a sample of the clients blood |
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Term
| an increase in white blood cells particularly neutrophils and monocytes is suggestive of an |
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Definition
| inflammatory or in some case an infectious process |
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Term
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Definition
| process which neutrophils and monocytes consume pathogens, coagulated blood and cellular debris |
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Term
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Definition
| a clean separation of skin and tissue with smooth even edges |
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Term
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Definition
| a separation of skin and tissue in which the edges are torn and irregular |
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Term
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Definition
| a wound in which the surface layers of skin are scraped away |
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Term
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Definition
| stripping away of large areas of skin and underlying tissue leaving cartilage and bone exposed |
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Term
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Definition
| a shallow crater in which skin or mucous membrane is missing |
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Term
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Definition
| an opening of skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object |
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Term
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Definition
| injury to soft tissue underlying the skin from the force of contact with a hard object, sometimes called a bruise |
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Term
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Definition
| period during which new cells fill and seal a wound, occurs from 2 days to 3 weeks after the inflammatory stage |
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Term
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Definition
| combination of new blood vessels, fibroblasts and epithelial cells, which is bright pink to red, because of the extensive projections of capillaries in the area |
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Term
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Definition
| a tough and inelastic protein substance, produced by fibroblasts causing the adhesive strength of the wound to increase |
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Term
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Definition
| process by which damaged cells recover and re-establish their normal function |
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Term
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Definition
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Term
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Definition
| replacement of damaged cells with fibrous scar tissue |
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Term
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Definition
| period during which the wound undergoes changes and maturation, follows the proliferation stage and may last 6 months to 2 years. During this time the wound contracts and the scar shrinks |
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Term
| the speed of wound repair and extent of scar tissue that forms depends on whether |
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Definition
| the wound heals by first, second or third intention |
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Term
| first intention healing is a |
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Definition
| process in which the wound edges are directly next to each other, only a small scar will form and most surgical procedures that are closely approximated will heal this way |
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Term
| second intention healing is when the |
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Definition
wound edges are widely spread apart, margin of the wound are not in direct contact the granulation tissue needs additional time to extend across the expanse of the wound, a conspicuous scar results
this is the process whereby an open would closes by new tissue formation with subsequent wound contraction and reepithelialization
usually from trauma, ulcers, infeciton
larger amount of exudate
greater inflammatory reaction= more debris
healing and granulations for this takes place from the bottom up, edges inward, more granulation, larger scar |
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Term
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Definition
the wound edges are widely separated and are later brought together with some type of closure material, results in a broad deep scar, to speed healing them may contain drainage devices or be packed with absorbent gauze.
this is a combination of primary and secondary
also called delayed primary intention.
- this wound needs to heal partially with secondary intention, and then is sutured closed.
- usually are infected wouns or contaminated wounds that can not be sutured closed due to the risk for infection.
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Term
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Definition
| adequate blood flow to the injured tissue |
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Term
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Definition
| separation of wound edges |
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Term
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Definition
| wound separation with protrusion of organs |
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Term
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Definition
| the nurse puts sterile dressings moistened with normal saline over the protruding organs and tissue and notifies the physician immediately |
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Term
| the primary goal of surgical or wound healing is to |
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Definition
| reapproximate the tissue to restore its integrity |
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Term
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Definition
| a wound caused by prolonged capillary compression that is sufficient to impair circulation to the skin and underlying tissue. the primary goal in managing pressure ulcers is prevention |
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Term
| transparent dressings are |
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Definition
| clear wound coverings that allow the nurse to view a wound without removing the dressings, commonly used to cover IV sites |
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Term
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Definition
| strips of tapes with eyelets |
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Term
| Hydrocolloid dressings are |
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Definition
| self adhesive opaque air and water occlusive wound coverings, that keeps wounds moist and can be left in place for up to one week, allow at least a one inch margin of healthy tissue around the wound |
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Term
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Definition
| when a wound requires assessment or care and when the dressing becomes loose or saturated with drainage |
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Term
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Definition
| are tubes that provide a means for removing blood and drainage from a wound. they promote wound healing by removing fluid and cellular debris, current trend is to place them so that they exit from a separate location beside the wound. this approach keeps the wound margins approximated and avoids a direct entry site for pathogens |
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Term
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Definition
| flat flexible tubes that provide a pathway for drainage toward the dressing |
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Term
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Definition
| are drains that terminate in a receptacle, closed drains are more efficient because the pull fluid by creating a vacuum or negative pressure |
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Term
| adhesive or steri-strips also known as butterfly strips are used to |
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Definition
| hold a weak incision together temporarily, sometime used for superficial lacerations |
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Term
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Definition
| a type of bandage generally applied to a particular body part sch as the abdomen or breast |
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Term
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Definition
| secure a dressing to the anus or perineum or within the groin |
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Term
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Definition
| the removal of necrotic tissue from the healthy areas of a wound with sterile scissors, forceps, or other instruments. this method is preferred if the wound is infected because it helps the wound to heal quickly and well, it is painful and the wound my bleed afterwards |
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Term
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Definition
Stage I: Intact skin with area of persistent, non blanchable redness; may feel warm/cool to touch. Tissue is swollen and congested with possible discomfort. Blue/purple in darker skin.
Stage II: Partial-thickness skin loss involving epidermis and dermis. Ulcer is visible and superficial and may appear as an abrasion, blister or shallow crater. Edema persists and the ulcer may become infected; possibly with pain and scant drainage.
Stage III: Full-thickness tissue loss; damage/necrosis of subQ tissue. May extend down to, but not through underlying fascia. Appears as a deep crater, no exposed muscle/bone. Drainage/infection are common
Stage IV: Full-thickness tissue loss with destruction, necrosis, or damage to muscle, bone, or supporting structures. May be sinus tracts, deep pockets of infection, tunneling, eschar or slough.
Unstageable: not determinable due to eschar/slough obscuring wound |
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Term
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Definition
| the use of topically applied chemical substance that break down and liquefy wound debris, it is appropriate for uninfected wounds or for clients who cannot tolerate sharp debridement |
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Term
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Definition
| self-dissolution, is painless natural physiologic process that allows the body's enzymes to soften and liquefy and release devitalized tissue. it is used when a wounds is small and free of infection |
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Term
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Definition
| involves physical removement of debris from a deep wound. one application is wet-to-dry dressings. the wound is packed with moist gauze which is removed 4-6 hours later, dead tissue adheres to the meshwork of the gauze and is removed when the dressing is changed |
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Term
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Definition
| therapeutic use of water, in which the body part with the wound is submerged in a whirlpool tank. the agitation of the water which contains an antiseptic, softens the dead tissue. loose debris that remains intact is later removed by sharp debridement |
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Term
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Definition
| technique used for flushing debris, is used when caring for a wound and also for cleaning an area of the body such as the eye, ear and vagina |
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Term
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Definition
| is a procedure for cleansing the vaginal canal sometimes necessary to treat an infection |
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Term
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Definition
| after tonsil removal and ice bags to any small injury in the process of swelling |
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Term
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Definition
| moist warm or cool cloths applied to the skin |
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Term
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Definition
| electrical or heating or cooling devices (k-pad)that contains hollow channels through which heated or cooled distilled water circulates, it is used alone or as a cover over a compress |
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Term
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Definition
| a technique in which a body part is submerged in fluid to provide warmth or apply a medicated solution, lasts 15-20 minutes |
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Term
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Definition
| those preformed for other than hygiene purposes, they help to reduce a high fever or used to apply medicated substances to the skin to treat skin disorders or discomfort |
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Term
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Definition
| reduce swelling and inflammation and promote healing of wounds |
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Term
| pressure ulcers appear over |
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Definition
| bony prominences of the sacrum, hips and heels. if compression reduces the pressure in local capillaries to less than 32 mm Hg for 1-2 hours the cells die from lack of oxygen and nutrition |
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Term
| stage 1 of pressure ulcers |
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Definition
| characterized by redness but skin is still intact |
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Term
| stage II of pressure ulcers |
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Definition
| ulcer is red and accompanied by blistering or a skin tear which may lead to colonization and infection of the wound |
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Term
| stage III of a pressure ulcer |
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Definition
| skin has a shallow crater that extends to sub Q tissue. it may be accompanied by serious drainage or purulent drainage caused by wound infection, it is relatively painless despite the severity of the ulcer |
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Term
| stage IV of a pressure ulcer |
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Definition
| are life threating, the tissue is deeply ulcerated exposing muscle and bone, the dead or infected tissue may produce foul odor. the infection easily spreads through out the body causing fatal systemic infection |
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Term
| prevention of pressure ulcers |
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Definition
1. identify clients with risk factors for pressure ulcers
2. implement measures that reduce conditions under which pressure ulcers are likely to form |
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Term
| the nurse compresses the bulb reservoir and closes the vent when |
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Definition
| emptying a jackson pratt to re-establish negative pressure within the drainage device |
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Term
| the best evidence that a wound is healing is |
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Definition
| when the cavity appears pink |
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Term
| What are the functions of injured skin? |
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Definition
1. Restoration
2. Resurfacing |
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Term
| What are the functions of the dermis in healthy uninjured skin? |
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Definition
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Term
| Normal wound healing of a surgical incision |
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Definition
this type of wound healing;
- incised tissue regain blood supply and begins to bind together
- slight swelling and pinkness to wound is normal
- after 3-4 days connective tissue strengthens, wound, pinkness of wound will decrease
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Term
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Definition
normal result of healing process during inflammatory and proliferative phases
Character by consistency, color and odor:
-Serous: portion of blood that is watery and clear or slightly yellow in appearance
-Sanguineous: serum and RBC; thick and reddish
-Purulent: infection; thick; WBCs, tissue debri and bacteria; may have foul odor and color reflects organism (green=P.aeruginosa) |
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Term
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Definition
- starts on day of incision, and last for 3-5 days after that.
- skin is sutured or stapled, area clots allowing WBCs to move across
- capillary growth will be established here due to the fibrin meshwork
- increases blood flow through vasodilation
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Term
Inflammatory phase
neutrophils |
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Definition
| these are the first leukocytes to arrive, and accumulate within minutes in the would of injury to help pervent invasive infection. they require oxygen to kill bacteria so they depend on blood flow, and deleivering oxygen to the wound |
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Term
inflammatory phase
(macrophages) |
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Definition
the activation of inflammation sends out chemical messages which attact theses to the wound. these long lived cells (weeks) orchestrate the remaining states of wound healing through the release of a variety of polypeptides known as growth factors
Cleaning the area before healing occurs. |
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Term
| inflammatory phase components |
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Definition
- clotting of bleeders(1-5mins)
- increased blood flow(20-30mins)
- increse oxygen in wound
- antibodies released in wound
- increased neutrophils (bacterial killing)
- increased macrophages (provides growth factor)
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Term
| Granulation phase (proliferative) |
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Definition
begins day 2 and last 5 to 3 weeks
- involves three key processes angiogenesis, fibroblast, prolifertion and epithelial cell proliferation
- need good kind of moisture
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Term
Granulation phase
(Angiogenesis) |
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Definition
this is the formation of new blood vessels. can occur easier if the tissues are approximated
secreted by macrophage |
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Term
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Definition
| migrate to the wound from connective tissue. dependent on oxygen and nutritional status of pt |
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Term
| epithelial cell proliferation |
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Definition
| this is epidermal cells divide and migrate across the wound. can travel up to 3cm. dependent on moisture. if exudate or dead tissue is present, cells cannot migrate and proliferate. need to keep wound clean of debris |
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Term
| Maturation/scar phase/remodeling |
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Definition
- this happens about 3 weeks after initial injury
- lasts up to one year or more
- increase in collagen and proliferation of layers of the skin
- strength of wound is increased during this phase
- scar is formed, pale and avascular
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Term
| factor that delay wound healing |
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Definition
these factors do what?
- age, malnutrition, poor circulation, infection, anemia, obesity, stress on wound keeps granulation form occuring, diabetes, smoking
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Term
| complications during wound healing |
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Definition
| hemorrhage- external ro internal, swelling, hematoma, increase size of anatomical part, infection, dehiscence and evisceration |
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Term
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Definition
sugical- usually 4-5 days post op
contaminated or trauma wound- within 2-3 days |
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Term
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Definition
this is partial or complete separation of the outer layer of the wound
possible causes: poor suturing, distention, excessive vomiting, coughing, dehydration, infeciton
treat: reclosure in the OR or leave open and treat wound so it heals by secondary intention, possibly third |
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Term
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Definition
total separationof the layers and protrusino of the internal organs or viscera through the open wound
cause: same as dehiscence
treat: call for help, cover with sterile gauze/towel saturated in normal saline, keep organs moist, do not attempt to reinsert, keep in supine position, VS every 5 mins |
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Term
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Definition
| a traumatic wound occurring principally on the extremities of older adults as a result of friction alone or shearing and friction forces which separate the epidermis from the dermis or both from underlying structure |
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Term
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Definition
| full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray green or brown) in the wound bed. until enough slough or eschar is removed to expose the base |
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Term
| pressure ulcer assessment |
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Definition
assess:
- site, stage, tunneling undermining, slough, exudate, pain, epithelialization, necrotic tissue type, color, edema, maceration
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Term
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Definition
| pink to dark red tissue, usually with granulation tissue |
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Term
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Definition
| slough or soft tissue necrosis, exudate whitish to yellowish to greenish, needs to be cleaned needs method for facilitating exudate out of wound as it is a great medium for bacterial growth |
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Term
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Definition
| tissue necrosis-= eschar, needs debridement, high risk of infection |
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Term
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Definition
-Least contaminated toward most
-Gentle friction
-isotonic solutions are the preferred cleansing agent
-never use the same gauze to cleanse across incision/wound more than once
-irrigation with solution filled syringe help 1inch above the wound may be used |
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Term
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Definition
Woven gauze/sponge: absorbs exudate
Nonadherent: does not adhere to bed
Self-adhesive: temp second skin; ideal for small superficial wounds
Hydrocolliod: occlusive that swells in prescence of exudate; to maintain granulating wound bed up to 5 days
Hydrogel: infected, deep wounds; moist wound bed
Use neg pressure of a wound vacuum-assisted closure if prescribed |
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Term
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Definition
Stage I: pressure relieving devices, such as an air-fluidized bed; pressure
Stage II: Maintain moist healing environment; promote natural healing; analgesics as prescribed
Stage III: Clean and/or debride; administer analgesics/antimicrobials as prescribed
Stage IV: clean and/or debride; perform nonadherent dressing changes every 12 hours; possible skin grafts; analgesics/antimicrobials as prescribed
Unstageable: debride as prescribed until it can be staged |
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