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Skin Integrity/Wound Care
Vocab and Study tips
50
Nursing
Undergraduate 1
09/25/2021

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Cards

Term
Aerobic
Definition
Growing Only in the presence of oxygen
Term
Anaerobic
Definition
Growing only in the absence of oxygen
Term
Approximated
Definition
Closed-Primary intention healing(surgical)
Term
Bandage
Definition
Strip of cloth used to wrap some parts of the body
Term
Binder
Definition
Type of bandage
Term
Collagen
Definition
Whitish protein substance that adds tensile strength to a wound
Term
Compress
Definition
Moist gauze dressing
Term
Debridement
Definition
Removal of necrotic tissue
Term
Dehiscence
Definition
Partial or total rupturing of a sutured wound
Term
Eschar
Definition
Wound covering of dried plasma proteins and dead cells
Term
Evisceration
Definition
Protrusion of internal viscera through an incision
Term
Excoriation
Definition
Area of loss of the superficial layers of the skin
Term
Exudate
Definition
Material such as fluid and cells that have Escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces
Term
Fibrin
Definition
Connective Tissue
Term
Granulation Tissue
Definition
Translucent red tissue that is fragile and bleeds easily
Term
Hematoma
Definition
Blood underneath the skin that appears as a bruise
Term
Hemorrhage
Definition
Massive Bleeding
Term
Hemostasis
Definition
The cessation of bleeding
Term
Immobility
Definition
Reduction in the amount and control of movement a person has
Term
Ischemia
Definition
Deficiency in blood supply to the tissue
Term
Keloid
Definition
Hypertrophic scar
Term
Maceration
Definition
Tissue softened by prolonged wetting or soaking
Term
Phagocytosis
Definition
The ingestion of bacteria and cellular debris
Term
Pressure Ulcers
Definition
Injury to skin and/or tissue usually on bony prominence
Term
Primary Intention Healing
Definition
An approximated surgical site
Term
Purulent exudate
Definition
Thick (pus) leukocytes, debris, dead cells, and living cells
Term
Reactive Hyperemia
Definition
When previously applied pressure is relieved, the skin takes on a bright red flush
Term
Regeneration
Definition
Healing/renewal of tissue
Term
Sanguineous Exudate
Definition
Drainage with large amounts of red blood cells
Term
Secondary Intention Healing
Definition
A wound that is extensive, involves considerable tissue loss and edges can't/shouldn't be approximated.
Term
Serosanguineous
Definition
Contains both red part of blood and clear part of blood (Pink)
Term
Serous Exudate
Definition
Water drainage containing the clear portion of blood
Term
Shearing Force
Definition
Combination of friction and pressure
Term
Suppuration
Definition
Formation of pus
Term
Tertiary Intention
Definition
Wound that is left open to drain and then closed
Term
Vasoconstriction
Definition
Reduces blood flow
Term
Vasodilation
Definition
Allows blood flow
Term
Slough
Definition
Yellowish material in the wound bed
Term
Risk Factors
Definition
-Friction and shearing
-Immobility
-Inadequate Nutrition
-Incontinence
-Chronic medical conditions
-Decrease mental status
-Diminished sensation
-Excessive body heat
-Advanced age
-transferring/equipment
Term

Pressure Ulcer Characteristics:

(Stages)

Definition
  • Stage 1: Epidermis-Non blanchable and Superficial.
  • Stage 2: Dermis-Shallow crater and wet open skin.
  • Stage 3: Subcutaneous Fat-Extends into tissue beneath skin.
  • Stage 4: Bone & Muscle- Very deep extensive damage
  • Unstageable: Can't determine depth due to eschar and slough. 
  • Deep tissue: Maroon/purple intact skin-looks like a blood blister.
Term

What is the Braden Scale?

What's Included? 

Definition

Scale used to determine Mobility. 

Look at Print out.

Term

Types of Wound Healing: 

 

Definition
  • Primary Intention: Approximated Surgical Site that is Clean, dry, and Intact. 
  • Secondary Intention: Pressure ulcers/extensive wounds that are NOT approximate. 
  • Tertiary: Open for period of time to allow for drainage before closure. Takes long time to heal. 
Term

Phases of wound healing: 

(3 phases)

Definition
  • Inflammatory phase: Immediately after injury & lasts 3-6 days. Hemostasis and phagocytosis occurs.
  • Proliferative Phase: Day 3-4 until day 21 post injury. 
  • Maturation phase- Day 21 until 1-2 years after surgery/injury. 
Term
Types of wound Exudate:
Definition
  • Serous: Watery drainage containing clear portion of blood. 
  • Sanguineous: Drainage with large amounts of red blood cells. 
  • Serosanguineous: Contains both red and clear part of blood. (Pink)
  • Purulent: Thick (pus) consists of leukocytes, debris, dead and living bacteria. (Bad Exudate-Infection)
Term
Complications of wound healing:
Definition
  • Hemorrhage or hematoma
  • Infection
  • Dehiscence
  • Evisceration
Term
Factors affecting wound healing:
Definition
  • Nutrition
  • Lifestyle
  • Developmental considerations
  • Medications
Term
Factors inhibiting healing in elderly:
Definition
  • Vascular changes impairing blood flow
  • Collagen tissue less flexible
  • Cell renewal is slower
  • Nutritional deficits
Term
Characteristics of elderly skin Integrity:
Definition
  • Skin dryness
  • Skin pallor
  • Skin fragility 
Term
Lab Data:
Definition

Albumin less than 3.5 equals poor Nutrition.

 

Elevated WBC count equals sign of infection.

Term
Review ADPIE related to Skin Integrity
Definition
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