Exam 2 Craven Ch 30 Skin Integrity and Wound Healing

A localized collection of white blood cells and cellular debris (pus) that appears swollen and inflamed

Wound in which skin or mucous membranes are rubbed or scraped away

Lightly pulled together

Large bandages used to support a body part or to hold a dressing in place

• (DTI)
• Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear that is unstageable

Removal of foreign material or dying tissue from a wound

• Surgical debridement: refers to the use of sharp instruments to debride the wound, as done during surgery or at the bedside. Physicians and other providers who specialize in wound care (e.g., WOCNs, nurse practitioners, physical therapists) perform sharp debridement.
• Enzymatic debridement: refers to the process of placing chemical products (e.g., collagenase) within the wound to help break down the necrotic debris.
• Autolytic debridement: is the process of removing debris and necrotic tissue using the body’s own fluids and cells. Autolytic debridement occurs when an occlusive dressing or a hydrogel is applied over a wound and left in place while wound exudates, containing endogenous enzymes, build up. The wound exudate softens the nonviable tissue, making it easier to remove, and, in some cases, totally dissolves debris so that it can be irrigated from the wound during a subsequent dressing change.
• Mechanical debridement: removes necrotic tissue using mechanical force. Although mechanical debridement is effective in removing necrotic tissue and debris, it is nonselective and likely will remove healthy granulating tissue as well. The simplest form of mechanical debridement is the wet-to-dry dressing. A wound bed is filled with saline-moistened gauze dressing, allowed to dry over several hours and then removed. Wound debris, including 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.

Accidental separation of wound edges, especially a surgical wound

An inflammation of the skin

Layer of skin beneath the epidermis; composed of dense connective fibers, blood vessels, nerves, hair follicles, and glands

Process in which the thin, outermost layer of the epidermis (the stratum corneum or horny layer) is continuously shed

Thin, avascular, outermost skin layer

Process in which epidermal cells, which appear pink in color, reproduce and migrate across the surface of the partial-thickness wound

• Protrusion of internal organs through an open wound
• Medical emergency: place patient in supine position and cover the exposed tissue and wound with saline-moistened gauze and a cover dressing to secure

Abnormal tubelike passage between organs or between an organ and the body surface, often as the result of poor wound healing

Occurs when two surfaces rub together

Soft, pink, highly vascularized connective tissue formed during wound repair

Localized accumulation of blood in a body tissue, organ, or space as a result of broken blood vessel

Firmness of skin and subcutaneous tissue when palpated from the surface

Wound caused by tearing of body tissue

Softened tissue due to excessive moisture

• (Medical Adhesive-Related Skin Injury)
• Damage to skin due to reaction to tape or adhesive products or from their improper removal

• (NPWT)
• A wound management system that applies negative pressure to a wound to decrease excess moisture and increase perfusion to the wound bed promoting wound healing; sometimes referred to as vacuum-assisted closure, or VAC

Around the wound edges

Result of the impeding of capillary blood flow to the skin or underlying tissue

drainage contains white cells and microorganisms 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.

Pertaining to or containing blood

Containing serum and blood

Thin, watery, serum-like

Tissue damaging force that occurs when tissue layers move on each other, causing blood vessels in subcutaneous tissue to stretch and become damaged

Underlies the skin; consists primarily of fat and connective tissues that support the skin

A narrow channel or pathway that extends from a wound

Wound edges not attached to wound bed

• hemostasis
• inflammatory phase
• proliferative phase
• maturation

• Vasoconstriction
• Platelet Aggregation
• Clot formation

• vasodilation and phagocytosis
• lasts up to 3 days

• Epithelialization occurs in partial thickness wounds - epidermal cells, which appear pink, reproduce and migrate across the surface of the wound. When epithelial cells have covered the base of the wound, cells continue to replicate, increasing the number of cellular layers in the epidermis to assume the thickness of normal healthy epidermis.
• Granulation tissue develops in full thickness wounds - appears as beefy, red, and granular and consists of a matrix of collagen embedded with macrophages, fibroblasts, and capillary buds.

• final stage of full thickness wounds
• can last up to 2 years
• The number of fibroblasts decreases, collagen synthesis stabilizes, and collagen fibrils become increasingly organized, resulting in greater tensile strength of the wound.
• The tissue usually reaches maximum strength in 10 to 12 weeks, but even after complete healing, only 70% to 80% of the original strength can be expected.

• small spot
• Primary Lesions (May Arise From Previously Normal Skin)
• Circumscribed, Flat, Nonpalpable Changes in Skin Color
• Examples: Freckle, petechia

• larger than macule
• Primary Lesions (May Arise From Previously Normal Skin)
• Circumscribed, Flat, Nonpalpable Changes in Skin Color
• Example: Vitiligo

• up to 0.5 cm
• Primary Lesions (May Arise From Previously Normal Skin)
• Palpable Elevated Solid Masses
• Example: Elevated nevus

• flat, elevated surface larger than 0.5 cm, often formed by the coalescence of papules
• Primary Lesions (May Arise From Previously Normal Skin)
• Palpable Elevated Solid Masses

• larger than 0.5 cm; often deeper and firmer than a papule
• Primary Lesions (May Arise From Previously Normal Skin)
• Palpable Elevated Solid Masses

• large nodule
• Primary Lesions (May Arise From Previously Normal Skin)
• Palpable Elevated Solid Masses

• somewhat irregular, relatively transient, superficial area of localized skin edema.
• Primary Lesions (May Arise From Previously Normal Skin)
• Palpable Elevated Solid Masses
• Examples: Mosquito bite, hive

• up to 0.5 cm; filled with serous fluid
• Primary Lesions (May Arise From Previously Normal Skin)
• Circumscribed Superficial Elevations of the Skin Formed by Free Fluid in a Cavity Within the Skin Layers
• Example: Herpes simplex

• >0.5 cm; filled with serous fluid
• Primary Lesions (May Arise From Previously Normal Skin)
• Circumscribed Superficial Elevations of the Skin Formed by Free Fluid in a Cavity Within the Skin Layers
• Example: Second-degree burn

• filled with pus
• Primary Lesions (May Arise From Previously Normal Skin)
• Circumscribed Superficial Elevations of the Skin Formed by Free Fluid in a Cavity Within the Skin Layers
• Examples: Acne, impetigo

• loss of the superficial epidermis; surface moist but does not bleed
• Secondary Lesions (Result From Changes in Primary Lesions)
• Loss of Skin Surface
• Example: Moist area after the rupture of a vesicle, as in chickenpox

• deeper loss of skin surface; may bleed and scar
• Secondary Lesions (Result From Changes in Primary Lesions)
• Loss of Skin Surface
• Examples: Stasis ulcer of venous insufficiency, syphilitic chancre

• linear crack in the skin
• Secondary Lesions (Result From Changes in Primary Lesions)
• Loss of Skin Surface
• Example: Athlete’s foot

• dried residue of serum, pus, or blood
• Secondary Lesions (Result From Changes in Primary Lesions)
• Material on Skin Surface
• Example: Impetigo

• thin flake of exfoliated epidermis
• Secondary Lesions (Result From Changes in Primary Lesions)
• Material on Skin Surface
• Examples: Dandruff, dry skin, psoriasis

• thickening and roughening of the skin with increased visibility of the normal skin furrows
• Example: Atopic dermatitis

• thinning of the skin with loss of the normal skin furrows; the skin looks shinier and more translucent than normal
• Example: Arterial insufficiency

abrasion or scratch mark; may be linear, as illustrated, or rounded, as in a scratched insect bite

Wounds with minimal tissue loss, such as clean surgical incisions or shallow sutured wounds, heal by primary intention. The edges of the primary wound are approximated or lightly pulled together. Granulation tissue is not visible, and scarring is usually minimal. Infection risk is lower when a clean, surgical wound heals by primary intention.

Wounds with full-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.

Healing by tertiary intention occurs when a delay ensues between injury and wound closure. This type of healing also is referred to as delayed primary closure. It may happen when a deep wound is not sutured immediately or is purposely 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.

Vitamins A, C, and E, protein, arginine, zinc, and water are especially important in wound healing. Carbohydrates, glucose, and fats also play key roles. Fats are essential because they are the building blocks for the cell membranes being formed.

• Immunosuppressive drugs (corticosteroids, chemotherapy, radiation
• Increased age (circulation slows)
• Obesity (adipose is relatively avascular)
• Smoking (functional HGB levels decrease, vasconstriction occurs, tissue oxygenation is impaired, increased platelets which are more adhesive, hypercoaguability can produce thrombi in small vessels)
• Anticoagulants (increase bleeding into the wound)
• Stress (releases catecholamines, causing vasoconstriction and ultimately decreasing blood flow to the wound. Trauma, pain, and acute or chronic illness can cause stress.)

• Intact skin is the body’s first line of defense against trauma and infection.
• Breakdown of the skin’s integrity must be prevented.
• Skin must be adequately hydrated.
• The body’s cells must be adequately nourished.
• Adequate circulation is needed to maintain cells.
• Skin hygiene is necessary.
• Skin sensitivity varies among people and according to their health status.

• Steri-Strips
• staples
• sutures
• cyanoacrylate glue
• binders
• Ace Wraps, Bandages, and Stretch Netting

• Penrose drain: a hollow, fat rubber tube placed directly into the incision or into a stab wound in the incisional area. It allows fluid to drain through capillary action into absorbent dressings. Penrose drains may be advanced or shortened to drain different areas.
• Hemovac: placed into a vascular cavity where blood drainage is expected after surgery (Fig. 30-10). Suction is maintained by compressing a springlike device. When inspecting a Hemovac drain, expect bloody drainage and ensure that it remains in the compressed state. Suction can be interrupted if leaks are present in the system or if the Hemovac has filled with drainage.
• Jackson-Pratt drain: permits drainage to collect in a bulblike device that can be compressed to create gentle suction (see Procedure 30-3). Suction is lost when the bulb is expanded because of too much drainage or a leak in the system.

• Promotes healing and suppuration (consolidation of pus): Mechanism - Results in vasodilation leading to increased blood flow, thus increasing oxygen and nutrients to the area and promoting removal of waste products. Used in - Surgical wounds, infected wounds, hemorrhoids, and episiotomies
• Decreases inflammation by accelerating inflammatory process: Mechanism - Increases capillary wall permeability, increases leukocyte and antibody flow to area, and promotes action of phagocytes. Used in - Phlebitis and intravenous infiltration
• Decreases musculoskeletal discomfort: Mechanism - Increases sensory nerve conduction, promotes muscle relaxation, and decreases viscosity of synovial fluid. Used in - Low back pain, menstrual cramps, contractures, arthritis, and muscle spasms

• Controls bleeding: Mechanism - Results in vasoconstriction, which decreases blood flow, and, in turn, decreases metabolic tissue demands and the supply of oxygen and nutrients. Used in - Fractures, trauma, superficial lacerations, and puncture wounds
• Decreases edema: Mechanism - Decreases capillary permeability; causes vasoconstriction. Used in - Sprains, muscle strains, and sports injuries
• Relieves pain: Mechanism - Decreases nerve conduction velocity; induces numbness or paresthesia. Used in - Arthritis, trauma, and musculoskeletal injuries