Exam 2 Craven Ch 30 Skin Integrity and Wound Healing

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  1. abscess
    A localized collection of white blood cells and cellular debris (pus) that appears swollen and inflamed
  2. abrasion
    Wound in which skin or mucous membranes are rubbed or scraped away
  3. approximated
    Lightly pulled together
  4. binders
    Large bandages used to support a body part or to hold a dressing in place
  5. deep tissue injury
    • (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
  6. debridement
    Removal of foreign material or dying tissue from a wound
  7. Types of debridement
    • 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.
  8. dehiscence
    Accidental separation of wound edges, especially a surgical wound
  9. dermatitis
    An inflammation of the skin
  10. dermis
    Layer of skin beneath the epidermis; composed of dense connective fibers, blood vessels, nerves, hair follicles, and glands
  11. desquamation
    Process in which the thin, outermost layer of the epidermis (the stratum corneum or horny layer) is continuously shed
  12. epidermis
    Thin, avascular, outermost skin layer
  13. epithelialization
    Process in which epidermal cells, which appear pink in color, reproduce and migrate across the surface of the partial-thickness wound
  14. evisceration
    • 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
  15. fistula
    Abnormal tubelike passage between organs or between an organ and the body surface, often as the result of poor wound healing
  16. friction
    Occurs when two surfaces rub together
  17. granulation tissue
    Soft, pink, highly vascularized connective tissue formed during wound repair
  18. hematoma
    Localized accumulation of blood in a body tissue, organ, or space as a result of broken blood vessel
  19. incision
  20. induration
    Firmness of skin and subcutaneous tissue when palpated from the surface
  21. laceration
    Wound caused by tearing of body tissue
  22. macerated
    Softened tissue due to excessive moisture
  23. MARSI
    • (Medical Adhesive-Related Skin Injury)
    • Damage to skin due to reaction to tape or adhesive products or from their improper removal
  24. necrotizing fasciitis
  25. negative-pressure wound therapy
    • (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
  26. periwound
    Around the wound edges
  27. pressure ulcer
    Result of the impeding of capillary blood flow to the skin or underlying tissue
  28. purulent
    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.
  29. sanguineous
    Pertaining to or containing blood
  30. serosanguineous
    Containing serum and blood
  31. serous
    Thin, watery, serum-like
  32. shear
    Tissue damaging force that occurs when tissue layers move on each other, causing blood vessels in subcutaneous tissue to stretch and become damaged
  33. subcutaneous tissue
    Underlies the skin; consists primarily of fat and connective tissues that support the skin
  34. tunneling
    A narrow channel or pathway that extends from a wound
  35. undermining
    Wound edges not attached to wound bed
  36. What are the Four Phases of Wound Healing?
    • hemostasis
    • inflammatory phase
    • proliferative phase
    • maturation
  37. What happens during hemostasis?
    • Vasoconstriction
    • Platelet Aggregation
    • Clot formation
  38. What happens during the inflammatory phase?
    • vasodilation and phagocytosis
    • lasts up to 3 days
  39. What happens during the proliferative phase?
    • 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.
  40. What happens during the maturation phase?
    • 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.
  41. Macule
    • small spot
    • Primary Lesions (May Arise From Previously Normal Skin)
    • Circumscribed, Flat, Nonpalpable Changes in Skin Color
    • Examples: Freckle, petechia
  42. Patch
    • larger than macule
    • Primary Lesions (May Arise From Previously Normal Skin)
    • Circumscribed, Flat, Nonpalpable Changes in Skin Color
    • Example: Vitiligo
  43. Papule
    • up to 0.5 cm
    • Primary Lesions (May Arise From Previously Normal Skin)
    • Palpable Elevated Solid Masses
    • Example: Elevated nevus
  44. Plaque
    • 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
  45. Nodule
    • larger than 0.5 cm; often deeper and firmer than a papule
    • Primary Lesions (May Arise From Previously Normal Skin)
    • Palpable Elevated Solid Masses
  46. Tumor
    • large nodule
    • Primary Lesions (May Arise From Previously Normal Skin)
    • Palpable Elevated Solid Masses
  47. Wheal
    • 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
  48. Vesicle
    • 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
  49. Bulla
    • >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
  50. Pustule
    • 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
  51. Erosion
    • 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
  52. Ulcer
    • 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
  53. Fissure
    • linear crack in the skin
    • Secondary Lesions (Result From Changes in Primary Lesions)
    • Loss of Skin Surface
    • Example: Athlete’s foot
  54. Crust
    • dried residue of serum, pus, or blood
    • Secondary Lesions (Result From Changes in Primary Lesions)
    • Material on Skin Surface
    • Example: Impetigo
  55. Scale
    • thin flake of exfoliated epidermis
    • Secondary Lesions (Result From Changes in Primary Lesions)
    • Material on Skin Surface
    • Examples: Dandruff, dry skin, psoriasis
  56. Lichenification
    • thickening and roughening of the skin with increased visibility of the normal skin furrows
    • Example: Atopic dermatitis
  57. Atrophy
    • thinning of the skin with loss of the normal skin furrows; the skin looks shinier and more translucent than normal
    • Example: Arterial insufficiency
  58. Excoriation
    abrasion or scratch mark; may be linear, as illustrated, or rounded, as in a scratched insect bite
  59. Primary Intention
    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.
  60. Secondary 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.
  61. Tertiary Intention
    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.
  62. Nutrients important for wound healing
    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.
  63. What can inhibit wound healing?
    • 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.)
  64. Principles of Skin Care
    • 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.
  65. Types of wound support
    • Steri-Strips
    • staples
    • sutures
    • cyanoacrylate glue
    • binders
    • Ace Wraps, Bandages, and Stretch Netting
  66. Types of drains
    • 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.
  67. Effects of heat application
    • 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
  68. Effects of cold application
    • 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

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Pandora320
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335183
Filename:
Exam 2 Craven Ch 30 Skin Integrity and Wound Healing
Updated:
2017-10-19 01:34:19
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BCC ADN NUR 101
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Exam 2 Terms from Craven Ch 30
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