46 - Skin integrity/Wound Care Flashcards
Blanching
skin turns lighter colour when pressured then reutrns to normal colour
hyperemia
an excess of blood in the vessels supplying an organ or other part of the body.
Pressure intensity
amount of pressure needed to close capillary, especially susceptibility if reduce sensation and can’t shift to offload pressure, tissue death may occur
Tissue tolerance
ability of tissue to support pressure
Pressure duration
assess amount of pressure and how long the pressure occurs
Shear
force exerted parallel to skin. Skin adheres to surface and muscle/bone slide across the surface
Shear causes DEEP tissue damage, friction causes surface damage
Tissue perfusion
amount of O2 reaching tissue cells (diabetes is a risk factor)
Granulated tissue
red/moist shows that it’s healing
Slough
stringly and yellow/white, attached to wound bed needs to be removed
Eschar
brown/black necrotic tissue, must be removed
Periwound
the whole area outside of the wound, is dry and clean.
raditionally limited to 4 cm outside the wound’s edge but can extend beyond this limit if outward damage to the skin is present
Wound
A disruption of the integrity and function of tissues in the body
Acute
caused by surgical incision. Heal in orderly manner
Chronic
caused by vascular compromise and fail to heal properly
Primary intention
wound that’s closed with sutures/staples, minimal scarring
Secondary intention
wound edges don’t approximate (not pulled together), ex in pressure injury or when tissue is removed. Healed by filling in with scar tissue. Increased risk of injection since its open
Tertiary intention
healing that occurs with wounds being open for several days then later approximated. Does when wound is contaminated/inflammed
Skin tears
popular in elderly pop’s due to thin skin, dehydration, poor nutrition, prolonged corticosteroid use. Avoid using tape with this fragile of skin
Venous and arterial ulcers
- result of poor circulation. Acount for 80% of leg wounds, have large amount of exudate. Due to pooling of blood in extremities. “wooden” like appearance. Dark/shiny. Treatment is compression therapy.
- Arterial ulcer looks like punched out skin
Diabetic ulcer
results from poorly controlled diabetic. Neuropathic changes, debridment and appreciate dressing.
Malignant or fungating wounds
painful have purulent dischange, and don’t heal.
Abrasions
superficial with minimal bleeding, partial thickness wound
Lacerations
jagged and unintentional. Bleed profusely
Puncture
bleed in relation to depth or size
Serous
clear watery plasma
Sanguineous
bright red, indicated active bleeding
Serosanguineous
pale red watery mixture of clear/red fluid
Purulent
thick yellow/green/tan/brown, pus
Hematoma
localized collection of blood underneath tissue
Hemorrhage
bleeding from a wound site
Dehiscence
when layers of skin/tissue begins to separate. People report feeling of something “giving way”
Evisceration
Organs begin to protrude out. This is a medical emergency and needs immediate attention,
Fistulas
abnormal passage between 2 organs or between organ and outside of body.
Irrigation
use saline under pressure to cleanse wound
Debridement
removal of non-viable tissue
Stage I
Intact skin with nonblanchable redness
In stage I, the injury appears as a defined area of persistent redness in lightly pigmented skin and as a darker red, blue, or purple area in darker pigmented skin, with no open skin areas. The skin is warmer or cooler there than in other areas, with a change in consistency and sensation.
Stage II
Partial thickness loss of skin with exposed dermis
A stage II injury is characterized by partial-thickness skin loss involving the epidermis and possibly the dermis.
Stage III
Full-thickness tissue loss with visible fat, rolled wound edges
In stage III, the injury appears as a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia.
Stage IV
Full-thickness tissue loss with exposed bone, muscle, or tendon
In stage IV, the injury is a full-thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.
Unstageable
Full-thickness tissue loss, in which the base of the ulcer is covered by slough or eschar in the wound bed
Suspected deep tissue injury
Discoloured intact skin
