Exam 6 - Skin Flashcards
Blanching
To loose color
Collagen
A protein substance that adds strength to a healing wound.
Tissue ischemia
In adequate blood supply to tissue
Tissue hypoxia
An oxygen deficiency to tissue.
Induration
An area of hardened tissue.
Normal reactive hyperemia
Skin flushes bright red when pressure to area is relieved extra blood rushes to area to compensate for ischemic period.
Abnormal reactive hyperemia
When redness does not disappear quickly tissue damage has occurred.
Eschar
Black leathery covering comprised of necrotic tissue and plasma protein
Debridement
Removal of devitilized tissue allows would to heal and removes the medium for bacterial growth.
Most common sites where pressure ulcers occur
Over bony prominences
Primary intention
Minimal tissue loss, approximated edges
Secondary intention
Extensive tissue loss edges not approximated. Heal from inner layer to outer layer by granulation.
Tertiary intention
Delayed primary closure , initially heal 2nd intention , then suturing
Serous
Serum “straw” colored watery in consistency
Sanguineous
“Bloody” see with deep wounds or in highly vascular areas. Bright red = fresh bleeding : darker red = older bleeding
Serosanguineous
Combination of bloody/serous drainage: commonly seen in new wounds “light pink”
Purulent
Thick malodorous , pus, “yellow” in color, filled with WBCs, bacteria, and cellular debris : “infected” wounds.
Purosanaguinous
Pus that is bloody/red tinged. Indicates small vessels in wound have ruptured.
Evisceration
Total separation of layers of wound with internal viscera protruding through the incision rare but surgical emergency. Cover with sterile dressing soaked with NS
Fistula
Abnormal passage connecting 2 body cavities most common sites is GI and GU tracts.
Pressure ulcer wound assessment.
Location
Size
Appearance
Drainage.
Pressure ulcer
Stage 1
Intact skin with non-blanching redness of a localized area usually over a bony prominence
Darkly pigmented skin may not have visible blanching its color may differ from surrounding area
Pressure ulcer
Stage 2
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound without slough
May also present as an intact or ruptured serum-filled blister.
Pressure ulcer
Stage 3
Full thickness tissue loss. Subcutaneous fat may be visible but bone tendon or muscle are not exposed.
Slough may be presented but does not obscure the depth. Of tissue loss
May include undermining and tunneling
Pressure ulcer
Stage 4
Full thickness tissue loss with exposed bone , tendon, or muscle
Slough or eschar may be present on some parts of the wound bed
Often included undermining and tunneling.
