Skin Integrity & Wound Care Flashcards
Phase 2 inflammatory
Last 4 to 6 days. WBC cells predominately leukocytes and macrophages, move to the wound. Leukocytes ingest bacteria and cellular debris
Phase 1 hemostasis
Occurs immediately after the initial injury but vessels constrict and blood clotting begins. Through platelet activation and clustering
Stage 3 proliferation phase
Fibroblastic, regenerative, or connective tissue phase. The proliferation phase last for several weeks. New tissue is built to fill wound space
Stage 4 maturation phase
3 weeks after injury could continue for months or years. Collagen in the wound is remodeled making the healing wound stronger
Friction, rubbing or scraping the epidermal layers of skin; top layer skin abraded
Abrasion
A collection of pus in any part of the body that, in most cases, causes swelling and inflammation
Abscess
The passage of blood from ruptures blood vessels into subcutaneous tissue, marked by purple discoloration of the skin (bruising)
Ecchymosis
Redness of the skin
Erythema
Excessive hairiness on women in areas that hair does not normally occur
Hirsutism
A flat, distinct, discolored area of skin that is usually less than 1 cm wide
Macule
Purple colored spots and patches that occur on the skin, and in mucous membranes, including the lining of the mouth
Purpura
A small bump on the skin that contains our produces pus (pimple)
Pustule
Crater like sores on skin or mucous membranes
Ulcer
Are raised, often itchy, red welts on the surface of the skin
Urticaria
A small pocket of fluid within the upper layers of the skin
Vesicle (blister)
Loss of pigment from areas of the skin
Vitiligo
A red, swollen mark left on flesh by a blow or pressure
Wheal
Nutrition and hydration
Protein deficiency leading to a negative nitrogen balance, electrolyte imbalance and insufficient caloric Intake predisposes the skin to injury
A defined area of intact skin with nonblanchable redness
Stage 1 pressure ulcer
Partial thickness loss of dermis
Stage 2 pressure ulcer
Full thickness tissue loss. Subcu fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present
Stage 3 ulcer
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present and often include undermining and tunneling
Stage 4 ulcer
Unstageable
Cannot tell (necrotic tissue)
Assessment of mental status, continence, mobility, activity, nutrition (prevent pressure ulcers)
Braden scale
