Tissue Integrity Flashcards
closed; with the wounds edges touching ea. other
approximated
inadequate blood flow through the arteries
arterial insufficiency
large blister; as seen with burns
bulla
injury to tissues with skin discoloration from blood seepage just under the skin and without tissue breakage; a bruise
Contusion
spontaneous opening of the edges of a surgical wound with partial or total separation of wound layers
dehiscence
area of loss of superficial layers of the skin
denuded
dehydration of the tissue
desiccation
hemorrhagic spot, or bruise, caused by bleeding under the skin and irregularly formed in a blue or purple or brown patches
ecchymosis
reddening of the skin caused by congestion of the capillaries
erythema
severe form of dehiscence where internal viscera protrudes outside the body
Evisceration
material such as fluid with a high content of protein and cellular debris that has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation
Exudate
any abnormal tube like passage in the body
fistula
localized collection of blood underneath the tissues, appearing as a swelling or mass often characterized by a Bluish discoloration.
-antinflammatory meds can affect hematomas making them worse
hematoma
sharply elevated, progressively enlarging scar that does not fade with time
keloid
cut; torn wound
laceration
softening or dissolution of tissue after lengthy exposure to fluid
maceration
spot or thickening of the skin, not raised above the surface
macule (freckle?)
malignant mole or tumor on the skin with atypical melanocytes (pigment-forming cells) in both the epidermis and the dermis and sometimes the subcutaneous cells
melanoma
small, solid mass that can be detected by touch
nodule
small, circumscribed, solid, elevated skin lesion
papule
condition characterized by various skin manifestations, including hemorrhages into the skin, mucous membranes, internal organs, and other tissues
purpura
pertaining to serum; thin and watery like serum
serous
stagnation (stopping) of the flow of body fluid, most commonly used to describe the impaired flow of blood back to the heart from the peripheral circulation (venous stasis)
Stasis
a canal or passageway within the wound bed
tunneling
An overhanging along the edge of the wound bed creating a sac or pocket
undermining
small blisters that contain liquid
vesicle
smooth, localized, reddened or pale, slightly elevated area on the skin that is either induced via intradermal injection or is typical of allergic reactions
wheal
Edges are well approximated (closed)
typically intentional wounds with minimal tissue damage ie. surgical incisions closed with sutures or staples
Type of Wound Healing
Primary Intention -
Edges are not approximated
Typically large open wounds ie. burns, pressure ulcers
some extensive damage
Type of Wound Healing
Secondary Intention-
Wounds that are left open for several days to allow edema or infection to resolve or exudate to drain; later closed with sutures, staples, etc.
Type of Wound Healing-
Tertiary Intention
Inflammatory Phase
Proliferative Phase
Maturation Phase
Phases of Wound Healing
Lasts 3-6 days after injury Hemostasis occurs (bleeding is ceased) Fibrin begins to form Blood clots arrive to area Scab begins to surface Dead and dying tissue is removed Blood supply increases to area Oxygen and nutrients arrive to area Macrophages arise *Client experiences physical symptoms
Phases of Wound Healing-
Inflammatory Phase
Lasts from day 3 to 4 of injury to up to 21 days
Collagen is produced to strengthen wound
Healing ridge may appear
Capillaries spread wound bed increasing blood supply
Granulation tissue forms
Scab covers wound bed
Phases of Wound Healing-
Proliferative Phase
Starts at day 21 of injury and can last 1 to 2 years
Collagen fibers re-organize themselves into a structure
Wound is remodeled and contracted
Scar strengthens
Possibility a keloid could develop
Phases of Wound Healing-
Maturation Phase
A local collection of blood beneath the skin
Appears as a bruise; Reddish, Blue in color
Swelling may be involved
If really large, can be dangerous
Hematoma
Also called drainage or discharge
Material is made up of fluid and dead phagocytic cells that escape during the inflammatory phase
Three major types of exudate:
Serous
Purulent
Sanguineous
Exudate
clear drainage
serous exudate
bloody drainage
Sanguineous exudate
clear with blood tinged drainage
Serosanguineous Exudate
Pharmacologic therapy:
Could be a variety of treatment options; ointments, antibiotics, analgesics, etc.
Non-pharmacologic therapy:
includes infection prevention, compression bandages, nurtition, VAC therapy, biosurgery, etc
Promoting Healing and Preventing Infection
- Dead tissue must be removed
- The wound must be cleaned and dressed regularly
- Measurements must be taken and documented on a -regular basis
- Frequent skin assessment necessary
- Pain needs to be controlled well
- Support nutrition & hydration
- Maintain mobility
- Promote effective elimination
- Prevent infection
- Educate client
Wound Management
-Dr. orders
-Clean technique until it runs clear
-Least contaminated to most contaminated; usually from top to bottom.
-Lay on side for irrigation
Longest to widest to depth (measurements)
Packing:
mechanical packing; 1 piece huge as possible
using wet to moist-promotes healing
ABD pad; then take three pieces
Cleaning and Packing Wounds
epidermis; surface
dermis; second deeper layer of skin
subcutaneous fatty layer; separate the skin from the underlying tissue
3 layers of skin
Millions of these wear off ea. day by abrasion. When mature b/come dead cells
Kearantinocytes
Form a shield that protects the keratinocytes and the nerve endings in the dermis from damaging effects of ultraviolet light.
This activity probably accounts for the difference in skin color in humans
Melanin
2nd deeper layer of skin; Flexible connective tissue; richly supplied with blood cells, nerve fibers, lymphatic vessels.
-hair follicles, sebaceous glands, sweat glands
Dermis
hypodermis; lies below dermis.
Layer consists of loose connective tissue and stores roughly 1/2 the fat cells in the body.
Insulator and cushion for the body; stores energy in the form of fat.
Subcutaneous Tissue
Utero greasy substance containing sebum and shed cells that covers and protects the fetal skin from amniotic fluid and loss of fluids and electrolytes.
Vernix Caseosa
Observable changes from normal skin structure, may indicate disorder in other systems and organs.
vary in shape, size, color and texture characteristics.
-Macules, patches, papules, nodules, tumors, vesicles, pustles, bullae and wheals.
Skin Lesions
thickening of the skin
lichenification
trauma occurs during therapy. ie. operations, venipunctures, removing tumors
Intentional wounds
accidental. closed or open;
Unintentional
uninfected; minimal inflammation, respiratory, alimentary, genial and urinary tracts aren’t entered. Primarily closed wounds
Clean wounds
surgical wounds in which respiratory, alimentary, genital or urinary tract has been entered. These wounds show no sign of infection.
Clean contaminated wounds
include open, fresh, accidental wounds and surgical wounds that involve a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Shows evidence of inflammation.
Contaminated wounds
wounds containing dead tissue and wounds with evidence of a clinical infection; ie purulent drainage.
Dirty or infected wounds
usually seen shortly after an injury (scene of an accident or ER visit)
Guidelines of treatment:
-control severe bleeding; apply pressure elevate the involved extremity
-prevent infection by flushing abrasion/laceration with normal saline and cover wound with a clean dressing.
-wrap wound tightly
apply ice over wound to control swelling and pain
Untreated Wounds
sharp instrument ie. knife, scalpel; open wound, deep or shallow
Incisional wound
Blow from a blunt instrument; closed wound, bruising
Contusion
Surface scrap, either unintensional or intensional; open wound involving the skin
Abrasion
Tissue torn apart; often from accidents; open wound, edges often jagged
laceration
Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional; open wound
Puncture
penetration of the skin & the underlying tissue usually unintentional, ie bullet or metal fragments; open wound
Penetrating wound
confined to the skin; the dermis and epidermis heal by regenerating
Partial thickness
Involving the dermis, epidermis, subcutaneous tissue and possibly muscle and bone; required connective tissue repair.
Full thickness of the wound by depth
epidermolysis bullosa
blistering
skin thick and scally
ichthyosis
too little melanin is produced
albinism
increased growth of coarse hair on the face and trunk is seen in Cushing syndrome, acromegaly, and ovarian dysfunction.
Hirsutism
Hair loss; maybe related to changes in hormones, chemical or drug treatment, or radiation.
Alopecia
inflammation of the skin caused by direct contact with an allergen or irritant.
- damage to the epidermis and dermis
- red, itch rash, bullae, vesicles, and wheals also could form
Contact dermatitis
cell-mediated or delayed hypersensitivity to a wide variety of allergens.
Allergic contact dermatitis
inflammation of the skin from irritants; it is not a hypersensitivity response. ie chemical, soaps, perfumes, poison plants, ie ivy, Latex
Irritant contact dermatitis
Impaired Skin Integrity r/t contact dermatitis as evidence by pruritus and rash.
Nursing Diagnosis
Area of loss of the superficial layer of the skin aka denuded area
Excoriation
Ischemic lesions of the skin and underlying tissues caused by external pressure that impairs the flow of blood and lymph.
Pressure Ulcers
tissues softened by prolonged wetting and soaking of skin
Maceration
digestive enzymes in feces, gastric tube drainage, urea in urine contribute. The area of loss of the superficial layers of skin aka denuded area
Skin excoriation
Non-blanchable erythema of intact skin. could be painful and different temp.
Use a skin prep, hydrocolloid or transparent dressing
Stage I pressure ulcer
partial-thickness skin loss involving the dermis. Shallow open ulcer. intact or open pus or blood filled blister, shiny or dry without slough.
Treat with Hydrocolloid or Transparent dressing (unless infected)
Stage II pressure ulcer
Full thickness; skin loss involving damage or necrosis of Subcutaneous tissue; bone, tendon and muscle. Not exposed. Deep crater with or without undermining or tunneling of adjacent tissue; slough may be present
Treat with wet to moist gauze, hydrocolloid or proteolytic enzyme
Stage III pressure ulcer
Full-thickness with extensive tissue damage and necrosis. -Muscle, tendon, and bone are exposed and directly palpable. Slough or eschar (black) maybe present. Undermining and tunneling are usually present.
-increased likely of osteomyelitis (infected bone)
Treat with wet to moist gauze or VAC therapy; sometiimes surgery is necessary. NEVER use a transparent or hydrocolloid dressing
Stage IV pressure ulcer
Full-thickness tissue loss with depth completely obscured by slough or eschar in wound bed. Depth cant be determined until slough or eschar are removed.-once removed can be classified as III or IV.
- Slough or eschar covering 50% of wound.
- Stable eschar on the heels serves as a natural biological cover and shouldnot be removed.
- Might need amputation
Unstageable
Intact skin with Purple or Maroon* discoloration or blood-filled blister. Indicates damage of underlying soft tissue from pressure or shear. Thin blister over a dark wound bed possibly or develop think eschar.
Suspected Deep Tissue Injury
dressing that contain wound moisture ie hydrocolloid and clear absorbent acrylic dressings, trap the wound drainage against the eschar.
-bodys own enzymes in the drainage break down the necrotic tissue
Autolytic debridement
alginic acid, an anionic polysaccharide distributed widely in the cell walls of brown algae, where through binding with water forms a viscous gum./gel
-derived from seaweed.
highly absorbent via strong hydrophillic gel formation that minimizes bacteria contaminate. Limits wound secretions
Alginate
Under 18 @ risk for pressure ulcers; sensory perception moisture mobility nutrition friction/shear
Braden Scale 1987
Possible 24 pts 15 or 16 indicators of pressure area risk 1962 activity mobility incontinence addition of meds in 1987
Norton Scale 1962
Explores 9 areas 6 general categories 3 special categories for only high risks general; build/weight for height skin type & assessment sex & age malnutrition screening continence mobility Primary UK 1 to 64
Waterlow Score 1985
blood-tinged drainage seeps (serosanguineous) from wounds healed by
thick grey, fibrinous tissue-converts to dense scar tissue
secondary intention
is the partial or total rupture of a surgical wound. -usually abdominal wound. Layers below also separate. “something has given way”
Dehiscence
Protrusion of the internal viscera through an incision. Obesity Poor nutrition multiple trauma failure of suturing excessive coughing vomiting dehydration all heightens clients risk of 4-5 days post-op
Evisceration
purulent exudate; thicker than serous, lg quantity of cell and necrotic cells; can vary in color depending on bacteria. blue, green, yellow, brown, black; depends on microb.
Pyogenic bacteria.
helps to strengthen the skin to prevent breakdown
skin prep
permeable to air and water vapor so aids in preventing the growth of anaerobic organisms
Hydocolloid (duoderm) dressing
allows oxygen and moisture permeability but prevents moisture and bacteria entry
transparent dressing Tagederm dressing
aids in debridement of necrotic tissue from wound bed no longer practiced; wet to moist perferred
Wet to dry gauze dressing
aid in debridement for infected wounds with dead tissue
Proteolytic enzymes
provides negative pressure environment to help reduce edema, increases blood supply, O2 to area, promotes moist environment, decreases bacterial agents and helps with formation of granulation tissue
Vacuum-assisted closure VAC therapy
when snthetic skin or skin forms a healthy area of the client is removed and placed over the non-healing wound and sutured
skin grafting
COPA
Color of wound bed and drainage
Odor
Consistency of drainage
Amount of drainage
Measurements
Size LxWxDiameter Sterile cotton swab Tunneling/undermining Sterile Cotton Swab Use Clock as a frame of reference
Wound Description
