UNIT 3 - Ch. 32 Wound and Skin Care Flashcards
Define epidermis
Outer layer of the skin
Define dermis
Tissue below the epidermis
Define subcutaneous layer
Tissue below the dermis
Define wounds
Disruption / injury to the skin
Define Infection
Contamination in the wound
Define open wound
Characterized by an actual break in the skin’s surface
Define closed wound
Skin is still intact, as in a bruise
Define superficial wound
Involves only the epidermis
Define full-thickness wound
Deepest wound, which extends through the dermis to the subcutaneous layer and may extend farther to the muscle, bone, or underlying structures
Define clean wound
There is no infection and the risk for development of an infection is low
Define partial-thickness wound
Involves the epidermis and the dermis but does not extend through the dermis to the subcutaneous layer
Define infected wound
A wound showing clinical signs of infection including redness, warmth, and increased drainage that may or may not be purulent (contain pus)
Define serous drainage
Contains clear, watery fluid from plasma. Straw colored
Define sanguinous drainage
Drainage usually indicating bleeding and is bright red
Define Serosanguinous drainage
Drainage is pink to pale red and contains a mix of serous fluid and red, bloody fluid
Define purulent drainage
Drainage is usually thick and indicates infection. It can be yellow, greenish, or beige. It contains pus
Define primary intention in wound healing
Edges are close to each other. Wound heals quickly with little scarring or infection
Define secondary intention in wound healing
It is an open wound and tissue loss is present. New tissue is filling the space. Risk of infection is high. Wound is deep
Define Tertiary intention in wound healing
Delay in healing. (Ex: surgical wound that became infected) Must go through same process as secondary intention but may take longer.
Define acute wound
Wound that progresses through phases of wound healing in a rapid, uncomplicated manner
Define chronic wound
Fails to heal in a timely manner. Remaining open for extended period of time.
Define inflammatory phase of healing
Begins with the body’s initial response to wounding of the skin; lasts about 3 days
Define proliferative phase of healing
Purposes of this phase are to repair and defect; fill the wound bed with granulation tissue and resurface the wound with skin
Define remodeling phase of healing
Granulation tissue continues to be deposited and remodeled; scar tissue is formed and strengthens. (Can last up to a year)
Define scar tissue
An avascular mass of collagen that gives strength to the repaired wound
Define pressure ulcers
Localized injury to the skin and or underlying tissue usually over a bony prominence; caused by combination of pressure, shear, and friction
Define friction
The rubbing together of two surfaces: In the case of patients, it is the skin and the bed
Define shearing forces
Unaligned forces pushing one part of a body in one direction, and another part of the body in the opposite direction: In the case of patients, it is when the skin sticks to the surface while the body’s weight continues to pull the body downward.
List intrinsic risk factors for pressure ulcers
Examples:
-Poor nutrition
-edema
-Poor O2 delivery
-Incontinence
-infection
List extrinsic risk factors leading to pressure ulcers
Examples:
-Moisture
-Friction
-Shear
What 6 factors does the Braden scale assess for?
- Sensory/Mental
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/Shear
Describe a stage I pressure ulcer
Characterized by intact, non-blistered skin with non-blanchable erythema or persistent redness in an area that has been exposed to pressure
Describe stage III pressure ulcer
Full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. Undermining and Tunnel may be present
Define undermining
An area of tissue loss present under intact skin, usually along the edges of the wound forming a “lip” around the wound
Define Tunnel
While similar to undermining, it is a narrower passageway extending outward from the edge of the wound
Describe stage II pressure ulcer
Partial-thickness wound that involves the epidermis and or dermis but does not extend below the level of the dermis.
-Shallow and superficial with a pink wound bed
-Intact or ruptured blisters due to pressure are also stage II ulcers
Describe stage IV pressure ulcers
This wound is deeper then a stage III and involves exposure of muscle, bone, or connective tissue like tendons or cartilage.
-The depth of the wound, particularly if the bone is palpable, makes osteomyelitis likely
Define osteomyelitis
An infection of the bone
Define eschar
-Nectrotic tissue (dead tissue).
-Dry dark scab or falling away of dead skin
Describe unstageable pressure ulcer
-Full-thickness wound with eschar
-Involvement of underlying structures
- Wound bed makes it impossible to assess depth of the wound until necrotic tissue is removed
Define Suspected deep tissue injury
An area of intact skin that is purple/maroon, or a blood-filled blister
Describe a suspected deep tissue injury
-Appears as stage I ulcers
-True depth of tissue damage is not apparent
-Injuries can progress rapidly, exposing deeper layers of tissue
-Can be difficult to identify in darker skinned people
Define dermatitis
Inflammation of the skin
Describe stasis dermatitis
Stasis dermatitis is caused by poor circulation and blood flow of the legs
Very common type of dermatitis.
Signs:
Thickened, reddish skin on ankles or shins, itching, open sores with oozing or crusting
Define necrotizing fasciitis
Flesh-eating strep. Extreme emergency!!
List out REEDA
Acronym for assessing any wound
Redness
Edema (swelling)
Ecchymosis (bruise)
Drainage
Approximation
-Warmth
-Pain
Define contamination
The presence of microorganisms in the wound
Define colonization
Microorganisms begin to increase in number but are causing no harm
Define critical colonization
The bacteria begin to overwhelm the body’s defenses. May notice an increase in drainage, odor, color
Define Ecchymosis in “REEDA”
a discoloration of the skin resulting from bleeding underneath, typically caused by bruising
Describe what the nurse is looking for in Approximation in “REEDA”
Looking to see if the wound is starting to close
Define a dehiserated wound (idk how to spell it lol)
you can see tissues pushing out of wound
Define an eviscerated wound
you can see the organs pushing out of wound
