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Skin/Wound Care
| Question | Answer |
|---|---|
| A protein substance that adds strength to a healing wound | Collagen |
| chronic wound caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia in the underlying tissue | Pressure Ulcer |
| to lose color(test of skin integrity of the circulation performed by applying and then relieving pressure) | Blanching |
| Inadequate blood supply to tissue | Tissue Ischemia |
| An oxygen deficiency to the tissues | Tissue hypoxia |
| An area of hardened tissue | Induration |
| Skin flushes bright red when pressure to area is relieved; extra blood rushes to area to compensate for ischemic period | Normal reactive hyperemia |
| When redness does not disappear quickly when pressure to area is relieved; tissue damage has occured | Abnormal reactive hyperemia |
| Black leathery covering comprised of necrotic tissue and plasma proteins | Eschar |
| Removal of devitalized tissue; allows wound to heal and removes the medium for bacterial growth | Debridement |
| Sharp debridement | The use of a sharp instrument to remove devitalized tissue. |
| Mechanical debridement | The use of wet-to-dry dressings, or hydrotherapy to remove devitalized tissue; reserved for wounds with large amount of nonviable tissue. |
| Enzymatic debridement | The application of a topical enzymatic agent to the wound. |
| Autolysis | The use of an occlusive moisture retaining dressing and the body's own mechanisms for ridding itself of necrotic tissue. |
| 5 Risk and Contributing Factors to Pressure Ulcer Development | Time, Pressure, Tolerance, Intrinsic factors, and Extrinsic factors |
| Alters skin characteristics or 02 delivery capablities: nutrition, age, circulation, underlying health status | Intrinsic factors |
| 3 Extrinsic factors | Friction, shearing, and exposure to moisture |
| Mechanical force from dragging across coarse surface | Friction |
| Pressure exerted against skin parallel to body surface; epidermal layer slides over dermis causing damage to vascular bed. | Shearing |
| Macerates the skin and decreases the amount of pressure required to produce ulceration | Moisture |
| Most common sites where pressure ulcers develop | Over bony prominences |
| Primary Intention | minimal tissue loss, approximated edges. (Clean surgical incision) |
| Secondary Intention | Extensive tissue loss, edges not approximated; heals from inner layer to outer layer by granulation. (Pressure ulcer, infected wound) |
| Tertiary Intention | Delayed primary closure, intially healed 2nd intention, then suturing. (Infected surgical wound) |
| 3 Stages of Wound Healing in the order they occur | Inflammatory, Proliferation, Maturation |
| Inflammatory | "Cleansing"--hemostasis and inflammation (takes 1-5 days) |
| Proliferation | "Regeneration"--fill defect and resurface skin; Collagen forms; granulation occurs (after 5-21 days) |
| Maturation | "Epethelialization"--scar tissue forms and wound strengthens. Final phase of healing. (after 2-3 weeks) |
| 5 Types of Wound Drainage | Serous, Sanguineous, Serosanguineous, Purulent, Purosanguineous |
| 5 Prevention factors to reduce formation of pressure ulcers | Skin Care, Nutritional Needs, Frequent positioning and turning q 2 hrs, Obtain health hx, Do a comprehensive Risk Assessment (Braden and Norton scales) |
| Dehiscence | Separation of 1 or more layers of wound (usually abd wound) |
| Evisceration | Total separation of layers of wound with internal viscera protruding through incision. Surgical emergency! |
| Fistula | Abnormal passage connecting two body cavities, usually resulting from infection. |
| Stage 1 Pressure Ulcer | Intact skin with non-blanchable redness of a localized area usually over a bony prominence |
| Stage 2 Pressure Ulcer | Partial thickness loss of dermis presenting as a shallow, open ulcer with a red pink wound bed, without slough. May also be intact, open, or ruptured serum-filled blister |
| Stage 3 Pressure Ulcer | Full thickness tissue loss, Subq fat may be visible but bone, tendon or ms are not exposed. Slough may be present, may include undermining and tunneling |
| Stage 4 Pressure ulcer | Full thickness tissue loss with exposed bone, tendon or ms. Slough or eschar may be present on some parts of wound bed, often include undermining and tunneling. |
| Unstageable | Full thickness tissue loss in which the base of the ulcer is covered by slough or eschar. |
Created by:
lydiapoe90
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