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Skin integrity,CH 48

Chapter 48 on Skin integrity and Wound care

Dehiscence partial or total separation of wound layers.
Abrasion superficial with little bleeding and is considered a partial thickness wound.
Approximated skin or edges are closed and risk for infection is low.
Blanching Occurs when the normal red tones of the light skinned client are absent.
Collagen tough, fibrous protein
Darkly pigmented skin skin that "remains unchanged (does not blanch) when pressure is applied over a bony prominence, irrespective of the cient's race or ethnicity.
Debridement removal of bacteria
Drainage evacuators convenient, portable units that connect to tubular drains laying withing a wound bed and exert a safe, constant, low pressure vacuum to remove and collect drainage.
Evisceration protusion of visceral organs through a wound opening.
Exudate the amount, color, consistency, and odor of wound drainage and is part of the wound assessment.
fistulas abnormal passage between two organs or between an organ and the outside of the body.
friction The force of two surgaces moving across one another, such as mechanical force exerted when skin is dragged across a coarse surface such as bed linens.
Granulation tissue red moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.
Hematoma localized collection of blood underneath the tissues.
Hemorrhage bleeding from a wound site
hemostasis injured blood vessels constrict, and platelets gother to stop bleeding.
pressure ulcer localized injury to the skin and other underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and or friction.
primary intention wound that is closed
secondary intention wound edges are not approximated
Stage I Intact skin with nonblanchable 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.
Stage II Partial-thickness skin loss involoving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage III Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage IV Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound. Often includes undermining and tunneling.
Pressure Intensity Research Study indenified capillary closing pressure as the minimal amount of pressure required to collaspe a capillary.
Pressure Duration Low pressure for a long period of time can cause tissue damage and high pressue for a short period can caues tissue damage.
Tissue Tolerance The ability of tissue to endure pressure depends upon the integrity of the tiessue and supporting structures.
slough stringy substance attached to the wound bed
Abnormal reactive hyperemia Excessive vasodilation, skin is bright pink to red; NO blanching with fingertip pressure; can last 1 HR to 2 WEEKS; Stage I pressure ulcer
Dehiscence Partial or total separation of wound layers
Epithelialization The growth of skin over a wound
Eschar crusty scabbed skin, necrotic
Fibrin A whitish filamentous protein formed by the action of thrombin.
Laceration a wound or irregular tear of the flesh
Normal reactive hyperemia Redness-Localized vasodilation; blanching w/ fingertip pressure; lasts less than 1 hour. NOT considered a pressure ulcer.
puncture a whole or wound caused by a sharp intrament
Purulent thick yellow, green, tan or brown wound drainage
Sanguineous Bright red; indicates active bleeding
Sersanguineous Pale, red, watery: mixture of clear and red fluid.
Serous Clear, watery plasma
Sutures threads or metal used to sew body tissues together.
Tertiary Intention wound left open for several days, then wound edges are approximated
tissue ischemia when tissue is deprived of oxygen
Vacuum Assisted Closure (V.A.C) a device that assists in wound closure by applying localized negative pressue to draw the edges of a wound together.
Wound a disruption of the interity and function of tissues in the body.
Created by: kurtandmelissa4