Term
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Definition
any fluid that has exuded out of tissue.
Note the presence of exudate: amount, color, consistency, and odor. Indicate amount of exudate by using part of dressing saturated or in terms of quantity (e.g., scant, moderate, or copious). |
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Definition
| formation of new epithelial tissue |
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Term
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Definition
soft rubber; pulled out in stages as wound heals from inside out
A Penrose drain lies under a dressing; at the time of placement a pin or clip is placed through the drain to prevent it from slipping farther into a wound. |
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Definition
| Bright red: Indicates active bleeding |
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Term
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Definition
partial or total separation of wound or incision edges
Older skin may be at higher risk for dehiscence after sutures are removed because of delayed healing. |
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Term
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Definition
proliferation stage of wound healing
Granulation tissue requires Protection; Support granulation tissue with a moist environment to facilitate healing. |
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Term
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Definition
| procedure to loosen necrotic tissue; Removal of dead tissue decreases risk of bacterial overgrowth and facilitates healing (healing will not take place in the presence of devitalized tissue). |
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Term
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Definition
| Pale, red, watery: Mixture of serous and sanguineous |
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Term
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Definition
| Purulent…thick yellow, green, tan, or brown |
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Term
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Definition
| total separation of wound layers and protrusion of viscera through the wound opening; Notify health care professional immediately! |
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Term
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Definition
(tan, brown, or black) scab or dry crust that results from excoriation of the skin(excoriate: to tear or wear off the skin);
eschar on the heels serves as “the body's natural (biological) cover” and should not be removed. |
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Term
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Definition
| Soft, pink, fleshy projection of tissue that forms during the healing process in a wound not healing by primary intention |
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Term
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Definition
Hemovac or ConstaVac drainage system is used for larger amounts of drainage (as much as 500 mL per 24 hrs)
portable drainage devices that are self-contained suction units that connect to a drainage tube within the wound and provide constant low-pressure suction to remove and collect drainage |
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Term
| Jackson-Pratt (J/P) drain |
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Definition
used for small amounts of drainage (100 to 200 mL per 24 hours)
portable drainage devices that are self-contained suction units that connect to a drainage tube within the wound and provide constant low-pressure suction to remove and collect drainage |
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Term
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Definition
| An overgrowth of scar tissue at the site of skin injury (i.e. wound, surgical site) |
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Term
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Definition
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Term
| Wound Vac or NPWT (negative pressuse wound therapy) |
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Definition
system using negative pressure to remove fluid from area surrounding the wound, reducing edema, and improving circulation to the area.
NPWT assists and accelerates wound healing by removing wound fluids, stimulating granulation tissue, reducing the bacterial burden in the wound, and providing a moist wound environment. |
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Term
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Definition
Skin is intact 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 the surrounding area.
Further description: The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate at-risk persons (a heralding sign of risk). |
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Term
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Definition
Partial-thickness loss of dermis presents as a shallow open ulcer with a red pink wound bed without slough. This stage may also present as an intact or open/ruptured serum-filled blister.
Further description: This stage presents as a shiny or dry shallow ulcer without slough or bruising.* It should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or denudement. |
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Term
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Definition
Stage III is full-thickness tissue loss. Subcutaneous fat may be visible; but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling.
Further description: The depth of a stage III ulcer varies by anatomical location. The bridge of nose, ear, occiput, and malleolus do not have subcutaneous tissue; and stage III ulcers can be shallow. In contrast, areas of significant adipose tissue can develop extremely deep stage III ulcers. Bone or tendon is not visible or directly palpable. |
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Term
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Definition
Stage IV is full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. It often includes undermining and tunneling.
Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. |
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Term
| Unstageable Pressure Ulcer |
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Definition
Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in wound bed.
Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body's natural (biological) cover” and should not be removed. |
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Term
| Preventing Pressure Ulcers |
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Definition
| Nursing Interventions: assessment tool to identify factors that place the patient at risk for skin breakdown, a daily skin inspection, including an examination of pressure points. Braden Scale for Predicting Pressure Sore Risk is also used to determine the patient's risk for pressure ulcer development (p 611) |
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Term
| Braden Scale for Predicting Pressure Sore Risk Categories |
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Definition
Sensory Perception - Ability to respond meaningfully to pressure-related discomfort
Moisture - Degree to which skin is exposed to moisture
Activity - Degree of physical activity
Mobility - Ability to change and control body position
Nutrition - Usual food intake pattern
Friction and Shear - measures patient's ability to move and posotion themselves
Scoring: Very high risk, <9; high risk, 10-12; moderate risk, 13-14; at risk, 15-18; low risk, 19-22; no risk, >23. |
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Term
| Common sites for the development of pressure ulcers include ___ . |
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Definition
| the sacrum, heels, elbows, lateral malleoli, trochanters, and ischial tuberosities |
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Term
| Three pressure-related forces lead to the development of a pressure ulcer; what are they? |
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Definition
| (1) intensity of pressure (how much pressure is applied), (2) duration of pressure (how long the pressure is applied), and (3) tissue tolerance (the ability of skin and its supporting structures to endure pressure without adverse effects). |
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Term
| Three external factors that make the tissues less tolerant to pressure |
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Definition
| shear, friction, and moisture |
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Term
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Definition
| a parallel force that stretches tissue and blood vessels such as when a patient is in a semi-Fowler's position and slides toward the foot of the bed. The skin over the sacrum sticks to the bed sheets, but the bony structure slides down, occluding the blood vessels, causing deep tissue destruction. |
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Term
| Other factors related to pressure ulcer development include ___ . |
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Definition
| poor nutrition; advanced age; medical conditions causing poor tissue perfusion and psychosocial status, in particular stress-induced cortisol secretion |
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Term
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Definition
| used for skin closure of abdominal incisions and orthopedic surgery when appearance of the incision is not critical. |
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Term
| Sutures and staples generally are removed within ___ after surgery if healing is adequate. |
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Definition
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Term
| If any sign of suture line separation is evident during the removal process ... |
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Definition
| the remaining sutures are left in place, and a description is documented and reported to the health care professional. |
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Term
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Definition
used to close a surgical incision both within tissue layers in deep wounds and for the outer skin layer.
Deep sutures are a material that is absorbed or an inert wire that remains indefinitely. Nonabsorbable sutures (those that require removal) are available in silk, cotton, Prolene, wire, nylon, and Dacron. |
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Term
| True or False: Steri-Strips are not removed and are allowed to fall off gradually. |
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Definition
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Term
| Steri-Strips over the incision to provide ___ . |
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Definition
support. They support the wound by distributing tension across it.
Cut Steri-Strips to allow strips to extend 4 to 5 cm ( 1.5 - 2 inches) on each side of the incision. |
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Term
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Definition
a tissue adhesive that forms a strong bond across apposed wound edges, allowing normal healing to occur below. It can be used to replace small sutures for incisional repair.
The wound edges are held together until the solution dries, providing an adhesive closure. |
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Term
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Definition
| Primary, secondary and tertiary intention |
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Term
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Definition
When edges of a clean surgical incision are sutured or stapled together
Tissue loss is minimal or absent |
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Term
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Definition
Wound is left open and allowed to heal by scar formation
Tissue loss and open wound edges |
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Term
| Tertiary Intention (delayed primary intention) |
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Definition
Surgical wounds are left open 3 -5 days
Wound edges are then sutured or stapled
Scarring is minimal |
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