Term
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Definition
| The top layer, or outermost portion of the skin. |
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Term
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Definition
| layer of the skin below the epidermis. 2nd layer. |
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Term
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Definition
| underlying layer that anchors the skin layers to the underlying tissue of the body. 3rd layer. |
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Term
| Functions of the skin: Protection |
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Definition
-acts as a barrier to water; microorganisms, and damaging ultraviolet rays of the sun.
-protection against infection.
-injury to underlying tissues and organs is decreased by the intact skin.
-prevents loss of moisture from the surface and underlying structures. |
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Term
| Functions of the skin: Temperature regulation |
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Definition
-The evaporation of perspiration draws heat from the skin.
-Blood vessels in the skin dilate to dissipate heat.
-in cold conditions, blood vessels in the skin constrict to diminish heat loss.
-In cold conditions, contraction of pilomotor muscles cause the hair to stand on end, forming a layer of air on the body for insulation(gooseflesh or goose bumps). |
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Term
| Functions of the skin: Psychosocial |
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Definition
-External appearance is a major contributor to self-esteem.
-Important role in identification and communication. |
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Term
| Functions of the skin: Sensation |
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Definition
-Millions of nerve endings in the skin provide the sense of touch, pain, pressure, and temperature.
-sensory impulses from the skin allow the body to adjust to the environment, in conjunction with the brain and spinal cord. |
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Term
| Functions of the skin: Vitamin D production |
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Definition
| -A precursor for vitamin D is present in the skin, which, in conjunction with ultraviolet rays from the sun, produces vitamin D. |
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Term
| Functions of the skin: Immunological |
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Definition
| -A breach in the surface of the skin triggers immunological responses in the skin. |
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Term
| Functions of the skin: Absorption |
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Definition
| Substances, such as medications, can be absorbed through the skin for local and systemic effect. |
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Term
| Functions of the skin: Elimination |
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Definition
| Water, electrolytes, and nitrogenous wastes are excreted in small amounts in sweat. |
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Term
| What is found in the EPIDERMIS |
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Definition
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Term
| What is found in the DERMIS? |
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Definition
-Sebaceous gland
-Arrector pili muscle
-Eccrine sweat gland
-Nerve
-Hair follicle
-Papilla |
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Term
| What is found in the SUBCUTANEOUS TISSUE? |
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Definition
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Term
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Definition
-Protection
-body temperature regulation
-Psychosocial
-Sensation
-Vitamin D production
-Immunological
-Absorbtion
-Elimination |
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Term
| Factors affecting the skin |
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Definition
-unbroken and healthy skin and mucous membranes defend against harmful agents
-resistance to inury is affected by age, amount of underlying tissue, and illness.
-adequately nourished and hydrated body cells are resistant to injury.
-Adequate circulation is necessary to maintain cell life. |
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Term
| Developmental Considerations (For skin) |
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Definition
-Infant's skin and mucous membranes are easily injured and subject to infection.
-A childs skin becomes increasingly resistant to injury and infection.
-The structure of the skin changes as a person ages.
-The maturation and epidermal cells is prolonged, leading to thin, easily damaged skin. |
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Term
| Causes of skin alterations |
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Definition
-Very thin and very obese people are more susceptible to skin injury.
->Fluid loss during illness causes dehydration.
->Skin appears losse and flabby.
-excessive perpiration during illness predisposes skin to breakdown(keep good hygiene when sick)
-jaundice causes yellowish, itchy skin.
-Diseases of the skin cause lesions that require care. |
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Term
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Definition
| is the result of planned invasive therapy or treatment. These wounds are purposefully created for therapeutic purposes. |
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Term
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Definition
| These wounds occur from unexpected trauma, such as from accidents, forcible injury(gunshot wound or stabbing), and burns. Because wounds occur in an unsterile environment, contamination is likely. Wound edges are usually jagged, multiple traumas are common, and bleeding is uncontrolled. These factors creat a high risk for infection and a longer healing time. |
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Term
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Definition
| Occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal for entry for microorganisms(EX:incisions and abrasions). |
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Term
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Definition
| Result from a blow, force, or strain caused by trauma such as a fall, an assault, or motor vehicle crash. The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur(Ex: ecchymosis and hematomas). |
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Term
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Definition
| Such as surgical uncisions, usually heal within days or weeks. |
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Term
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Definition
| Do not progress through the normal sequence of repair. the healing process is impeded. The wound edges are often not approximated, the risk of infection is increased, and the normal healing time is delayed(pressure ulcers, atrial or venous insufficiency). |
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Term
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Definition
| intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by this method. |
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Term
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Definition
| have edges that are not well approximated. large, open wounds, such as burns,major trauma, which require more tissue replacement and are often contaminated, commonly heal by this method. Form scare tissue. |
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Term
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Definition
| are those wounds left open for several days to allow edema or infection to resolve or exudate to drain, and the are closed. |
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Term
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Definition
| Involved blood vessels contrict and blood clotting begins. |
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Term
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Definition
| Fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells. |
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Term
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Definition
| White blood cells move to wound. |
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Term
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Definition
| Granulation tissue is formed to fill the wound. |
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Term
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Definition
| New tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill in open wound when it starts to heal. |
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Term
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Definition
| Collagen is remodeled forming a scar. |
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Term
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Definition
| is caused by a blunt intrument and may result in bruising or hematoma. |
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Term
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Definition
| is the rubbing or scraping of epidermal layers of skin. |
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Term
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Definition
| is the tearing of skin and tissue with a blunt or irregular instrument. |
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Term
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Definition
| is the tearing of a structure from normal anatomic position. |
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Term
| Principals of wound healing |
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Definition
-intact skin is the first line of defense against microorganisms.
-Surgical asepsis is used in caring for a wound.
-The body respounds systematically to trauma of any of its parts.
-An adequate blood supply is essential for normal body response to injury.
-normal healing is promoted when wound is free of foreign material.
-The extent of damage and the person's state of health affect wound healing
-Response to wound is more effective if proper nutrition is maintained. |
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Term
| Primary Intention Healing |
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Definition
-tissue surfaces closed
-minimal or no tissue loss.
-Formulation of minimal granulation and scarring. |
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Term
| Secondary Intention healing |
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Definition
-extensive tissure loss
-edges cannot be closed
-Repair time longer
-scarring greater
-susceptibility to infection greater. |
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Term
| Tertiary intention healing(delayed primary intention) |
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Definition
-initially left open
-edemal,infection, or exudate resolves.
-then closed.
-needs to be clean and stay clean. |
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Term
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Definition
-hemostasis
-inflammatory
-proliferation
-maturation |
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Term
| What happeneds during Inflammatory phase |
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Definition
-begins at time of injury
-prepares wound for healing
-hemostasis(blood clotting) occurs
-Vascular and cellular phase of inflammation |
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Term
| What happends during Hemostasis |
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Definition
-Occurs immediately after initial injury
-involved blood vessels constrict and blood clotting begins
-Exudate is formed causing swelling and pain
-increased perfusion results in heat and redness
-Platelets stimulate other cells to migrate to the injury to participate in other phases of healing. |
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Term
| What happeneds during inflammatory phase |
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Definition
-follows hemostasis and lasts about 4-6 days.
-WBCs move to the wound
-Macrophages enter wound area and remain for extended period
-They ingest debris and release growth factors that attract fibroblasts to fill in wound.
-Patient has generalized body response. |
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Term
| What happeneds during Proliferation phase |
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Definition
-phase begins within 2-3 days of injury and may last up to 2-3 weeks
-new tissue is built to fill wound space through action of fibroblasts.
-capillaries grow across wound
-a thin layer of epithelial cells forms across wound
-Granulation tissue forms a foundation for scar tissue development. |
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Term
| What happeneds during Maturation phase |
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Definition
-final stage of healing begins about 3 weeks to 6 months after injury
-collagen is remodeled
-new collagen tissue is deposited
-scar becomes a flat, thin, white line. |
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Term
| Factors affecting wound healing: Age |
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Definition
| age-children and healthy adults heal more rapidly. |
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Term
| Factors affecting wound care:circulation and oxygenation |
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Definition
| adequate blood flow is essential |
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Term
| Factors affecting wound care: Nutritional status |
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Definition
| healing requires adequate nutrition |
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Term
| Factors affecting wound care: Wound condition |
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Definition
| specific condition and wound affects healing. |
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Term
| Factors affecting wound care: Health status |
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Definition
| Corticosteroid durgs and postoperative radiation therapy delay healing. |
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Term
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Definition
-infection
-hemorrhage
-dehiscence and evisceration
-fistula formation |
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Term
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Definition
| Is caused by overhydration related to incontinence that causes impaired skin integrity. |
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Term
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Definition
| is dead tissue present in the wound that delays healing. |
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Term
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Definition
| is swelling at a wound site that interferes with blood supply to the area. |
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Term
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Definition
| is the process in which the cells dehydrate and die. |
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Term
| Psychological effects of wounds |
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Definition
-pain
-anxiety
-fear
-change in body image |
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Term
| Factors affecting pressure ulcer development |
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Definition
-aging skin
-chronic illnesses
-immobility
-malnutrition
-fecal and urinary incontinence
-altered level of consciousness
-spinal cord and brain injuries
-neuromuscular disorders |
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Term
| Risk factors for pressure ulcers |
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Definition
-Friction and shearing
-immobility
-Inadequate nutrition
-Fecal and urinary incontinence
-Decreased mental status
-Diminished sensation
-Excessive body heat
-Advanced age
-Chronic mental conditions
-Poor lifting and trasferring techniques
-Incorrect positioning
-Hard support surfaces
-Incorrect application of pressure-relieving devices |
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Term
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Definition
| is the partial or total spearation of wound layers as a result of excessive stress on wound sthat are not healed. |
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Term
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Definition
| protrusion of viscera through an incision. |
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Term
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Definition
| is an abnormal passage from an internal organ to the outside of the body or from one internal organ to another. |
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Term
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Definition
| is a wound with a localized area of tissue necrosis. |
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Term
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Definition
| deficiency of blood in a particular area. |
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Term
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Definition
| occurs when two surfaces rub against each other. |
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Term
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Definition
| Results when one layer of tissue slides over another layer. |
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Term
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Definition
| Is a thick, leathery scab or dry crust that is necrotic(dead tissue) and must be removed before the stage can be determined accurately. |
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Term
| Factors affecting wound healing: Wound condition |
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Definition
| Specific condition of wound affects healing. |
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Term
| Factors affecting wound care: Health status |
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Definition
| Corticosteroid drugs and postoperative radiation therapy delay healing. |
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Term
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Definition
-Infection
-Hemorrhage
-Dehiscence and evisceration
-Fistula formation |
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Term
| Psychological effects of wounds |
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Definition
-Pain
-Anxiety
-Fear
-Change in body image |
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Term
| Factors affecting pressure ulcer development |
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Definition
-aging skin
-chronic illness
-immobility
-malnutrition
-fecal and urinary incontinence
-altered level of consciousness
-spinal cord and brain injuries
-neuromuscular disorders |
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Term
| Risk factors for pressure ulcers |
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Definition
-friction and shearing
-immobility
-inadequate nutrition
-fecal and urinary incontinence
-Decreased mental status
-diminished sensation
-excessive body heat
-advanced age
-chronic mental conditions
-poor lifting and transferring techniques
-incorrect positioning
-hard support surfaces
-incorrect application or pressure-relieving devices |
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Term
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Definition
-Braden scale for predicting pressure sore risk
-Norton's pressure area risk assessment form scale |
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Term
| Mechanisms in pressure ulcer development |
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Definition
-External pressure compressing blood vessels
-Friction or shearing forces tearing or injuring blood vessels |
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Term
| Stages of pressure ulcers: Stage 1 |
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Definition
| nonblanchable erythema of intact skin |
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Term
| stages of pressure ulcers: Stage 2 |
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Definition
| Partial-thickness skin loss |
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Term
| stages of pressure ulcers: Stage 3 |
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Definition
| Full-thickness skin loss; not involving underlying fascia |
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Term
| Stages of pressure ulcers: Stage 4 |
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Definition
| Full-thickness skin loss with extensive destruction |
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Term
| Stages of pressure ulcers: Unstageable |
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Definition
| Base of ulcer covered by slough and or eschar in wound bed. |
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Term
| assessment of pressure ulcers |
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Definition
-location of the ulcer related to a bony prominence
-size of ulcer in centimeters including length(head to toe), with(side to side), and depth
-presence of undermining or sinus tracts
-stage of ulcer
-color of the wound bed
-location of necrosis or eschar
-condition of the wound margins
-integrity of surrounding skin
-clinical signs of infection |
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Term
| assessment of pressure sites |
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Definition
-inspect pressure areas for discoloration and capillary refill or blanche response.
-inspect pressure areas for abrasions and excoriations
-palpate the surface temperature over the pressure area sites.
-palpate bony prominence and dependent body areas for the presence of edema |
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Term
| assessment of laboratory data |
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Definition
-leukocyte count
-hemoglobin level
-blood coagulation studies
-serum protein analysis
->albumin level
-results of wound culture and sensitivities. |
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Term
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Definition
-Risk for impaired skin integrity
-impaired skin integrity
-impaired tissue integrity
-risk for infection
-pain |
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Term
| Goals in planning client care: Risk for impaired skin integrity |
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Definition
-maintain skin integrity
-avoid or reduce risk factors |
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Term
| Goals in planning client care:impaired skin integrity |
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Definition
-Progressive wound healing
-regain intact skin |
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Term
| Goal in planning client care:Client and family education |
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Definition
-Assess and treat existing wound
-Prevention of pressure ulcers |
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Term
| Measures to prevent pressure ulcers |
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Definition
-providing nutrition
-maintaining skin hygiene
-Avoiding skin trauma
-providing supportive devices |
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Term
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Definition
-fluid intake
-protein, vitamins, zinc
-dietary consult
-weight/lab data monitoring |
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Term
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Definition
-mild cleansing agents
-avoid hot water
-Reduce irritants
-moisturizing lotions, skin protection |
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Term
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Definition
-smooth,firm surfaces
-semi-fowler's position
-frequent weight shifts
-exercise and amubulation
-lifting devices
-reposition q 2 hours
-turning schedule |
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Term
| Providing supportive devices |
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Definition
-mattresses
-beds
-wedges,pillows
-miscellaneous devices |
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Term
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Definition
-minimize direct pressure
-schedule and record position changes
-provide devices to reduce pressure areas
-Clean and dress the ulcer using surgical asepsis
-never use alcohol or hydrogen peroxide
-obtain C&S, if infected
-Teach the client
-Provide ROM exercise |
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Term
| Cleaning a pressure ulcer |
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Definition
-clean with each dressing change.
-use careful, gentle motions to minimize trauma
-use 0.9% normal saline solution to irrigate and clean the ulcer.
-report any drainage or necrotic tissue. |
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Term
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Definition
-inspection for sight and smell
-palpation for appearance, drainage, and pain
-sutures, drains or tube, and manifestation of complications. |
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Term
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Definition
-wound is swollen
-wound is deep red in color
-wound feels hot on palpation
-drainage is increased and possibly purulent
-foul odor may be noted
wound edges may be separated with dehiscence present. |
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Term
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Definition
-Material such as fluid and cells that have escaped from blood vessels during inflammatory process
-deposited in tissue or on tissue surface
-3 major types
-serous
-purulent
-sanguineous(hemorrhagic) |
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Term
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Definition
-mostly serum
-watery, clear of cells
-Example: fluid in a blister |
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Term
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Definition
-thicker
-presence of pus
-Color varies with organisms |
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Term
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Definition
-hemorrhagic
-Large number of RBCs
-Indicates severe damage to capillaries |
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Term
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Definition
-Serosanguineous
-Clear and blood-tinged drainage
-Purosanguineous
-Pus and blood |
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Term
| Purposes of wound dressings |
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Definition
-Provide physical, psychological, and aesthetic comfort.
-remove necrotic tissue.
-prevent, eliminate, or control infection.
-absorb drainage.
-maintain a moist wound environment
-protect wound from further injury
-protect skin surrounding wound. |
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Term
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Definition
-Transparent film
-Impregnated inadherent
-Hydrocolloids
-Clear absorbent acrylic
-Hydrogel
-Telfa
-Gauze dressings
-Polyurethane foam
-alginate |
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Term
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Definition
-Retain dressings on wounds
-Bandage hands and feet |
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Term
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Definition
-provide pressue to an area
-improve venous circulation in legs |
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Term
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Definition
-Support large areas of body
-Triangular arms sling; straight abdominal binder |
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Term
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Definition
-roller bandages
-cicular turn
-spiral turn
-figure-of-eight turn
-recurrent-stump bandage |
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Term
| Types of binders:Straight |
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Definition
| Used for chest and abdomen |
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Term
| Types of Binders: T-binder |
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Definition
| Used for rectum, perineum, and groin area |
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Term
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Definition
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Term
| Types of drainage systems |
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Definition
-Open systems
-Penrose drain
-Closed system
-Jackson-pratt drain
-hemovac drain |
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Term
| Color classification of open wounds |
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Definition
R=Red-protect
Y=yellow-protect
B=Black-debride
-Mixed wound-contains components of RY&B wounds |
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Term
| Topics for home care teaching |
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Definition
-supplies
-infection prevention
-wound healing
-appearance of the skin/recent changes
-Activity/mobility
-nutrition
-pain
-elimination |
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Term
| Factors affecting the response to hot and cold treaments |
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Definition
-method and duration of application
-degree of heat and cold applied
-Patient's age and physical condition
-Amount of body surface covered by the application |
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Term
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Definition
-dilates peripheral blood vessels
-increases tissue metabolism
-reduces blood viscosity and increases capillary permeability
-reduces muscle tension
-helps relieve pain |
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Term
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Definition
-constructs peripheral blood vessels
-reduces muscle spasms
-promotes comfort |
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Term
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Definition
-hot water bags or bottles
-electric heating pads
-aquathermia pads
-hot packs
-moist heat
-sitz baths
-warm soaks |
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