Term
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Definition
| Any lesion caused by unrelieved pressure. |
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Term
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Definition
| Deficiency in blood supply to the tissue; unrelieved pressure without oxygenation. |
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Term
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Definition
| Bright red flush once pressure has been relieved. |
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Term
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Definition
| Cause for the bright red flush of reactive hyperemia; body is trying to get circulation restored to the area. |
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Term
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Definition
Risk Factor for Pressure Ulcer
Sheets rubbing against the skin |
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Term
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Definition
Risk Factor for Pressure Ulcer
Friction + Pressure (can occur when a patient is improperly re-positioned; use a draw sheet to help prevent) |
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Term
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Definition
Risk Factor for Pressure Ulcer
Body needs protein |
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Term
| Fecal/Urinary Incontinence |
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Definition
Risk Factor for Pressure Ulcer
The enzymes in feces and urea/excess moisture in urine can be caustic to the skin and lead to breakdown as well. |
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Term
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Definition
Risk Factor for Pressure Ulcer
Those with a reduced level of awareness, unconscious, heavily sedated or dementia patients are at risk because they are not always able to recognize and respond to the pain of prolonged pressure. |
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Term
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Definition
Risk Factor for Pressure Ulcer
Loss of sensation reduces a person's ability to respond to feelings associated with prolonged pressure. |
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Term
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Definition
Risk Factor for Pressure Ulcer
Elevated body temp increases the metabolic rate which increases the cells' need for O2. This need is more severe in cells under pressure because they are already O2 deficient. |
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Term
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Definition
Risk Factor for Pressure Ulcer
Changes in skin and its supporting structures make older people more prone to impaired skin integrity. |
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Term
| Chronic Medical Conditions |
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Definition
Risk Factor for Pressure Ulcer
Diabetes, Cardiovascular disease are examples of medical conditions that already compromise oxygen delivery to the tissues. |
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Term
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Definition
Risk Factor for Pressure Ulcer
Level less than 3.5: Risk
Level less than 2: HIGH RISK |
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Term
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Definition
| Tissue softened by prolonged wetting or soaking. |
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Term
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Definition
| Area of loss of the superficial layers of the skin. Also known as "denuded" area. |
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Term
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Definition
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Term
| Stage II (Pressure Ulcer) |
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Definition
| Loss of initial layer(s) epidermic and/or dermis; blister; partial-thickness skin loss. |
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Term
| Stage III (Pressure Ulcer) |
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Definition
| Full-thickness skin loss; into the subcutaneous tissue/fatty tissue. |
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Term
| Stage IV (Pressure Ulcer) |
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Definition
| Full-thickness skinn loss with damage to muscle, bone or supporting tissues. |
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Term
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Definition
| Heels, Sacrum, Elbows, Scapulae, Occipital bone, Ear |
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Term
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Definition
| Confined to the skin, that is, the dermis and epidermis; heal by regeneration. |
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Term
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Definition
| Involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone; require connective tissue repair. |
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Term
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Definition
<18 ( 17 or below ) Patient is at risk for skin breakdown
* Turn q2h
*Follow a pattern with the turning
*Provide adequate nutrition
*Assess every single time you turn
*Use special beds, mattresses, devices as indicated |
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Term
| Primary Intention Healing |
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Definition
| Tissue surfaces have been approximated (brought together/closed) and there is minimal tissue loss. |
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Term
| Secondary Intention Healing |
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Definition
| Extensive wound, involves considerable tissue damage, and edges cannot or should not be approximated. |
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Term
| Tertiary Intention Healing |
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Definition
| Wounds that are left open for 3-5 days to allow edema or infection to resolve or exudate to drain; prolonged healing. |
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Term
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Definition
Inflammatory
Proliferative
Maturation |
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Term
| Inflammatory Phase of Wound Healing |
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Definition
Starts immediately after injury, last 3-6 days.
Hemostasis - cessation of bleeding
Phagocytosis - responsible for drainage during the breakdown of microorganisms and cellular debris. |
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Term
| Proliferative Phase of Wound Healing |
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Definition
From days 3-4 to day 21 post-injury.
Collagen is synthesized which causes the wound edges to adhere.
Granulation tissue forms - healthy, healing tissue; fragile. |
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Term
| Maturation Phase of Wound Healing |
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Definition
Starts on day 21 and can last from 6 months up to 1-2 years post-injury.
Scar or keloid forms; skin won't be as elastic as it was before the injury. |
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Term
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Definition
| Mainly serum, clear portion of the blood, watery (think of the fluid found in a blister) |
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Term
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Definition
| Thicker than serous fluid, contains pus. |
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Term
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Definition
| White blood cells, dead tissue debris, dead and living bacteria. |
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Term
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Definition
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Term
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Definition
| Contains large amounts of RBC, indicating damage to the capillaries. Seen in open wounds. |
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Term
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Definition
| Commonly seen in surgical incisions, mixture of clear and blood-tinged drainage; could be pale pink or dark red. |
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Term
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Definition
| Discharge of pus and blood, often seen in a new wound that is infected. |
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Term
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Definition
| Massive bleeding. Can be caused by a dislodged clot, a slipped stitch, or erosion of a vessel. |
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Term
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Definition
| A localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise). |
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Term
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Definition
| Partial or total rupturing of a sutured wound; usually involves an abdominal wound in which the layers below the skin also separate. |
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Term
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Definition
| The protrusion of the internal viscera through an incision. More likely to occur 4-5 days postop before extensive collagen is deposited in the wound. |
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Term
| Treatment for Dehiscence or Evisceration |
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Definition
| Quickly support wound by large sterile dressing soaked in sterile normal saline. Place the client in bed with knees bent to decrease pull on the incision. Notify surgeon immediately because surgical repair of the area must take place right away. |
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Term
| Most likely time for a surgical wound infection to appear- |
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Definition
| 2-11 days postoperatively. |
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Term
| Important Considerations for Obtaining a Wound Culture |
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Definition
Administer an analgesic 30 minutes prior to the procedure if the patient is complaining of pain at the wound site.
Assess wound drainage (TACO) type, amount, color, odor.
Cleanse the wound.
Obtain culture by rotating the swab back and forth over the clean areas of granulation tissue from the sides or base of wound. |
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Term
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Definition
| Grows only in the presence of O2. |
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Term
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Definition
| Grows only in the absence of O2; usually done by aspiration with a needle. Do NOT refrigerate the specimen. |
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Term
| Important considerations for cleaning a wound |
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Definition
| Clean from the wound in an outward direction to avoid transferring organisms from the surrounding skin into the wound. For a linear wound, cleanse from top to bottom, beginning in the middle and moving progressively laterally. Always cleanest to dirtiest...in to out. |
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Term
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Definition
Red - protect and cover
Yellow - indicates infection; clean it!
Black - means eschar, debride it! |
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Term
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Definition
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Term
| Risk for Impaired Skin Integrity (NANDA) |
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Definition
| At risk for skin being adversely altered. |
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Term
| Impaired Skin Integrity (NANDA) |
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Definition
| Altered epidermis and/or dermis; commonly applies to pressure ulcers and to wounds extending through the epidermis but not through the dermis. |
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Term
| Impaired Tissue Integrity (NANDA) |
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Definition
| Damage to mucous membrane, corneal, integumentary or subcutaneous tissues; applies to pressure ulcers and to wounds extending into the subcutaneous tissue, muscle, or bone. |
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Term
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Definition
| Related to nerve involvement within the tissue impairment or as a consequence of procedures used to treat the wound. |
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Term
| Risk for Infection (NANDA) |
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Definition
| If the skin impairment is severe, the client is immunosuppressed, or the wound is caused by trauma. |
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Term
| 2 Things to avoid using in a patient who is at risk for skin breakdown: |
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Definition
| Corn starch and Baby Powder |
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