Term
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Definition
| outermost layer of the skin that is continually proliferating and sloughing off. |
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Term
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Definition
| provides strength, mechanical support and protection of the underlying tissues, bones, and muscles. Has COLLAGEN, blood vessels and nerves in this layer. FIBROBLASTS synthesize collagen! |
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Term
| Age related changes to the skin |
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Definition
| decreased elasticity, decreased collagen, thinning of underlying tissues and muscles. |
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Term
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Definition
| redness, usually from tissue ischemia and vasodilation during low O2. |
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Term
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Definition
| demonstrates the body's attempt to overcome an ischemic episode and the red patch turns white when you press it. |
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Term
| Pressure ulcer risk factors |
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Definition
| sensory impairment, neurological impairment (altered LOC), shear, friction, impaired mobility, moisture |
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Term
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Definition
| causes a tear in the dermis and necrosis which occurs at a blood supply is a common occurrence as well. |
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Term
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Definition
| Non blanching area, no skin breaking. |
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Term
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Definition
| partial thickness skin loss, usually like a blister, affects dermis and epidermis. |
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Term
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Definition
| Full thickness skin loss, looks like a crater, subcutaneous fat, tunneling, and slough may be apparent but NO BONES, TENDONS, OR MUSCLES YET! |
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Term
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Definition
| full thickness skin loss, necrotic tissue present, can see bone muscle or tendon, usually has undermining and tunneling. |
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Term
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Definition
| soft, red, meaty vascularized new tissue that demonstrates healing. |
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Term
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Definition
| stringy yellow or white substance attached to wound bed that needs to be removed before the wound can heal. |
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Term
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Definition
| black necrotic tissue that will need to be removed as well. |
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Term
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Definition
| drainage/odor coming from wound and excessive amounts indicate an infection. |
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Term
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Definition
| heals in the expected amount of time. Surgical wound or trauma, easily cleaned and repaired, edges are approximated. |
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Term
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Definition
| wound that does not heal quickly and in a timely manner, usually vascular issues, constant inflammation, or repetitive insult. |
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Term
| Healing by primary intention |
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Definition
| wound is closed like surgical incision, with sutures or staples, HEALING WITH EPITHELIALIZATION, MINIMAL SCARS |
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Term
| Healing by secondary intention |
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Definition
| healing with granulation tissue wound contraction and epithelialization, like in a pressure ulcer or tissue loss surgical wounds. |
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Term
| Healing by tertiary intention |
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Definition
| wounds that are contaminated and need to clear the infection before proper healing can begin. |
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Term
| Partial thickness wound healing |
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Definition
1. inflammatory response: swelling and bringing wbcs to the infected area.
2. epithelial proliferation and migration a wound edges and migrate across the wound top, NEED MOISTURE TO MOVE SO KEEP COVERED AND MOIST!
3. Reestablishment of epidermal layers, new cells appear dry and pink. |
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Term
| Full thickness wound repair |
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Definition
1. Inflammatory: Hemostasis for constriction and platelet aggregation and fibrin network to form. Redness/warmth/edema/throbbing of the area. Bring on the leukocytes, Macrophages eat/clear wound of debris. CONTROLS BLEEDING AND ESTABLISHES A CLEAN WOUND BED!
2. Filling wound with granulation tissue, contraction of the wound, and epithelialization. Collagen comes into play. GRANULATION TISSUE (ESTABLISHES VASCULAR BED), REPLACEMENT TISSUE FILLS IN (COLLAGEN, CONTRACTION, GRANULATION), SURFACE IS REPAIRED (EPITHELIALIZATION).
3. Remodeling: collagen remodeling and scar tissue formation. |
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Term
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Definition
| change in type/amount of drainage, swelling of body part, signs of hypovolemic shock. |
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Term
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Definition
| collection of blood underneath the tissue |
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Term
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Definition
| partial or total separation of wound layers, clients with > amounts of fat are more at risk for this. increase in serosanguineous drainage is a sign that it is likely to happen |
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Term
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Definition
| total separation of wound layers and protrusion of visceral organs through a wound opening. |
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Term
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Definition
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Term
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Definition
| yellow, green tan or brown and thick |
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Term
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Definition
| pale red watery and mixture of clear and red fluid |
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Term
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Definition
| bright red and indicates active bleeding. |
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Term
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Definition
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Term
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Definition
| primary dangers are internal bleeding and infection. |
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Term
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Definition
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Term
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Definition
| wet to dry dressing, allow to dry completely, don't use on granulating wound |
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Term
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Definition
| allowing eschar to be broken down by natural bodily enzymes. Important to keep wound bed moist for this to happen. Use transparent or hydrocolloid dressings for this. |
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Term
| Steps of treating pressure ulcers |
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Definition
1. Hand hygiene and clean gloves
2. Remove old dressing and place in biohazard bag, assess TACO of the drainage.
3. New clean gloves
4. Assess wound bed, TACO of tissue in wound bed.
5. Measure width, length, and for tunneling.
6. Assess periwound skin for maceration redness and denuded area
7. STERILE GLOVES
8. Cleanse ulcer with NS.
9. Apply topical agents as ordered
10. Discard gloves, and biohazard bag, perform hand hygiene
11. Compare assessment data to that of the care plan to see if wound is healing as planned or not.
11. |
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Term
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Definition
| Use topical enzyme preparation, sterile maggots. |
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Term
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Definition
| with sharps, or scissors to remove devitalized tissue. |
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Term
| Growth factors of wound healing |
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Definition
| epidermal, fibroblast, platelet derived, transforming. |
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Term
| Recommended daily intake of protein vs that of an individual who is wound healing |
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Definition
| .8g/kg/day vs 1.8g/kg/day, also important to be getting increased amounts of vitamin C for collagen synthesis and formation. |
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Term
| Transparent Film dressing |
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Definition
| ideal for small wounds with partial thickness loss, ca also be used for autolytic debridement. |
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Term
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Definition
| used in clean granulating wounds and autolytically debriding necrotic wounds. Most useful on shallow to moderately deep dermal ulcers. DONT USE IN FULL THICKNESS OR INFECTED WOUNDS. |
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Term
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Definition
| hydrates wounds and absorbs some smaller amounts of exudate. Very useful in painful full/partial wounds, burns and necrotic as well. soothing to the client and don't adhere to wound be. |
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Term
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Definition
| used for infected wounds and made from seaweed, dont use in dry wounds though. |
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Term
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Definition
| Dont cover bleeding wound with heat because it wont stop the bleeding,also don't use with acute localized inflammation (like appendicitis) because it will cause it to rupture. |
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Term
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Definition
| contraindicated at an already present site of edema because halts vasodilation and retards circulation preventing absorption of interstitial tissue. Also don't use with neuropathy or altered LOC. |
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Term
| Effects of Heat Application |
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Definition
| improved blood flow to an injured part, vasodilation, reduced blood viscosity, increased tissue metabolism, reduced muscle tension, increased capillary permeability. |
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Term
| Effects of cold application |
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Definition
| initially diminishes swelling and pain, vasoconstriction, local anesthesia, reduced cell metabolism, increased blood viscosity, and decreased muscle tension |
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Term
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Definition
| Open wounds, rectal surgery, tension, wound debridement. |
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Term
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Definition
| direct trauma, superficial laceration or puncture wound, burns, joint pain, arthritis. |
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Term
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Definition
| Open wounds, rectal surgery, tension, wound debridement. |
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Term
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Definition
| open wounds to improve circulation, relieve edema, and promote consolidation of pus or drainage. |
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Term
| Cold moist/dry compresses |
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Definition
| apply for 20 minutes to relieve inflammation and swelling. |
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Term
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Definition
| promotes circulation lessens edema and increases muscle relaxation/ provides means to debride wounds and apply medicated solutions. NEVER ADD HOTTER SOLUTION WHILE BODY PART IS IN IT! |
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Term
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Definition
| 20 minutes and make sure client is not chilled. |
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