Term
| What does the integumentary system consist of? |
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Definition
The skin, hair, nails, sweat glands, and the subcutaneous tissue blow the skin.
Largest organ of the body. |
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Term
| What are the major functions of the skin? |
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Definition
Protection of the internal organs
unique ID of an individual
thermoregulation
metabolism of nutrients and metabolic waste products
sensation |
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Term
| What are children born with? |
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Definition
| Vernix caseosa - a creamy substance that protects their skin. |
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Term
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Definition
Outer layer of skin
Four or five layers
Keratinocytes, melanocytes, and Langerhans cells are located in the epidermal layer |
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Term
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Definition
Outer layer of the epidermis
composed of numerous thicknesses of dead cells
functions as a barrier, restricts water loss and prevents fluids, pathogens, and chemicals from entering the body |
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Term
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Definition
Innermost layer of the epidermis
produces new cells continually |
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Term
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Definition
| Protein-containing cells that give the skin strength and elasticity |
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Term
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Definition
| produce melanin, a pigment that gives skin its color and provides protection from UV light |
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Term
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Definition
are mobile
function is to phagocytize foreign material and trigger an immune response |
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Term
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Definition
lies below the epidermis
middle layer
irregular fibrous connective tissue that provides strength and elasticity to the skin
generously supplied with blood vessels
contains sweat glands, sebaceous (oil) glands, ceruminous glands, hair and nail follicles, sensory receptors, elastin, and collagen |
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Term
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Definition
composed primarily of connective and adipose tissue
provides insulation, protection, and a reserve of calories in the event of severe malnutrition. |
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Term
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Definition
| Itchy, red, dry, scaly, cracked, or fissured skin |
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Term
| Diabetes predisposes people to ______? |
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Definition
| infection, liver dysfunction, interferes with synthesis of blood-clotting factors. |
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Term
| Why is protein important for the skin? |
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Definition
| Protein is necessary to maintain the skin, repair minor defects, and preserve intravascular volume. |
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Term
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Definition
Excess fluid in the tissues
decreases skin elasticity and interferes with the diffusion of O2 to the cells. |
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Term
| Why is cholesterol important to the skin? |
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Definition
Abnormally low cholesterol levels predispose patients to skin breakdown and inhibit wound healing.
Fats aid in providing fuel for wound healing and maintain a waterproof barrier in the stratum corneum. |
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Term
| Why is calorie intake important for the skin? |
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Definition
| If calorie intake is inadequate, the body uses proteins for energy (catabolism); they are then unavailable for building and maintenance functions (anabolism) |
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Term
| Why is ascorbic-acid important in the skin? |
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Definition
Vit c or ascorbic acid, is involved in the formation and maintenance of collagen.
Zinc and copper are also involved in collagen formation.
Deficiencies may impair healing. |
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Term
| Why is hydration important to the skin? |
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Definition
Skin turgor depends on hydration.
Poor skin turgor may occur as a result of dehydration, whereas edema may result from overhydration. |
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Term
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Definition
| diminished sensation or cognition |
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Term
| Impaired arterial circulation does what? |
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Definition
| Restricts activity, produces pain, and leads to muscle atrophy and development of thin tissue that is prone to ischemia and necrosis. |
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Term
| Impaired venous circulation results in what? |
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Definition
| Engorged tissues with high levels of metabolic waste products that are prone to edema, ulceration, and breakdown. |
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Term
| Blood pressure medications _________? |
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Definition
| Decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia An inadequate blood supply to an organ or part of the body, esp. the heart muscle). |
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Term
| Anti-inflammatory medications ______? |
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Definition
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Term
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Definition
| Can lead to extravasation of blood into subcutaneous tissue. As a result, even minimal pressure or injury can cause a hematoma (a collection of blood outside a blood vessel). |
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Term
| Chemotherapeutic agents _______? |
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Definition
| Delay wound healing because of their cellular toxicity. |
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Term
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Definition
| Increases sensitivity to sunlight, increasing the risk for sunburn. |
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Term
| Herbal products _________? |
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Definition
| Cleanse the skin, but also have a drying effect. |
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Term
| Exposure to moisture leads to ________? |
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Definition
| Maceration (softening of the skin.) |
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Term
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Definition
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Term
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Definition
| Scratching that can scrap away superficial skin layers. |
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Term
| A wound is considered infected when? |
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Definition
100,000 organisms per gram of tissue.
Only one beta-hemolytic streptococci is needed for infection. |
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Term
| A wound becomes critically colonized when? |
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Definition
| The bacteria begin to overwhelm the body's defenses. |
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Term
| Regular exercise does what for the skin? |
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Definition
| Improves circulation, which is necessary for maintaining skin integrity and wound healing. |
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Term
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Definition
A disruption in the normal integrity of the skin.
A nurse is responsible for monitoring skin integrity and providing skin and wound care.
Classified according to length of time the would has existed, as well as the condition of the wound. |
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Term
| If a wound is closed, there are _________? |
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Definition
No breaks in the skin
(contusions (bruises)). |
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Term
| If a wound is open, there is ________? |
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Definition
A break in the skin or mucous membranes.
(abrasions, lacerations, puncture wounds, and surgical incisions) |
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Term
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Definition
| Expected to be of short duration. |
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Term
| Three phases of wound healing are? |
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Definition
Inflammation
Proliferation
Maturation |
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Term
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Definition
| Wounds that exceed the expected length of recovery. |
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Term
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Definition
Uninfected wounds with minimal inflammation.
May be open or closed.
Do not involve respiratory, gastrointestinal, or genitourinary tracts. |
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Term
| Clean-contaminated wounds? |
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Definition
Surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tracts.
No obvious infection, but increased risk for one. |
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Term
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Definition
Include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred.
Risk for infection is high. |
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Term
| What are superficial wounds? |
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Definition
Involve only the epidermal layer of the skin.
Usually the result of friction, shearing, or burning. |
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Term
| What is partial-thickness wounds? |
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Definition
| Extend through the epidermis but not through the dermis. |
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Term
| What are full-thickness wounds? |
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Definition
Extend into the subcut tissue and beyond.
Sometimes the word penetrating is used to indicate the wound involves internal organs. |
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Term
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Definition
Regenerative / Epithelial Healing
Primary Intention Healing
Secondary Intention Healing
Tertiary Intention Healing |
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Term
| Regenerative / Epithelial Healing |
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Definition
Occurs when the wound affects only the epidermis and dermis
No scar forms
New skin cannot be distinguished from intact skin
Partial-thickness wounds heal by regeneration |
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Term
| Primary Intention Healing |
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Definition
When a wound involves minimal or no tissue loss and has edges that are closed.
Little scarring is expected.
A clean surgical incision heals like this. |
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Term
| Secondary Intention Healing |
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Definition
Occurs when a wound:
1. Involves extensive tissue loss, which prevents wound edges from approximating.
2. Should not be closed (because it is infected)
(Pressure ulcers and infected wounds) |
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Term
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Definition
| When a wound heals from the inner layer to the surface, it is filled with beefy red granulation tissue. |
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Term
| Tertiary Intention Healing |
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Definition
Called delayed primary closure.
Occurs when two surfaces of granulation tissue are brought together.
Strict aseptic technique used for these wounds. |
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Term
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Definition
Inflammatory Phase - Cleansing
Proliferative Phase - Granulation
Maturation Phase - Epithelialization |
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Term
| Inflammatory Phase - Cleansing |
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Definition
Last from 1-5 days and consists of hemostasis and inflammation
Hemostasis - when tissue is destroyed, blood and plasma leak into the wound. Platelets are activated.
Inflammation - Characterized by edema, erythema, pain, temp, and migration of white blood cells. Scab is formed. |
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Term
| Proliferative Phase - Granulation (also called regeneration) |
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Definition
Occurs from day 5 - 21
Cells develop to fill the wound
Fibroblasts migrate to the wound where they form collagen
New blood and lymph vessels sprout from the existing capillaries at the edge of the wound
The result is the formation of granulation tissue |
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Term
| Maturation Phase - Epithelialization |
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Definition
Final phase of healing
Begins the second or third week and continues even after the wound has closed. |
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Term
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Definition
| Closes superficial low-tension wounds, such as tears or lacerations. |
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Term
| Most common places for surgical staples? |
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Definition
| Arms, legs, abdomen, back, scalp, or bowel. |
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Term
| Negative Pressure Wound Therapy |
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Definition
vacuum assisted
gets fluid out
big wounds or wounds that do not look like they are healing |
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Term
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Definition
| Drainage from a wound or cavity |
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Term
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Definition
Watery in consistency
Contains very little cellular matter
Consists of serum, the straw-colored fluid that separates out of blood when a clot is formed. |
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Term
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Definition
Often seen with deep wounds or wounds in highly vascular areas.
Bloody drainage and indicates damage to the capillaries. |
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Term
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Definition
Mostly seen in new wounds
A combination of bloody and serous drainage |
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Term
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Definition
Thick drainage that is seen in infected wounds.
Contains pus
Commonly caused by pyogenic (pus-forming) bacteria
If it is blue-green, it is Pseudomonas aeruginosa |
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Term
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Definition
Red-tinged pus
Indicates that small vessels in the wound have ruptured |
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Term
| Most common complications of would healing |
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Definition
Hemorrhage
Infection
Dehiscence
Evisceration
Fistulas |
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Term
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Definition
| Bleeding - Hemostasis - (cessation of bleeding) does not occur |
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Term
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Definition
| A red-blue collection of blood under the skin |
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Term
| Signs of internal bleeding |
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Definition
| Swelling of the affected body part, pain, and changes in vital signs |
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Term
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Definition
| Remember to look underneath the patient |
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Term
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Definition
| Localized swelling, redness, heat, pain, fever (>100.4), foul-smelling or purulent drainage. |
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Term
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Definition
Leave open to drain
Rupture of one or more layers of a wound
Most likely to occur in the inflammatory phase of healing
Most often associated with abdominal wounds
Head should be elevated 20 degrees and knees flexed
Apply a binder |
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Term
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Definition
Total separation of the layers of a wound in which internal viscera protrude through the incision.
Immediately cover with sterile towels or dressings.
Notify the surgeon. |
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Term
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Definition
An abnormal passage connecting two body cavities or a cavity and the skin.
Often result from an infection.
Most common sites are gastrointestinal and genitourinary tracts. |
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Term
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Definition
Chronic Wound
5-8.5 billion annually spent
Localized areas of injury to the skin, and
possibly the underlying tissue
Can occur in as little as 2 hours
Most commonly happen over bony prominences |
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Term
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Definition
| Damages the outer protective epidermal layer, decreasing the amount of pressure needed to develop skin lesions. |
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Term
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Definition
Occurs when the epidermal layer slides over the dermis, causing damage to the vascular bed.
(Patient slides down in bed when head of bed is elevated) |
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Term
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Definition
| Diabetes causes narrowing of arteries, decreasing oxygenation to the feet |
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Term
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Definition
| Usually occur over the lower leg, ankle, or bony areas of the foot |
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Term
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Definition
Localized area of intact skin with nonblanchable redness, usually over a bony prominence.
Discoloration will remain for >30 min after pressure is relieved. |
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Term
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Definition
Involves partial-thickness loss of dermis
Are open but shallow and with a red pink wound bed
No slough |
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Term
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Definition
Deep crater characterized by full-thickness skin loss with damage or necrosis of subcutaneous tissue
Bone / tendon is not visible or palpable |
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Term
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Definition
Involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures.
Exposed bone / tendon is visible
Sough or eschar may be present |
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Term
| Eschar (Unstageable Pressure Ulcer) |
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Definition
Involves full-thickness skin loss
Wound is obscured by slough
Do not remove stable eschar - it is the body's natural cover |
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Term
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Definition
Used to predict pressure sore risk
Six major risk factors:
1. Sensory perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction and sheer
Use on admission and again in 48-72 hours |
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Term
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Definition
Assesses risk based on the patient's physical condition, mental state, activity, mobility, and incontinence.
Low score = high risk |
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Term
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Definition
| Wounds in high vascular areas (scalp or hands) heal faster than wounds in less vascular regions (abdomen or heel) |
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Term
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Definition
Sough
Eschar
Granulation TIssue
Clean, Nongranulating
Epithelial |
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Term
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Definition
Soft, moist, devitalized (necrotic) tissue
May be white, yellow, tan
May be stringy, loose
Debride the wound |
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Term
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Definition
Necrotic tissue, dry, thick, leathery, may be black, brown, or gray
Debride the wound |
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Term
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Definition
Pink to red moist tissue; made of new blood vessels, connective tissue, and fibroblasts; surface is granular or pebble-like
Cleanse and protect |
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Term
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Definition
Absence of granulation tissue, but bed is pink, shiny, and smooth
Cleanse and protect |
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Term
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Definition
Regenerating epidermis
May appear pink or pearly white
Cleanse and protect |
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Term
|
Definition
Caused by excessive moisture
Skin may appear as pale and wrinkled or "pruned"
May flake and peel |
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Term
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Definition
| Will produce a boggy feel around the wound |
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Term
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Definition
gas trapped under the skin
Will feel crackling (like rice krispies) around the skin while palpating |
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Term
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Definition
| Closed or rolled wound edges |
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Term
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Definition
| Used to evaluate pressure ulcers |
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Term
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Definition
| The most common and most noninvasive method to obtain a culture of a wound |
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Term
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Definition
| Most accurate method for culturing a chronic wound |
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Term
| Impaired tissue integrity |
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Definition
| Appropriate for patients with wounds that extend into the subcut tissue, muscle, or bone |
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Term
| Skin infection should be ______? |
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Definition
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Term
|
Definition
| Elevate the head of the bed 30 degrees or less |
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Term
|
Definition
Lavage
cleanse wounds gently by flushing
4 psi to 15 psi
Do not use a bulb syringe - use piston |
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Term
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Definition
| A flexible latex tube that is placed in the wound bed but usually not sutured into place |
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Term
| Hemovac, Jackson-Pratt, and Davol drains |
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Definition
Attached to a collection device
Suction device |
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Term
| Describing drain placements |
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Definition
Describe placement according to the position on the clock face.
Patient's head is 12 o'clock
Label the drains numerically |
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Term
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Definition
Removal of devitalized tissue or foreign material from a wound.
It also helps remove cells that are alive but not functioning (senescent) from the wound bed and edges. |
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Term
|
Definition
Sharp or surgical
Mechanical
Enzymatic
Autolytic
Biotherapy or maggot debridement |
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Term
|
Definition
| Use of a sharp instrument to remove devitalized tissue |
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Term
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Definition
| Performed via lavage (irrigation), wet-to-dry dressings, or hydrotherapy (whirlpool). |
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Term
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Definition
| Uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound. |
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Term
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Definition
The use of an occlusive, moisture-retaining dressing and the body's own enzymes and defense mechanisms to break down necrotic tissue.
Change dressing every 72 hours. |
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Term
| Biotherapy or maggot debridement therapy |
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Definition
Use of medical-grade larvae of the greenbottle fly to dissolve dead and infected tissue from wounds.
The larvae secrete enzymes that liquify dead tissue and create an alkaline environment.
Larvae are usually changed every 48-72 hours and disposed of as biohazardous medical waste. |
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Term
|
Definition
Use for wounds with moderate to large amounts of exudate
Highly absorbent - large wounds |
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Term
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Definition
Should be reserved for wounds with large amounts of exudate. Ideal for wounds that have depth, tracts, tunneling, or undermining.
Highly absorbent (20-40 times their weight)
Promotes a moist environment
Facilitates autolytic debridement - large wounds |
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Term
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Definition
Use on partial or full-thickness wounds, with little to large amounts of drainage, or highly contaminated or infected wounds.
Promotes a moist environment
Minimal to large wounds |
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Term
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Definition
| Use with partial or full thickness wounds, and contaminated or infected wounds. |
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Term
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Definition
Simplest and most widely used dressing
Used for packing large wounds, cavities, or tracts, deep or dirty wounds, or heavily draining wounds.
Absorbency
Packing
Cleansing
Protection
large wounds |
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Term
|
Definition
Absorbency
insulation
promote a moist environment
used under compression
minimal to large wounds |
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Term
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Definition
Promote a moist environment
Provide a protective layer against friction
Promotes autolysis
Used under compression
Light to moderate wounds
Should not be used on infected wounds |
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Term
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Definition
Promotes a moist environment
Rehydrate the wound bed
Promote autolysis
Minimal wounds
Opaque - can't see the wound while they are in place
Should not be used on infected wounds |
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Term
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Definition
Promotes a moist environment
Occlusive with O2 permeability
Promotes autolysis
Minimal to none wounds
Often used to dress IV sites |
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Term
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Definition
readily molds to the contours of the body
ideal for joints |
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Term
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Definition
One with ties
Use if frequent wound changes are required |
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Term
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Definition
Keep a wound closed or immobilize a body part to aid in the healing process.
Triangular arm binder or sling
T-binder (perineal area)
Abdominal binder (support the abdomen) |
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Term
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Definition
| Most commonly used as slings to immobilize an upper extremity or to hold large abdominal dressings in place |
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Term
|
Definition
most frequently used type of bandage
put meds on
plaster of Paris - when dry, forms a cast |
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Term
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Definition
| Used to apply pressure and give support |
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Term
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Definition
vasoconstrictor
Produces local anesthesia, reduces cell metabolism, increases blood viscosity, and decreases muscle tension.
It also slows bacterial growth.
Used to prevent or limit edema and reduce inflammation, pain, O2 requirements, and bleeding.
May elevate patient BP |
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Term
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Definition
vasodilator
Used to relieve stiffness and discomfort associated with musculoskeletal problems.
Increased blood flow brings O2 and WBC to the wound and aids in healing. |
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Term
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Definition
| soaks the patient's perineal area |
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