Term
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Definition
| damaged skin or soft tissue results from trauma |
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Term
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Definition
| general term referring to injury |
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Term
| examples of tissue trauma are |
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Definition
| cuts, blows, poor circulation, strong chemicals, and excessive heat or cold |
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Term
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Definition
| ones in which the surface of the skin or mucous membrane is no longer intact |
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Term
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Definition
| when there is no opening in the skin or mucous membrane, occur more often from blunt trauma or pressure |
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Term
| the three sequential phases of wound repair are |
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Definition
1. inflammation
2. proliferation
3. remodeling |
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Term
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Definition
| the physiological defense immediately after tissue injury lasts approximately 2 to 5 days |
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Term
| the three purposes of inflammation are to |
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Definition
1. limit the local damage
2. remove injured cells and debris
3. prepare the wound for healing |
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Term
| the first stages of inflammation is |
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Definition
* immediately following an injury, blood vessels constrict to control blood loss and confine damage
*then blood vessels dilate to deliver platelets that form a loose clot
*the membranes of damaged cells become more permeable, causing release of plasma and chemical substances that transmit a sensation of discomfort |
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Term
| signs and symptoms of inflammation are |
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Definition
| * swelling, redness, warmth, pain and decreased function |
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Term
| second stage of inflammation is when |
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Definition
| leukocytes and macrophages migrate to the site of injury, and the body produces more and more white blood cells to take their place |
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Term
| leukocytes and macrophages are |
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Definition
| types of white blood cells |
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Term
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Definition
| increased production of white blood cells is confirmed and monitored by counting the number and type of white blood cells in a sample of the clients blood |
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Term
| an increase in white blood cells particularly neutrophils and monocytes is suggestive of an |
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Definition
| inflammatory or in some case an infectious process |
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Term
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Definition
| a process which neutrophils and monocytes consume pathogens, coagulated blood and cellular debris |
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Term
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Definition
| a clean separation of skin and tissue with smooth even edges |
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Term
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Definition
| a separation of skin and tissue in which the edges are torn and irregular |
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Term
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Definition
| a wound in which the surface layers of skin are scraped away |
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Term
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Definition
| stripping away of large areas of skin and underlying tissue leaving cartilage and bone exposed |
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Term
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Definition
| a shallow crater in which skin or mucous membrane is missing |
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Term
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Definition
| an opening of skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object |
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Term
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Definition
| injury to soft tissue underlying the skin from the force of contact with a hard object, sometimes called a bruise |
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Term
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Definition
| period during which new cells fill and seal a wound, occurs from 2 days to 3 weeks after the inflammatory stage |
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Term
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Definition
| combination of new blood vessels, fibroblasts and epithelial cells, which is bright pink to red, because of the extensive projections of capillaries in the area |
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Term
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Definition
| a tough and inelastic protein substance, produced by fibroblasts causing the adhesive strength of the wound to increase |
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Term
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Definition
| process by which damaged cells recover and re-establish their normal function |
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Term
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Definition
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Term
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Definition
| replacement of damaged cells with fibrous scar tissue |
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Term
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Definition
| period during which the wound undergoes changes and maturation, follows the proliferation stage and may last 6 months to 2 years. During this time the wound contracts and the scar shrinks |
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Term
| the speed of wound repair and extent of scar tissue that forms depends on whether |
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Definition
| the wound heals by first, second or third intention |
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Term
| first intention healing is a |
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Definition
| process in which the wound edges are directly next to each other, only a small scar will form and most surgical procedures that are closely approximated will heal this way |
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Term
| second intention healing is when the |
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Definition
| wound edges are widely spread apart, margin of the wound are not in direct contact the granulation tissue needs additional time to extend across the expanse of the wound, a conspicuous scar results |
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Term
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Definition
| the wound edges are widely separated and are later brought together with some type of closure material, results in a broad deep scar, to speed healing them may contain drainage devices or be packed with absorbent gauze. |
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Term
| the key to wound healing is |
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Definition
| adequate blood flow to the injured tissue |
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Term
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Definition
| separation of wound edges |
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Term
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Definition
| wound separation with protrusion of organs |
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Term
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Definition
| the nurse puts sterile dressings moistened with normal saline over the protruding organs and tissue and notifies the physician immediately |
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Term
| the primary goal of surgical or wound healing is to |
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Definition
| reapproximate the tissue to restore its integrity |
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Term
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Definition
| a wound caused by prolonged capillary compression that is sufficient to impair circulation to the skin and underlying tissue. the primary goal in managing pressure ulcers is prevention |
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Term
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Definition
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Term
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Definition
| strips of tapes with eyelets |
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Term
| transparent dressings are |
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Definition
| clear wound coverings that allow the nurse to view a wound without removing the dressings, commonly used to cover IV sites |
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Term
| Hydrocolloid dressings are |
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Definition
| self adhesive opaque air and water occlusive wound coverings, that keeps wounds moist and can be left in place for up to one week, allow at least a one inch margin of healthy tissue around the wound |
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Term
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Definition
| when a wound requires assessment or care and when the dressing becomes loose or saturated with drainage |
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Term
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Definition
| are tubes that provide a means for removing blood and drainage from a wound. they promote wound healing by removing fluid and cellular debris, current trend is to place them so that they exit from a separate location beside the wound. this approach keeps the wound margins approximated and avoids a direct entry site for pathogens |
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Term
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Definition
| flat flexible tubes that provide a pathway for drainage toward the dressing |
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Term
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Definition
| movement of a liquid at the point of contact with a solid, which in this case is the gauze dressing |
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Term
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Definition
| are drains that terminate in a receptacle, closed drains are more efficient because the pull fluid by creating a vacuum or negative pressure |
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Term
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Definition
| knotted ties that hold an incision together, generally are constructed from silk or synthetic materials such as nylon |
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Term
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Definition
| wide metal clips. that do not encircle a wound like sutures but form a bridge that holds the two wound margins together. they do not compress the tissue if the tissue should swell |
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Term
| adhesive or steri-strips also known as butterfly strips are used to |
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Definition
| hold a weak incision together temporarily, sometime used for superficial lacerations |
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Term
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Definition
| a strip or roll of cloth wrapped around a body part |
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Term
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Definition
| a type of bandage generally applied to a particular body part sch as the abdomen or breast |
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Term
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Definition
| secure a dressing to the anus or perineum or within the groin |
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Term
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Definition
| the removal of necrotic tissue from the healthy areas of a wound with sterile scissors, forceps, or other instruments. this method is preferred if the wound is infected because it helps the wound to heal quickly and well, it is painful and the wound my bleed afterwards |
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Term
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Definition
| the use of topically applied chemical substance that break down and liquefy wound debris, it is appropriate for uninfected wounds or for clients who cannot tolerate sharp debridement |
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Term
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Definition
| self-dissolution, is painless natural physiologic process that allows the body's enzymes to soften and liquefy and release devitalized tissue. it is used when a wounds is small and free of infection. |
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Term
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Definition
| involves physical removement of debris from a deep wound. one application is wet-to-dry dressings. the wound is packed with moist gauze which is removed 4-6 hours later, dead tissue adheres to the meshwork of the gauze and is removed when the dressing is changed |
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Term
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Definition
| therapeutic use of water, in which the body part with the wound is submerged in a whirlpool tank. the agitation of the water which contains an antiseptic, softens the dead tissue. loose debris that remains intact is later removed by sharp debridement |
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Term
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Definition
| a technique used for flushing debris, is used when caring for a wound and also for cleaning an area of the body such as the eye, ear and vagina |
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Term
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Definition
| is a procedure for cleansing the vaginal canal sometimes necessary to treat an infection |
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Term
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Definition
| after tonsil removal and ice bags to any small injury in the process of swelling |
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Term
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Definition
| moist warm or cool cloths applied to the skin |
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Term
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Definition
| electrical or heating or cooling devices (k-pad)that contains hollow channels through which heated or cooled distilled water circulates, it is used alone or as a cover over a compress |
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Term
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Definition
| a technique in which a body part is submerged in fluid to provide warmth or apply a medicated solution, lasts 15-20 minutes |
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Term
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Definition
| a commercial device for applying moist heat |
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Term
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Definition
| those preformed for other than hygiene purposes, they help to reduce a high fever or used to apply medicated substances to the skin to treat skin disorders or discomfort |
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Term
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Definition
| reduce swelling and inflammation and promote healing of wounds |
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Term
| pressure ulcers appear over |
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Definition
| bony prominences of the sacrum, hips and heels. if compression reduces the pressure in local capillaries to less than 32 mm Hg for 1-2 hours the cells die from lack of oxygen and nutrition |
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Term
| stage 1 of pressure ulcers |
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Definition
| characterized by redness but skin is still intact |
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Term
| stage II of pressure ulcers |
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Definition
| ulcer is red and accompanied by blistering or a skin tear which may lead to colonization and infection of the wound |
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Term
| stage III of a pressure ulcer |
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Definition
| skin has a shallow crater that extends to sub Q tissue. it may be accompanied by serious drainage or purulent drainage caused by wound infection, it is relatively painless despite the severity of the ulcer |
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Term
| stage IV of a pressure ulcer |
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Definition
| are life threating, the tissue is deeply ulcerated exposing muscle and bone, the dead or infected tissue may produce foul odor. the infection easily spreads through out the body causing fatal systemic infection |
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Term
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Definition
| potentially fatal systemic infection |
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Term
| prevention of pressure ulcers |
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Definition
1. identify clients with risk factors for pressure ulcers
2. implement measures that reduce conditions under which pressure ulcers are likely to form |
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Term
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Definition
| promotes wound drainage from an abdominal incision |
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Term
| the nurse encloses the soiled dressing within a latex glove |
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Definition
| after changing a clients dressing |
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Term
| the nurse compresses the bulb reservoir and closes the vent when |
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Definition
| emptying a jackson pratt to re-establish negative pressure within the drainage device |
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Term
| why does a nurse apply wet-to-dry dressings over skin ulcers |
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Definition
| to remove dead cells and debris |
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Term
| the best evidence that a wound is healing is |
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Definition
| when the cavity appears pink |
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