Tissue Integrity Flashcards
1
Q
closed; with the wounds edges touching ea. other
A
approximated
2
Q
inadequate blood flow through the arteries
A
arterial insufficiency
3
Q
large blister; as seen with burns
A
bulla
4
Q
injury to tissues with skin discoloration from blood seepage just under the skin and without tissue breakage; a bruise
A
Contusion
5
Q
spontaneous opening of the edges of a surgical wound with partial or total separation of wound layers
A
dehiscence
6
Q
area of loss of superficial layers of the skin
A
denuded
7
Q
dehydration of the tissue
A
desiccation
8
Q
hemorrhagic spot, or bruise, caused by bleeding under the skin and irregularly formed in a blue or purple or brown patches
A
ecchymosis
9
Q
reddening of the skin caused by congestion of the capillaries
A
erythema
10
Q
severe form of dehiscence where internal viscera protrudes outside the body
A
Evisceration
11
Q
material such as fluid with a high content of protein and cellular debris that has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation
A
Exudate
12
Q
any abnormal tube like passage in the body
A
fistula
13
Q
localized collection of blood underneath the tissues, appearing as a swelling or mass often characterized by a Bluish discoloration.
-antinflammatory meds can affect hematomas making them worse
A
hematoma
14
Q
sharply elevated, progressively enlarging scar that does not fade with time
A
keloid
15
Q
cut; torn wound
A
laceration
16
Q
softening or dissolution of tissue after lengthy exposure to fluid
A
maceration
17
Q
spot or thickening of the skin, not raised above the surface
A
macule (freckle?)
18
Q
malignant mole or tumor on the skin with atypical melanocytes (pigment-forming cells) in both the epidermis and the dermis and sometimes the subcutaneous cells
A
melanoma
19
Q
small, solid mass that can be detected by touch
A
nodule
20
Q
small, circumscribed, solid, elevated skin lesion
A
papule
21
Q
condition characterized by various skin manifestations, including hemorrhages into the skin, mucous membranes, internal organs, and other tissues
A
purpura
22
Q
pertaining to serum; thin and watery like serum
A
serous
23
Q
stagnation (stopping) of the flow of body fluid, most commonly used to describe the impaired flow of blood back to the heart from the peripheral circulation (venous stasis)
A
Stasis
24
Q
a canal or passageway within the wound bed
A
tunneling
25
An overhanging along the edge of the wound bed creating a sac or pocket
undermining
26
small blisters that contain liquid
vesicle
27
smooth, localized, reddened or pale, slightly elevated area on the skin that is either induced via intradermal injection or is typical of allergic reactions
wheal
28
Edges are well approximated (closed)
| typically intentional wounds with minimal tissue damage ie. surgical incisions closed with sutures or staples
Type of Wound Healing
| Primary Intention -
29
Edges are not approximated
Typically large open wounds ie. burns, pressure ulcers
some extensive damage
Type of Wound Healing
| Secondary Intention-
30
Wounds that are left open for several days to allow edema or infection to resolve or exudate to drain; later closed with sutures, staples, etc.
Type of Wound Healing-
| Tertiary Intention
31
Inflammatory Phase
Proliferative Phase
Maturation Phase
Phases of Wound Healing
32
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Lasts 3-6 days after injury
Hemostasis occurs (bleeding is ceased)
Fibrin begins to form
Blood clots arrive to area
Scab begins to surface
Dead and dying tissue is removed
Blood supply increases to area
Oxygen and nutrients arrive to area
Macrophages arise
*Client experiences physical symptoms
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Phases of Wound Healing-
| Inflammatory Phase
33
Lasts from day 3 to 4 of injury to up to 21 days
Collagen is produced to strengthen wound
Healing ridge may appear
Capillaries spread wound bed increasing blood supply
Granulation tissue forms
Scab covers wound bed
Phases of Wound Healing-
| Proliferative Phase
34
Starts at day 21 of injury and can last 1 to 2 years
Collagen fibers re-organize themselves into a structure
Wound is remodeled and contracted
Scar strengthens
Possibility a keloid could develop
Phases of Wound Healing-
| Maturation Phase
35
A local collection of blood beneath the skin
Appears as a bruise; Reddish, Blue in color
Swelling may be involved
If really large, can be dangerous
Hematoma
36
Also called drainage or discharge
Material is made up of fluid and dead phagocytic cells that escape during the inflammatory phase
Three major types of exudate:
Serous
Purulent
Sanguineous
Exudate
37
clear drainage
serous exudate
38
bloody drainage
Sanguineous exudate
39
clear with blood tinged drainage
Serosanguineous Exudate
40
Pharmacologic therapy:
Could be a variety of treatment options; ointments, antibiotics, analgesics, etc.
Non-pharmacologic therapy:
includes infection prevention, compression bandages, nurtition, VAC therapy, biosurgery, etc
Promoting Healing and Preventing Infection
41
- Dead tissue must be removed
- The wound must be cleaned and dressed regularly
- Measurements must be taken and documented on a -regular basis
- Frequent skin assessment necessary
- Pain needs to be controlled well
- Support nutrition & hydration
- Maintain mobility
- Promote effective elimination
- Prevent infection
- Educate client
Wound Management
42
-Dr. orders
-Clean technique until it runs clear
-Least contaminated to most contaminated; usually from top to bottom.
-Lay on side for irrigation
Longest to widest to depth (measurements)
Packing:
mechanical packing; 1 piece huge as possible
using wet to moist-promotes healing
ABD pad; then take three pieces
Cleaning and Packing Wounds
43
epidermis; surface
dermis; second deeper layer of skin
subcutaneous fatty layer; separate the skin from the underlying tissue
3 layers of skin
44
Millions of these wear off ea. day by abrasion. When mature b/come dead cells
Kearantinocytes
45
Form a shield that protects the keratinocytes and the nerve endings in the dermis from damaging effects of ultraviolet light.
This activity probably accounts for the difference in skin color in humans
Melanin
46
2nd deeper layer of skin; Flexible connective tissue; richly supplied with blood cells, nerve fibers, lymphatic vessels.
-hair follicles, sebaceous glands, sweat glands
Dermis
47
hypodermis; lies below dermis.
Layer consists of loose connective tissue and stores roughly 1/2 the fat cells in the body.
Insulator and cushion for the body; stores energy in the form of fat.
Subcutaneous Tissue
48
Utero greasy substance containing sebum and shed cells that covers and protects the fetal skin from amniotic fluid and loss of fluids and electrolytes.
Vernix Caseosa
49
Observable changes from normal skin structure, may indicate disorder in other systems and organs.
vary in shape, size, color and texture characteristics.
-Macules, patches, papules, nodules, tumors, vesicles, pustles, bullae and wheals.
Skin Lesions
50
thickening of the skin
lichenification
51
trauma occurs during therapy. ie. operations, venipunctures, removing tumors
Intentional wounds
52
accidental. closed or open;
Unintentional
53
uninfected; minimal inflammation, respiratory, alimentary, genial and urinary tracts aren't entered. Primarily closed wounds
Clean wounds
54
surgical wounds in which respiratory, alimentary, genital or urinary tract has been entered. These wounds show no sign of infection.
Clean contaminated wounds
55
include open, fresh, accidental wounds and surgical wounds that involve a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Shows evidence of inflammation.
Contaminated wounds
56
wounds containing dead tissue and wounds with evidence of a clinical infection; ie purulent drainage.
Dirty or infected wounds
57
usually seen shortly after an injury (scene of an accident or ER visit)
Guidelines of treatment:
-control severe bleeding; apply pressure elevate the involved extremity
-prevent infection by flushing abrasion/laceration with normal saline and cover wound with a clean dressing.
-wrap wound tightly
apply ice over wound to control swelling and pain
Untreated Wounds
58
sharp instrument ie. knife, scalpel; open wound, deep or shallow
Incisional wound
59
Blow from a blunt instrument; closed wound, bruising
Contusion
60
Surface scrap, either unintensional or intensional; open wound involving the skin
Abrasion
61
Tissue torn apart; often from accidents; open wound, edges often jagged
laceration
62
Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional; open wound
Puncture
63
penetration of the skin & the underlying tissue usually unintentional, ie bullet or metal fragments; open wound
Penetrating wound
64
confined to the skin; the dermis and epidermis heal by regenerating
Partial thickness
65
Involving the dermis, epidermis, subcutaneous tissue and possibly muscle and bone; required connective tissue repair.
Full thickness of the wound by depth
66
epidermolysis bullosa
blistering
67
skin thick and scally
ichthyosis
68
too little melanin is produced
albinism
69
increased growth of coarse hair on the face and trunk is seen in Cushing syndrome, acromegaly, and ovarian dysfunction.
Hirsutism
70
Hair loss; maybe related to changes in hormones, chemical or drug treatment, or radiation.
Alopecia
71
inflammation of the skin caused by direct contact with an allergen or irritant.
- damage to the epidermis and dermis
- red, itch rash, bullae, vesicles, and wheals also could form
Contact dermatitis
72
cell-mediated or delayed hypersensitivity to a wide variety of allergens.
Allergic contact dermatitis
73
inflammation of the skin from irritants; it is not a hypersensitivity response. ie chemical, soaps, perfumes, poison plants, ie ivy, Latex
Irritant contact dermatitis
74
Impaired Skin Integrity r/t contact dermatitis as evidence by pruritus and rash.
Nursing Diagnosis
75
Area of loss of the superficial layer of the skin aka denuded area
Excoriation
76
Ischemic lesions of the skin and underlying tissues caused by external pressure that impairs the flow of blood and lymph.
Pressure Ulcers
77
tissues softened by prolonged wetting and soaking of skin
Maceration
78
digestive enzymes in feces, gastric tube drainage, urea in urine contribute. The area of loss of the superficial layers of skin aka denuded area
Skin excoriation
79
Non-blanchable erythema of intact skin. could be painful and different temp.
Use a skin prep, hydrocolloid or transparent dressing
Stage I pressure ulcer
80
partial-thickness skin loss involving the dermis. Shallow open ulcer. intact or open pus or blood filled blister, shiny or dry without slough.
Treat with Hydrocolloid or Transparent dressing (unless infected)
Stage II pressure ulcer
81
Full thickness; skin loss involving damage or necrosis of Subcutaneous tissue; bone, tendon and muscle. Not exposed. Deep crater with or without undermining or tunneling of adjacent tissue; slough may be present
Treat with wet to moist gauze, hydrocolloid or proteolytic enzyme
Stage III pressure ulcer
82
Full-thickness with extensive tissue damage and necrosis. -Muscle, tendon, and bone are exposed and directly palpable. Slough or eschar (black) maybe present. Undermining and tunneling are usually present.
-increased likely of osteomyelitis (infected bone)
Treat with wet to moist gauze or VAC therapy; sometiimes surgery is necessary. NEVER use a transparent or hydrocolloid dressing
Stage IV pressure ulcer
83
Full-thickness tissue loss with depth completely obscured by slough or eschar in wound bed. Depth cant be determined until slough or eschar are removed.-once removed can be classified as III or IV.
- Slough or eschar covering 50% of wound.
- Stable eschar on the heels serves as a natural biological cover and shouldnot be removed.
- Might need amputation
Unstageable
84
Intact skin with **Purple or Maroon*** discoloration or blood-filled blister. Indicates damage of underlying soft tissue from pressure or shear. Thin blister over a dark wound bed possibly or develop think eschar.
Suspected Deep Tissue Injury
85
dressing that contain wound moisture ie hydrocolloid and clear absorbent acrylic dressings, trap the wound drainage against the eschar.
-bodys own enzymes in the drainage break down the necrotic tissue
Autolytic debridement
86
alginic acid, an anionic polysaccharide distributed widely in the cell walls of brown algae, where through binding with water forms a viscous gum./gel
-derived from seaweed.
highly absorbent via strong hydrophillic gel formation that minimizes bacteria contaminate. Limits wound secretions
Alginate
87
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Under 18 @ risk for pressure ulcers;
sensory perception
moisture
mobility
nutrition
friction/shear
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Braden Scale 1987
88
```
Possible 24 pts
15 or 16 indicators of pressure area risk
1962
activity
mobility
incontinence
addition of meds in 1987
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Norton Scale 1962
89
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Explores 9 areas
6 general categories
3 special categories for only high risks
general;
build/weight for height
skin type & assessment
sex & age
malnutrition screening
continence
mobility
Primary UK
1 to 64
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Waterlow Score 1985
90
blood-tinged drainage seeps (serosanguineous) from wounds healed by
thick grey, fibrinous tissue-converts to dense scar tissue
secondary intention
91
is the partial or total rupture of a surgical wound. -usually abdominal wound. Layers below also separate. "something has given way"
Dehiscence
92
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Protrusion of the internal viscera through an incision.
Obesity
Poor nutrition
multiple trauma
failure of suturing
excessive coughing
vomiting
dehydration
all heightens clients risk of
4-5 days post-op
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Evisceration
93
purulent exudate; thicker than serous, lg quantity of cell and necrotic cells; can vary in color depending on bacteria. blue, green, yellow, brown, black; depends on microb.
Pyogenic bacteria.
94
helps to strengthen the skin to prevent breakdown
skin prep
95
permeable to air and water vapor so aids in preventing the growth of anaerobic organisms
Hydocolloid (duoderm) dressing
96
allows oxygen and moisture permeability but prevents moisture and bacteria entry
transparent dressing Tagederm dressing
97
aids in debridement of necrotic tissue from wound bed no longer practiced; wet to moist perferred
Wet to dry gauze dressing
98
aid in debridement for infected wounds with dead tissue
Proteolytic enzymes
99
provides negative pressure environment to help reduce edema, increases blood supply, O2 to area, promotes moist environment, decreases bacterial agents and helps with formation of granulation tissue
Vacuum-assisted closure VAC therapy
100
when snthetic skin or skin forms a healthy area of the client is removed and placed over the non-healing wound and sutured
skin grafting
101
COPA
Color of wound bed and drainage
Odor
Consistency of drainage
Amount of drainage
Measurements
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Size
LxWxDiameter
Sterile cotton swab
Tunneling/undermining
Sterile Cotton Swab
Use Clock as a frame of reference
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Wound Description
