Chapter 31, Nursing

Front 1

The body's first line of defense

Back 1

The skin

Front 2

The top or outermost portion of the skin; composed of layers of stratified epithelial cell

Back 2

Epidermis

Front 3

The second layer of the skin; consists of a framework of connective tissue; nerves, hair follicles, glands, and blood vessels are located in this layer

Back 3

Dermis

Front 4

The underlying layer that anchors the skin to the underlying tissues of the body; consists of adipose tissue

Back 4

Subcutaneous tissue

Front 5

Skin functions:

Back 5

Protection, temperature regulation, psychosocial, sensation, vitamin d production, immunologic, absorption and elimination

Front 6

A break or disruption in the normal integrity of the skin and tissues.

Back 6

Wound

Front 7

Wound classification:

Back 7

Intentional, unintentional, open, closed, acute, or chronic

Front 8

A wound that results from a blow, force, or strain caused by trauma; skin is not broken, but soft tissue is damaged

Back 8

Closed wound

Front 9

A wound that results from a planned invasive therapy or treatment

Back 9

An intentional wound

Front 10

Wounds that are accidental and occur from unexpected trauma; wound edges are usually jagged; risk for infection is high with a longer healing time

Back 10

Unintentional wound

Front 11

Occurs from an intentional or unintentional trauma; the skin surface is broken, providing a portal of entrance for microorganisms.

Back 11

Open wound

Front 12

A wound, such as surgical incision, that heal within days to weeks; the edges are well approximated and he risk for infection is lessened.

Back 12

Acute wound

Front 13

Any wounds that do not heal along the expected continuum; remains in the inflammatory phase of healing; wound edges are not approximated and the risk for infection are increased

Back 13

Chronic wound

Front 14

Wound repairs occur by:

Back 14

Primary intention, secondary intention, or tertiary intention

Front 15

Wounds healed by ____ intention has well approximated edges with minimal tissue loss

Back 15

Primary intention

Front 16

Wounds healed by ______ intention have edges that are not well approximated; large, open wounds that require more tissue replacement and are often contaminated

Back 16

Secondary intention

Front 17

Wounds healed by _______ intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and are then closed

Back 17

Tertiary intention

Front 18

The wound process can be divided into 4 phases:

Back 18

Hemostasis, inflammation, proliferation, and maturation

Front 19

The first phase of the healing process; occurs immediately after the initial injury; involved blood vessels constrict and blood clotting begins through platelet activation and clustering; increased perfusion results in heat and redness

Back 19

Homeostasis

Front 20

The second step in the healing process which follows hemostasis; lasts about 4-6 days; white blood cells and macrophages move to the wound; the growth factors also attract fibroblasts that help to fill in the wound.

Back 20

Inflammatory phase

Front 21

The 3rd stage of the healing process; known as the fibroblastic, regenerative, or connective tissue phase; this phase lasts for several weeks; new tissue is built to fill the wound space, primarily through the action of fibroblasts

Back 21

Proliferation phase

Front 22

New tissue; forms the foundation for scar tissue development; it is highly vascular, red, and bleeds easily

Back 22

Granulation tissue

Front 23

The final stage of the healing process; usually occurs about 3 weeks after injury, continuing for months or years; collagen that was deposited into the wound is remodeled, making the healed wound stronger and more like adjacent tissue

Back 23

Maturation phase

Front 24

An avascular collagen tissue that does not sweat, grow hair, or tan in sunlight; the strength of the tissue remains less than that of normal tissue and is never fully restored

Back 24

Scar

Front 25

Factors effecting wound healing:

Back 25

Desiccation (dehydration)

Maceration (overhydration such as edema)

Necrosis (death of tissue)

Presence of biofilm & systematic factors (age, circulation, oxygen)

Front 26

Results when the patients immune system fails to control the growth of microorganisms; symptoms usually become apparent within 2-7 days after injury or surgery ; symptoms include purulent drainage, pain, redness, swelling, increased body temperature, and increased white blood cell count

Back 26

Wound infection

Front 27

The partial or total separation of wound layers as a result of excessive stress on wounds that are not healed; if this occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride, place the patient in semi fowlers and notify the physician

Back 27

Dehiscence

Front 28

The most serious complication of dehiscence; the wound completely separates, with protrusion of viscera through the incisional area

Back 28

Evisceration

Front 29

An abnormal passage from an internal organ or vessel to the outside of the body, or from one internal organ or vessel to another; often a result of an infection that has turned into an abscess , leading to the formation of unnatural passage

Back 29

Fistula

Front 30

Deficiency of blood in a particular area

Back 30

Ischemia

Front 31

A wound with a localized area of injury to the skin and/or underlying tissue; most develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time; may form in as little as 1-2 hours of non movement

Back 31

Pressure ulcer

Front 32

Deficiency of blood in a particular area

Back 32

Ischemia

Front 33

Inadequate amount of oxygen available to cells

Back 33

Hypoxia

Front 34

Occurs when two surfaces run against each other; resembles an abrasion and can damage superficial blood vessels directly under the skin

Back 34

Friction

Front 35

Results when one layer of tissue slides over another layer; separates the skin from underlying tissues

Back 35

Shear

Front 36

Risks for pressure ulcer development

Back 36

Immobility, nutrition, hydration, skin moisture, mental status, and age

Front 37

Pressure ulcer that is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence

Back 37

Stage I pressure ulcer

Front 38

Pressure ulcer that is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence

Back 38

Stage I pressure ulcer

Front 39

A pressure ulcer that involves partial thickness loss of dermis and presents as a shallow, open ulcer

Back 39

Stage II pressure ulcer

Front 40

Pressure ulcer that is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence

Back 40

Stage I pressure ulcer

Front 41

A pressure ulcer that involves partial thickness loss of dermis and presents as a shallow, open ulcer

Back 41

Stage II pressure ulcer

Front 42

A pressure ulcer that presents with full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed

Back 42

Stage III pressure ulcer

Front 43

A pressure ulcer that involves full thickness tissue loss with exposed bone, tendon, or muscle; slough or Eschar may be present on some part of he wound bed

Back 43

Stage IV

Front 44

Softening and breakdown of skin; results from prolonged exposure to moisture

Back 44

Maceration

Front 45

Dead tissue present in the wound delays healing; may appear as sloth, moist, yellow, stringy tissue

Back 45

Necrosis

Front 46

Dead tissue present in the wound delays healing; may appear as sloth, moist, yellow, stringy tissue

Back 46

Necrosis

Front 47

Skin that appears as dry, black, leathery tissue

Back 47

Eschar