Skin And Wound

Front 1

clean wounds

Back 1

uninfected wounds in which minimal inflammation is encountered and the respiratory, alimentary, genital, and urinary tracts are not entered. clean wounds are primarily closed wounds

Front 2

clean-contaminated wounds

Back 2

surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. such wounds show no evidence of infection

Front 3

contaminated wounds

Back 3

open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. contaminated wounds show evidence of inflammation.

Front 4

dirty or infected wounds

Back 4

wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage

Front 5

how are wounds, excluding pressure ulcers and burns, classified?

Back 5

by depth, this is, the tissue layers involved in the wound

Front 6

incision

Back 6

open wound; deep or shallow
cause: sharp instrument (e.g. knife or scalpel)

Front 7

contusion

Back 7

closed wound, skin appears ecchymotic (bruised) b/c of damaged blood vessels
cause: blow from a blunt instrument

Front 8

abrasion

Back 8

open wound involving the skin
cause: surface scrape, either unintentional or intentional

Front 9

puncture

Back 9

open wound
cause: penetration of the skin & often the underlying tissues by a sharp instrument, either intentional or unintentional

Front 10

laceration

Back 10

open wound; edges are often jagged
cause: tissues torn apart, often from accidents (e.g. w/ machinery)

Front 11

penetrating wound

Back 11

open wound
cause: penetration of the sking & the underlying tissues, usually unintentional (e.q. from a bullet or metal fragments)

Front 12

classifying wounds by depth:
partial thickness

Back 12

confined to the skin, that is, the dermis & epidermis; heal by regeneration

Front 13

classifying wounds by depth:
full thickness

Back 13

involving the dermis, epidermis, subcutaneous tissue, & possibly muscle & bone; require connective tissue repair

Front 14

pressure ulcers

Back 14

previously called decubitus ulcers, pressure sores, or bedsores; any lesion caused by unrelieved pressure that results in damage to underlying tissue

Front 15

ischemia

Back 15

a deficiency in the blood suppl to the tissue; pressure ulcers are due to localized ______

Front 16

reactive hyperemia

Back 16

bright red flush the skin takes on when pressure is relieved

Front 17

vasodilation

Back 17

a process in which extra blood floods to the area to compensate for the preceding period of impeded blood flow; causes the flush

Front 18

friction

Back 18

one factor that acts in conjunction w/ pressure to form pressure ulcers; force acting parallel to the skin surface

Front 19

shearing force

Back 19

another factor that can contribute to formation of pressure ulcers; a combination of friction & pressure; occurs commonly when a client assumes a Fowler's position in bed. p.904

Front 20

immobility

Back 20

refers to a reduction in the amount & control of movement a person has; another risk factor contributing to formation of pressure ulcers

Front 21

maceration

Back 21

tissue softened by prolonged wetting or soaking; makes epidermis more easily eroded & susceptible to injury; promoted by moisture from incontinence

Front 22

excoriation

Back 22

area of loss of the superficial layers of the skin also known as denuded area; contributed to by digestive enzymes in feces, gastric tube drainage, & urea in urine

Front 23

changes that come with age that make an older person more prone to impaired skin integrity

Back 23

loss of lean body mass;
generalized thinning of the epidermis;
decreased strength & elasticity of the skin due to changes in the collagen fibers of the dermis;
increased dryness due to a decrease in the amount of oil produced by the sebaceous glands;
diminished pain perception due to a reduction in the # of cutaneous end organs responsible for the sensation of pressure & light touch;
diminished venous & arterial flow due to aging vascular walls

Front 24

risk factors for pressure ulcers

Back 24

friction & shearing;
immobility;
inadequate nutrition;
fecal & urinary incontinence;
decreased mental status;
diminished sensation;
excessive body heat;
advanced age;
chronic medical conditions;
poor lifting & transferring techniques;
incorrect positioning;
hard support surfaces;
incorrect application of pressure relieving devices

Front 25

regeneration

Back 25

healing; renewal of tissues

Front 26

primary intention healing

Back 26

occurs where the tissue surfaces have been approximated (closed) & there is minimal or no tissue loss; characterized by the formation of minimal granulation tissue & scarring; also called primary union or first intention healing

Front 27

secondary intention healing

Back 27

a wound that is extensive & involves considerable tissue loss, & in which the edges cannot or should not be approximated heal by this type; an example of a wound healing by this type is a pressure ulcer; difffers from primary intention healing in 3 ways: (a) repair time is longer (b) scarring is greater (c) susceptibility to infection is greater

Front 28

tertiary intention

Back 28

those wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain & are then closed with sutures, staples, or adhesive skin closures heal by this type ; also called delayed primary intention

Front 29

phases of wound healing

Back 29

1. inflammatory phase
2. proliferative phase
3. maturation phase

Front 30

inflammatory phase

Back 30

initiate immediately after injury & lasts 3-6 days; includes hemostasis and phagocytosis

Front 31

hemostasis

Back 31

the cessation of bleeding; results from vasoconstriction of the larger blood vessels in the affected area, retraction of injured blood vessels, the deposition of fibrin (connective tissue), & the formation of blood clots in the area

Front 32

phagocytosis

Back 32

during cell migration, leukocytes move into the interstitial space. these are replaced about 24 hours after injury by macrophages, which arise from the blood monocytes. these macrophages engulf microorganisms and cellular debris by this process.

Front 33

collagen

Back 33

a whitish protein substance that adds tensile strength to the wound

Front 34

granulation tissue

Back 34

capillaries grow across the wound, increaasing the blood supply. fibroblasts move from the bloodstream into the wound, depositing fibrin. as the capillary network develops, the tissue becomes a translucent red color. this tissue, called _____, is fragile & bleeds easily.

Front 35

eschar

Back 35

if the wound does not close by epithelialization, the area becomes covered with dried plasma proteins and dead cells.