Skin Assessment And Wound Care

Front 1

approximated wound edges

Back 1

edges lightly pulled together, appear to be touching.

Front 2

dehiscence

Back 2

accidental separation of edges, especially surgical wounds

Front 3

ecchymosis

Back 3

discoloration of an area resulting from infiltration of blood into subcutaneous tissue.
bruise

Front 4

epithelialization

Back 4

stage of wound healing, epithelial cells move across surface of wound----pink

Front 5

erythema

Back 5

redness or inflammation, resulting from dilation and congestion of capillaries

Front 6

eschar

Back 6

thick, leathery scab---dead cells, and dried plasma

Front 7

granulated tissue

Back 7

new tissue, pink/red, composed of fibroblasts and small blood vessels

Front 8

ischemia

Back 8

insufficient blood supply to body part due to obstruction of circulation

Front 9

maceration

Back 9

softening of tissue due to excessive moisture

Front 10

peripheral neuropathy

Back 10

condition with inflammation and degeneration of peripheral nerves. sensations include burning, tingling, numbness.

Front 11

sinus tract

Back 11

cavity or channel underneath wound with potential for infection

Front 12

tachycardia

Back 12

rapid heart rate >100

Front 13

tunneling

Back 13

passageway/opening maybe visible but most is under skin surface

Front 14

undermining

Back 14

areas of tissue destruction underneath intact skin along margins of a wound

Front 15

vasoconstriction

Back 15

narrowing of the lumen of a blood vessel

Front 16

vasodilation

Back 16

increase in diameter of blood vessel

Front 17

epidermis

Back 17

hair, nails, glandular structures, depends on dermis for nutrition

Front 18

dermis

Back 18

thicker, produces collagen and elastin home for lymphatic vessels and nerve tissues.

Front 19

temp reg

Back 19

dilation and constriction of blood vessels regulates body temp

Front 20

skin

Back 20

makes vit. D to aid in calcium absorption and phosphorous

Front 21

primary intention wound

Back 21

shorter healing time. wounds approximated, surgical incision

Front 22

secondary intention wound

Back 22

primary will become 2nd if get infected.
large with considerable tissue loss. healing by formation of granulated tissue. >infection >longer healing >scars

Front 23

wound assessment

Back 23

-appearance, inspection and palpation.
-size
-drainage: assess amount, color, odor, and consistency
-pain: incisional pain is usually severe for the 1st 2-3 days. if increased or acute, sign of delayed healing.
-sutures, drains, tubes
-evidence of complications

Front 24

Pressure Ulcer assessment

Back 24

size: draw shape and describe.
depth: steril swab w/ saline @ 90degree angle. mark pt on swab that is even with surrounding skin.
presence of undermining: tunneling, or sinus tract. saline sterile swab under wound edge.

Front 25

stage I pressure ulcer

Back 25

change in temp (cool/warm)
change in tissue consistency
change in sensation
pink-caucasians
blue/purple-blacks

Front 26

stage II pressure ulcer

Back 26

partial thickness skiin loss. presents as blister, shallow crater

Front 27

stage III pressure ulcer

Back 27

full thickness skin loss. damage/necrosis of dermis not to underlying fascia.

Front 28

Stage IV pressure ulcer

Back 28

full thickness skin loss with extensive destruction, necrosis, damage to muscle, bone, or supporting structure. sinus tracts can be associated.

Front 29

turgor

Back 29

elasticity of skin

Front 30

hyperkeratosis

Back 30

skin thickening, flaking, scales

Front 31

abnormal skin color

Back 31

(normal is even toned, w/o variation)
pallor-poor circulation
cyanosis-low O2
jaundice-liver disease

Front 32

dermatitis

Back 32

rash. if rash is all over body, usually a drug or food allergy

Front 33

inflammatory phase

Back 33

1st phase in wound healing.
hemostasis.
-vasoconstriction
-immediate
-blood clotting
-leukocytes

Front 34

proliferative phase

Back 34

second phase.
-epitheliazation
-fibroblasts (conn tissue)
-granulation
-lasts 2days-3wks

Front 35

maturation phase

Back 35

3rd stage
-remodeling
-collagen remodeled
-contraction
-scar
-3wks to 2 years.

Front 36

scar

Back 36

avascular, doesn't sweat, grow hair, or tan in sunlight.
-fire victims can't thermoregulate body

Front 37

sterognosis

Back 37

sensation to touch

Front 38

skin assessment

Back 38

-temp
-color
-moisture
-turgor
-integrity

Front 39

edema

Back 39

a decrease in skin mobility due to accumulation of fluid in intercellular spaces.
-not a normal finding
-document on 4-pt scale

Front 40

acute wound

Back 40

-surgical incision
-healing within days to weeks
-edges well-approximated
-decreased risk for infection

Front 41

chronic wound

Back 41

-pressure ulcers, peripheral arterial or venous ulcers
-normal healing time is delayed
-edges not approximated
-increased risk for infection
-bacterial counts >100,000 per gram of tissue impede healing

Front 42

older adult: factors affecting wound healing

Back 42

-slower inflammatory response
-reduced antibody productiona nd endocrine system function
-increased incidence of chronic illness such as DM and CVD that compromise circulation and tissue oxygenation
-decreased secretion of enzymes and absorption of nutrients and minerals

Front 43

factors affecting wound healing

Back 43

-age
-circulation and oxygenation (obese people/ few bld vessels)
-nutritional status
-wound condition
-health status: corticosteroids decrease the inflammatory process

Front 44

evisceration

Back 44

protrusion of viscera through the incision area.
risk factors: obesity/malnurishment, infected wounds, excessive coughing/vomiting, or straining.
-an increase in the flow of serosanguineous fluid from teh wound btwn postoperative days 4 and 5 indicates an impending dehiscence.
-cover with sterile towel soaked in NS, notify doctor

Front 45

fistula

Back 45

an abnormal passage from internal organ to the skin or from one internal organ to another.
signs: drainage from an opening in the skin or surgical site, pain.
-risk for fluid and electrolyte imbalance, skin breakdown, and infection

Front 46

serous drainage

Back 46

clear and watery

Front 47

sanguineous drainage

Back 47

RBC

Front 48

purulent drainage

Back 48

thick, foul odor, yellow or green

Front 49

serosanguineous drainage

Back 49

mixture of serum and RBC

Front 50

dressing layers

Back 50

most are 3 layers:
-contact layer allows draingage to pass into
-middle layer absorbs drainage
-outer layer keeps the two inner layers in place

Front 51

gauze

Back 51

-mechanical debridement (wet to dry)
-healing wounds (moist to damp) NEVER LET IT DRY OUT
-used as packing, don't pack above the surface of a wound

Front 52

Transparent films

Back 52

-acu-derm, bioclusive, op-site, tegaderm
-for superficial wound iwth little or no drainage
-may remain in place for 24-72 hours
-softens dry eschar by moisture (autolysis)

Front 53

Hydrocolloid

Back 53

-duoderm, tegasorb, restore, comfeel
-for shallow or moderate depth ulcers with minimal drainage
-absorb drainage
-maintain a moist wound environment
-decrease the risk for inf.
-remain in place for 3-5 days.

Front 54

Hydrogel

Back 54

-aquasorb, biolex, clearsite, nugel, vigilon
-sheets or gel
-cooling ability, nonadhesive
-for thermal burns or painful wounds w/ minimal exudate
-add moisture to dry eschar
-remain in place for 8-48 hrs.
GELS:
-maintain moist healing environment
-fill empty space

Front 55

alginate

Back 55

-for wounds with moderate to heavy exudate
-masses of fibers (curasorb, kaltostat, sorbsan) to form a moisture-retentive gel on contact with exudate
-high absorbent capability
-"seaweed" odor
-needs secondary dressing ot hold in place
-for infected wounds