Key Terms for Skin Integrity and Wound Healing
Terms
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- abrasion
- a superficial wound with little bleeding and is considered a partial-thickness wound. May appear weepy.
- Approximated
- the skin edges are closed as in a surgical insicision (no tissue is lost)
- Blanching
- turns light in color. A normal characterists for lightly pigmented skin.
- Debridement
- the removal of nonviable necrotic tissue.
- Mechanical Debridement
-
1. use of wet-to-dry saline gauze dressings
2. high pressure irrigation
3. whirlpool - Autolytic debridement
- uses synthetic dressings over a wound that allow the necrotic tissue (eschar) to be digested by the body's enzymes. ex.transparent film dressings.
- chemical debridement
- employ the use of topical enzymes to breakdown the necrotic tissue. ex: sterile maggots and Dakin's solution.
- surgical debridement
- surgical removal of necrotic tissue. used when client has cellulitis or sepsis.
- Dehiscence
- the partial or total separation of wound layers.
- Dermis
- the inner layer of the skin it proveds support to the epidermis and protection to the muscles, contains connective tissue and collagen.
- epidermis
- the top layer of the skin
- erythema
- red discoloration of the skin, may indicate circulatory changes
- eschar
- necrotic tissue, usually black or brown in color.
- edema
- swelling
- evisceration
- a protrusion of viseral organs through a wound opening.
- exudate
- describes the amount, color, odor, and consistency of wound drainage.
- granulation tissue
- red moist tissue
- slough
- stringy sbstance attached to wound bed that must be removed before wound can heal.
- friction
- the mechanical force that is created when skin is dragged across a coarse surface.
- Shearing force
- example: The head of the bed is elevated and the sliding of the skeleton starts, but the skin is fixed becuase of friction with the bed.
- Hematoma
- a localized collection of blood underneath the tissues.
- homeostasis
- equilibrium
- ischemia
- an inadequate blood supply to an organ or part of the body. resulting from collapsed capillaries= vessel occluding
- Necrosis
- dead cells
- purulent
- consistingof, containing, or discharging of pus.
- pressure ulcer
- impaired skin integrity related to unrelieved, prolonged pressure.
- Norten Scale
- It scores 5 risk factors for pressure ulcers. total score ranges from 5 to 20.
- Braden Scale
- most commonly used. Composed of 6 sudscales: sensory perc., moisture, mobility, nutrition, friction and shear. A lower score indicates a higher risk.
- Sanguinous
- Bright red wound drainage; indicates active bleeding.
- Serosanguinous
- Pale red, watery: mixture of clear and red fluid.
- Serous
- Clear watery plasma.
- Stage I pressue ulcer
- No open skin areas, does not blanch, compare to adjacent skin; temp., tissue consistancy(firm or boggy), sensation(itching or pain)
- Stage II Pressure Ulcer
- Skin is not intact. There is a partial thickness loss of the epidermis or dermis. Ulcer is superficial
- Stage III Pressure Ulcer
- Skin loss is full thickness. Subcutaneous tissue damage/necrotic. Deep crater-like appearance or eschar present
- Stage IV Pressure Ulcer
- Skin loss is full thickness with extensive destruction, necrosis, or damage to muscle or bone. underming is present. Sinus tracts may develope.
- Undermining
- seperation of the skin layers at the wound margins.