Skin Integ/Wound Heal

  1. Define Abrasion
    • Results when skin rubs against a hard surface.
    • Friction scrapes away the epithlial layer exposing epidermal or dermal layer.
  2. Define Approximated:
    • The edges of the primary wound are lightly pulled together.
    • Granulation tissue is not visible and scarring is usually minimal.
  3. Define Binder
    • Wound support used to support a specific body part or to hold dressing in place.
    • The use of velcro has increased ease of applications and comfort.
  4. Define Debridement
    The removal of foreign material or dead tisue from a wound to discourage the growth of microorganisms and to promote healing.
  5. What are the types of Debridement?
    • Mechanical
    • Surgical
    • Enzymatic
    • Autolytic
  6. What Is Surgical Debridement?
    Use of sharp instruments to debride the wound-Surgical procedure.
  7. What is Enzymatic Debridement?
    Process of placing chemical products within the wound to help breakdown necrotic debris
  8. What is Autolytic Debridement?
    • Removal of debris and necrotic tissue using body's own fluid and cells.
    • Occurs when an occlusive dresing is applied ove a wound and lef in place while wound exudate and body fluids build up.
  9. What is Mechanical Debidement?
    Removal of necrotic or devitalized tissue from a wound using friction, hydrotherapy, scraping or wet-to-dry-dressings.
  10. Define Dehiscence:
    • Total or partial disruption in wound edges.
    • Wound seperation, most commonly used to descrie surgical inscisions in which the skin has seperated by underlying subq has not.
  11. Define Dermis
    • Underlies the epidermis, is the thickest skin layer and is composed of tough connective tissue.
    • Major cell is Fibroblast which produces collagen and elastin.
    • Well Vascularized, Contains lymphatic vessels and nerve tissues
  12. Define Desquamation:
    • The process of continuously sheding of the thin outermost layer of the epidermis.
    • (Process of shedding the stratum corneum or horny layer)
  13. Define Epidermis
    • The skin's outer layer, is avasuclar and composed of layers of stratified squamous epithelial cells.
    • Specializes to form the hair, nails, and glandular structures.
    • Relies on dermis for nutrition
  14. Define epithelialiation.
    The process in partial-thickiness wounds, in the third phase the proliferation phase, epidermal cells, which appear pink, reproduce and migrate across the suface of the wound.
  15. What are the phases of Wound Healing?
    • Hemostasis
    • Inflammatory
    • Proliferative
    • Maturation
    • Process takes 12-24 months to complete.
  16. Define Evisceration:
    • The protrusion of viscera through an abdominal wound opening.
    • Can follow dehiscence of the opening.
    • Extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.
  17. Define Fistula
    • An abnormal tube-like passageway that forms between two organs or from one organ to outside of the body.
    • (ie recto-vaginal fistula permits feces to enter the vagina)
  18. Define Granulation Tissue:
    • Proliferation Phase begins with development of beefy, red and granular tissue that consists of collage embeded with macrophages, fibroblasts and capillary buds.
    • Last 4 after injury to 21 days in normal healing full thicknes wound.
  19. Define Hematoma
    • The localized collection of blood.
    • Appears as a swelling or mass underneath the skin surface often with a bluish color.
  20. Define Laceration.
    • An open wound or cut.
    • Most only affect the upper layers of skin and subcutaneous tissue underneath.
  21. Define Macerated:
    • Skin that is continually exposed to moisture softens.
    • Appears wrinkled and is lighter in appearance than healthy tissue.
    • Increasing its susceptibility to trauma and infection.
  22. Define Pressure Ulcer
    A localized area of tissue destruction caused by compression of soft tissue over a bony prominence and an external surface for a prolonged period of time.
  23. Define Purulent:
    • Drainage contains white cells and microorganisms and occurs when infection is present.
    • Thick, opaque and can vary from yellow, green, tan, depending on organism.
    • Presence of undermining/tunneling.
  24. Define Sanguineous
    Drainage is bloody a from an acute laceration.
  25. Define Serous:
    Drainage is pale yellow, watery, and like th fluid from a blister.
  26. Define Serosanguineous
    Drainage is pale pink-yellow, thin and contains plasma and red cells.
  27. Define Subcutaneous Tissue
    • Underlies the skin.
    • Primarly consists of fat and connective tissue that support the skin
  28. Functions of Skin Include:
    • Protection
    • Thermoregulation
    • Sensation
    • Metabolism - Vit D
    • Communication
  29. Characteristics of Normal Skin Include
    • Temperature - Warm
    • Moisture - Dry
    • Texture and Thickness - Elastic, Smooth
    • Odor - Free of
  30. Affecting Factors of Integumentary Function
    • Circulation
    • Nutrition
    • Condition of Epidermis
    • Allergy
    • Infection
    • Abnormal Growth Rate
    • Individual factors (age, weight, smoker Medication, stress)
  31. Disruption of normal skin integrity can cause:
    • Pain
    • Pruritus
    • Rashes
    • Lesions
    • Open Wounds
  32. Types of Wound Healing:
    • Primary Intention-Shallow or clean surgical
    • Secondary Intention-Full-thickness tissue loss
    • Tertiary Intention-Delay between injury and wound closure
  33. Subjective Data Assessment Includes
    • Risk Identification-Factors that may delay healing
    • Dysfunction Indentification-Ask about present wounds.
  34. Objective Data Assessment Includes:
    • Physical examination of skin
    • Wound assessment.
  35. Possible Nursing Dx in Skin include
    • Impared Skin Integrity.
    • Impared Tissue Integrity. (mucous membrane corneal intgumentary or subq)
    • Risk for Impaired Skin Integrity.
  36. What is Friction
    • Occurs when two surfaces rub together.
    • (ie skin rubs against wrinkled bedding)
  37. What is Shear
    • Occurs when tissue layers move on each other causing blood vessels to stretch as they pass through subq Tissue.
    • (ie Clients skin remains immobile bc of friction but deeper structures, facia, move with client bc of attachment to bone)
  38. Types of Dressing include:
    • Transparent Films
    • Foams
    • Hydrocolloids
    • Hydrogels
    • Alginate
    • Collagens
    • Composites
    • Contact Layers
    • Silver Dressings
  39. An Alginate Dressing is used for
    Absorption, indicated for deep or moderately draining wounds
  40. Hydrogels dressings are used for
    Encourage granulation within full-thickness wounds and privde comfort for tender, partial-thickness wounds.
  41. Foams in Dressing are used for:
    Hydrophilic polyurethane used for partial and full thickness wounds with small to moderate drainage, foams provde absorption and protection.
  42. Contact Layer Dressings are
    • nonadherent dressing that will not stick to wound surface.
    • Minimizes disruption of new cells.
  43. Silver Dressing wounds are:
    antimicrobial dressing used for infected wounds.
Card Set
Skin Integ/Wound Heal
Chapter 39 Vocab