Chapter 48: Skin Integrity and Wound Care
Abrasion
Superficial with little bleeding and is considered a partial-thickness wound
Approximated
To come close together, as in the edges of a wound
Blanch Test
Pressing a finger on the affected area; it turns a lighter color and returns to a normal color.
Blanching
When the normal red tones of the light-skinned patient are absent
Blanchable Hyperemia
Redness of the skin caused by dilation of the superficial capillaries. When pressure is applied to the skin, the area blanches, or turns a lighter color
Collagen
A tough, fibrous protein
Debridement
The removal of nonviable, necrotic tissue
Dehiscence
Separation of the edges of a wound, revealing underlying tissues.
Dermal-Epidermal Junction
The membrane that separate the two skin layers
Dermis Layers
Drainage Evacuators
Convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage.
Epidermis Layers
Epithelialization
The formation of granulation tissue into an open wound allows the reepithelialization phase to take place, as epithelial cells migrate across the new tissue to form a barrier between the wound and the environment.
Eschar
Thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn. It may be allowed to be sloughed off naturally, or it may need to be surgically removed.
Evisceration
Protrusion of visceral organs through a surgical wound.
Extravasation
A discharge or escape, as of blood, from a vessel into the tissues.
Exudate
Fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes.
Fibrin
A fibrous, non-globular protein involved in the clotting of blood
Fluctuance
Soft, boggy feeling when tissue is palpated; usually a sign of tissue infection.
Friction
The force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens.
Granulation tissue
Red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.
Hematoma
Collection of blood trapped in the tissues of the skin or an organ.
Hemorrhage
Bleeding from a wound site
Hemostasis
Termination of bleeding by mechanical or chemical means or the coagulation process of the body.
Hyperemia
Redness in the skin after the pressure is relieved and blood flow returns.
Induration
Hardening of a tissue, particularly the skin, because of edema or inflammation.
Laceration
Torn, jagged wound.
Negative Pressure Wound Therapy
A therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of second and third degree burns.
Nonblanchable Erythema
If the erythematous area does not blanch when you apply pressure, deep tissue damage is probable.
Pressure Duration
Low pressure over a long period of time and high pressure over a short period of time both cause tissue damage.
Pressure Intensity
If pressure is applied and exceeds normal pressure and the vessel is occluded may cause damage.
Pressure Ulcer
Inflammation, sore, or ulcer in the skin over a bony prominence.
Primary Intention
Primary union of the edges of a wound, progressing to complete scar formation without granulation.
Puncture
Wounds bleed in relation to the depth, size, and location of the wound (e.g., a nail puncture does not cause as much bleeding as a knife wound).
Purulent
A yellow, green, or brown color wound drainage.
Reactive hyperemia
The transient increase in organ blood flow that occurs following a brief period of ischemia
Sanguineous
Bright red; indicates active bleeding wound drainage.
Secondary intention
In which the wound is left open and closes naturally (Scar tissue)
Serosanguineous
Pale, pink, watery; mixture of clear and red fluid wound drainage.
Serous
Clear, watery plasma wound drainage
Shearing force
Unaligned forces pushing one part of a body in one specific direction, and another part of the body in the opposite direction.
Slough
Stringy substance attached to wound bed
Sutures
Threads or metal used to sew body tissues together
Tissue ischemia
Point at which tissues receive insufficient oxygen and perfusion
Tissue Tolerance
The ability to endure pressure depends on the integrity of the tissue and the supporting structures.
Vacuum-assisted closure (V.A.C.)
A device that helps in wound closure by applying localized negative pressure to draw the edges of a wound together.
Wound
A disruption of the integrity and function of tissues in the body
Category/Stage I
Intact Skin with nonblanchable redness in a localized area.
Category/Stage II
Partial thickness loss of the dermis and has a shallow, open ulcer.
Category/Stage III
Full thickness skin loss, subcutaneous fat may be visible, and it may include undermining and tunneling; slough may be present.
Category/Stage IV
Full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present.
Unstageable/Unclassified
Full tissue loss with the depth of the ulcer obscured by slough and/or eschar in the wound bed.
Suspected Deep
Purple or maroon localized area of discolored intact skin or a blood filled blister caused by underlying soft tissue damage.
When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
What is the correct sequence of steps when performing a wound
irrigation?
1. Use slow continuous pressure to irrigate wound.
2. Attach angio catheter to syringe
3. Fill syringe with
irrigation fluid
4. Place water proof bag near bed
5.
Position angio catheter over wound
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?
Which of the following describes a hydrocolloid dressing?
What is the removal of devitalized tissue from a wound called?
What does the Braden Scale evaluate?
On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient’s pressure ulcer?
After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.)
Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.)
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.)
When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.)
Which of the following are measures to reduce tissue damage from shear? (Select all that apply.)
Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present.
Full thickness skin loss, subcutaneous fat may be visible. May include undermining
Full thickness tissue loss, muscle and bone visible. May include undermining.
Partial thickness skin loss or intact blister with serosanginous fluid