Wounds and Skin Integrity Lecture Review

Flashcards covering key vocabulary, definitions, and concepts related to wounds and skin integrity from the lecture notes.

Epidermis

The first layer of skin, which has no blood vessels and regenerates easily.

Dermis

The second layer of skin, composed of connective tissue, containing nerves, blood vessels, and hair follicles.

Subcutaneous layer

The third layer of skin that anchors the skin to underlying tissue, stores fat for energy, provides heat insulation, and cushioning for protection.

Functions of Skin

Includes protection, body temperature regulation, psychosocial function, sensation, Vitamin D production, immunologic response, absorption, and elimination.

Avulsion

An open wound caused by the tearing away of a body part.

Chemical wound

A type of open wound caused by exposure to corrosive substances.

Thermal wound

A type of open wound caused by extreme temperatures (heat or cold).

Incision

A type of open wound with clean, sharp edges, typically caused by a sharp object or surgical cut.

Laceration

A type of open wound characterized by irregular, jagged edges.

Abrasion

A type of open wound caused by superficial rubbing or scraping of the skin.

Puncture wound

A type of open wound caused by a sharp, pointed object that penetrates the skin.

Penetrating wound

A type of open wound where an object enters the body and remains embedded in the tissue.

Contusion

A type of closed wound caused by a blunt instrument, leading to injury of underlying soft tissue with the overlying skin remaining intact (a bruise).

Hemostasis (Wound Healing)

The initial phase of wound healing immediately after injury, involving blood vessel constriction, clotting, and exudate formation.

Inflammatory phase (Wound Healing)

The phase of wound healing lasting 2-3 days, where leukocytes and macrophages clean the wound, and fibroblasts begin to fill the wound.

Proliferation phase (Wound Healing)

The phase of wound healing lasting several weeks, characterized by fibroblasts secreting collagen and growth factors, granulation tissue formation, and blood vessel regeneration.

Maturation phase (Wound Healing)

The final phase of wound healing, beginning around 3 weeks and potentially lasting years, involving collagen remodeling and scar formation.

Desiccation

Localized factor affecting wound healing, referring to the dehydration or drying out of the wound.

Maceration

Localized factor affecting wound healing, referring to the overhydration or softening of the skin due to prolonged moisture exposure.

Necrosis

Localized factor affecting wound healing, referring to the death of tissue.

Biofilm

A thick grouping of microorganisms that can form on wounds and delay healing.

Acute Wound

A wound that heals within days to weeks, typically with approximated edges and a lessened risk of infection.

Chronic Wound

A wound that generally takes longer than 3 months to heal, often remaining in the inflammatory phase, with unapproximated edges and an increased risk of infection.

Protein and amino acids (for wound healing)

Nutrients essential for building muscle, ligaments, skin, transporting lipids, vitamins, minerals, oxygen, and involved in repair and synthesis of enzymes for wound healing.

Vitamin A (for wound healing)

Nutrient needed for protein synthesis, immune function, and maintenance of epithelial tissues.

Vitamin C (for wound healing)

Nutrient needed for collagen formation and absorption of iron.

Zinc (for wound healing)

Nutrient that serves as a co-factor for collagen formation, many aspects of cell metabolism, and assists in immune function.

Iron (for wound healing)

Nutrient that helps form red blood cells, transports oxygen, and supports a healthy immune system.

Infection (Wound Complication)

A serious complication of wound healing, characterized by the presence and multiplication of microorganisms in the wound.

Hemorrhage (Wound Complication)

A serious complication of wound healing involving excessive bleeding.

Dehiscence

A complication of wound healing where the wound separates, typically involving the bursting open of a surgical incision.

Evisceration

The most serious complication of dehiscence, involving the protrusion of internal organs (viscera) through an opened surgical incision.

Fistula formation

A complication of wound healing characterized by an abnormal passage between two internal organs or between an organ and the body surface.

Primary Intention (Wound Healing)

A type of wound healing where the wound edges are well-approximated, leading to minimal tissue loss and a fine scar (e.g., a clean surgical incision).

Secondary Intention (Wound Healing)

A type of wound healing for gaping, irregular wounds where the edges are not approximated, involving granulation tissue formation and a larger scar (e.g., pressure ulcers, severe burns).

Tertiary Intention (Wound Healing)

Also known as delayed primary closure, where a wound is left open to allow for increased granulation, then closed later with sutures, resulting in a wider scar.

Open drainage system

A wound drainage system, such as a Penrose drain, that allows wound drainage to flow out onto a dressing.

Closed drainage system

A wound drainage system, such as a Jackson-Pratt or Hemovac drain, that uses suction to collect drainage in a reservoir.

Arterial Ulcer

A wound caused by insufficient blood supply (ischemia), often presenting with a 'punched out' appearance, smooth wound edges, and pain that may be relieved by elevating the leg.

Venous Ulcer

A wound caused by pooling of blood (increased pressure in veins), often characterized as shallow, superficial, and irregular in shape, typically in the lower legs or ankles.

Pressure Ulcer

A wound with a localized area of tissue necrosis that develops over a bony prominence due to prolonged pressure combined with shear or friction.

Friction (Pressure Ulcer mechanism)

The rubbing of one surface against another, which can damage the epidermis and contribute to pressure ulcer development.

Shear (Pressure Ulcer mechanism)

A mechanism of injury where one layer of tissue slides over another layer, separating the skin from underlying tissues, often when patients are pulled rather than lifted.

Braden Scale

A widely used assessment tool for predicting pressure sore risk, evaluating sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Undermining (Wound Assessment)

A wound characteristic where the wound extends beneath the skin's surface, creating a 'lip' or shelf around the wound edge.

Tunneling (Wound Assessment)

A wound characteristic describing a passageway or channel extending in any direction from the wound bed through subcutaneous tissue or muscle.

Sinus tract (Wound Assessment)

A narrow, elongated channel that usually opens into a wound or abscess.

Blanching

When normal red tones of light-skinned patients are absent, indicating insufficient circulation, ischemia, and potential tissue damage.

Stage I Pressure Ulcer

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin; changes in sensation or temperature may precede visual changes.

Stage II Pressure Ulcer

Partial-thickness skin loss involving the epidermis and/or dermis, presenting clinically as an abrasion, blister, or shallow crater.

Stage III Pressure Ulcer

Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; presents as a deep crater.

Stage IV Pressure Ulcer

Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon or joint capsule); sinus tracts may be present.

Unstageable Pressure Ulcer

A pressure ulcer where the full extent of tissue damage cannot be determined because the base of the wound is covered by eschar or slough, requiring debridement for staging.

Eschar

Dark, leathery, necrotic tissue that may cover a wound, making it unstageable.

Slough

Yellow, tan, gray, green, or brown dead tissue, often moist and stringy, that may cover a wound, making it unstageable.

Red Wounds (Wound Care)

A classification of wounds that appear beefy red due to granulation tissue, indicating a need for protection with dressings and moisture maintenance.

Yellow Wounds (Wound Care)

A classification of wounds with yellow exudate or dead cells, indicating a need for cleansing.

Black Wounds (Wound Care)

A classification of wounds covered with necrotic eschar (black, dry), indicating a need for debridement.

Wound Cleansing

The process of removing debris, contaminants, and excess exudate from a wound, typically using 0.9% normal saline solution.

Sterile Dressing

A wound dressing applied using aseptic technique to prevent infection.

Clean Dressing

A wound dressing applied using clean technique, which reduces microorganisms but is not necessarily sterile.

Occlusive Dressing

A wound dressing that creates a seal over the wound, protecting it from the external environment and maintaining a moist healing environment.

Wet-to-dry Dressing

A wound dressing procedure where a wet dressing is applied and allowed to dry on the wound, then removed, aiding in debridement.

Transparent dressing

A clear, semi-permeable film dressing that allows for visualization of the wound and provides a moist environment.

Hydrocolloid dressing

A dressing that forms a gel upon contact with wound exudate, creating a moist, protective healing environment.

Hydrogel dressing

A dressing that provides moisture to a dry wound and can absorb some exudate.

Alginate dressing

A highly absorbent dressing made from seaweed, used for wounds with heavy exudate.

Foam dressing

A highly absorbent dressing that provides cushioning, insulation, and manages exudate.

Antimicrobial dressing

A dressing that contains agents (e.g., silver) to reduce bacterial presence in the wound.

Contact layer dressing

A non-adherent dressing placed directly on the wound bed to protect it and facilitate atraumatic removal of secondary dressings.

Composite dressing

A multi-layered dressing that combines features of two or more dressing types into a single product.

Osteomyelitis

An infection of the bone, a serious complication that can occur from a Stage 4 pressure ulcer.

Sepsis

A life-threatening complication of infection, often arising from severe pressure ulcers if left untreated.