nur 121 skin integrity and wound care

fistula

abnormal tunnel that forms between two body parts that aren’t supposed to be connected

friction

rubbing of the skin against something that damages the surface

granulation tissue

new healthy tissue that grows in a healing wound (bringing in new blood vessels and helping the wound close + heal)

hematoma

a collection (pool) of blood under the skin looks like a big, swollen bruise with a lump (blood vessels breaks and gets trapped under the skin)

incontinence associated dermatitis IAD

skin irritation and damage caused by pee or poop staying on the skin (moisture and chemicals irritate the skin)

ischemia

lack of blood flow to a body part causing tissue damage (blood carries oxygen and nutrients, if it can’t the tissue starves and gets damaged)

maceration

skin that gets too wet and becomes soft + damaged (white soggy skin)

necrosis

dead body tissue (usually after ischemia, tissue didn’t get blood/oxygen so it died) it’s usually black/brown + dry

negative pressure wound therapy NPWT

suction device/wound dressing that uses suction (vacuum) to help a wound heal (pulls out drainage, removes infection risk)

off-loading

taking pressure off a body part to protect or heal skin

pressure injury

skin damage caused by too much pressure (usually over bony areas) pressure → ischemia → tissue damage

primary intention

wound that is closed right away (edges are brought together and closed) to heal faster

purulent

pus (sign of infection) thick fluid! yellow, green or brown, bad smell

sanguineous

bloody drainage (fresh blood coming from a wound) a little is normal, a lot is a problem

secondary intention

wound that is left open to heal (wound can’t be closed so the body has to fill it from the bottom up) heals slower, risk of infection and see granulation tissue forming

serosanguineous

a mix of clear fluid and a little of blood (pink drainage) it’s usually good and normal

serous

clear, watery drainage from a healing wound, it’s good and normal

shear

skin stays in place, but the tissue underneath moves which causes deep damage + decreases blood flow (ischemia) which leads to pressure injuries

sitz bath

sitting in warm water to soak your bottom area (soothes pain, helps healing, keeps area clean)

sloughing

dead tissue in a wound (soft and yellow) usually needs to be removed because it’s bad for healing since blocks granulation

subcutaneous tissue

layer of fat under your skin (under the dermis and above the muscles) it protects your body, stores fat, keep you warm

sutures

stitches used to close a wound (hold wound edges together, heals faster, low risk of infection)

tertiary intention

wound is left open at first, then closed later (wound is dirty or infected to close right away so you let it heal/clean then close it) it prevents trapping infection inside

wound

any break or damage in the skin, it’s open or injured when it’s supposed to be closed and protected