2. Tissue Integrity Glossary

Tissue Integrity (Lecture Notes from ATI)

_______ is the process of Comparing results and outcomes to other sources of similarly retrieved data.

Benchmarking

________ ______ is an area of skin that temporarily turns white or pale when light pressure is applied.

blanchable erythema

Cellulitis is an infection of the __ layers of skin.

superficial

_______ is the process of surgically removing dead tissue and other debris that can cause infection.

Debridement

Deep tissue pressure injury (DTPI) is a persistent __tissue injury of the skin appearing __, __, or __ in color.

nonblanchable, deep red, maroon, or purple

_______ is the complete or partial separation of the suture line and underlying tissues that occurs when a wound fails to heal properly.

Dehiscence

__ is a red skin irritation that develops when the skin is exposed to irritants such as feces, urine, and wound exudates.

Dermatitis

The dermis is the layer under the epidermis composed mainly of __ tissue.

connective

The epidermis is the outermost layer of the skin made of __ epithelial cells.

squamous

_____ is redness of the skin due to dilation of blood vessels.

Erythema

____ is hard nonviable black/brown tissue found in the wound bed.

Eschar - is hard nonviable black/brown tissue found in the wound bed.

________ is the protrusion of internal organs through a surgical wound which has dehisced.

Evisceration - A serious surgical complication where internal organs come out through the incision site.

Exudate is fluid secreted by the body during the __ stage of healing.

inflammatory

____ is the force created when two objects rub together.

Friction

__ tissue is new skin tissue that forms on the _surface of the wound.

Granulation

A __ is an accumulation of blood in the body.

hematoma

__ refers to bleeding that may be internal or external.

Hemorrhage

___ results in low oxygen levels in tissues caused by inadequate supply of blood circulation.

Hypoperfusion

____ refers to levels of oxygen that are below the expected level in body tissue.

Hypoxia

Keratinocytes are cells formed in the __ layer of the skin.

basal

__ refer to any tearing of the skin, usually caused by blunt or sharp objects.

Lacerations

__ cells play a role in the cutaneous immune system reactions.

Langerhans

___ is an irritation of the epidermis caused by moisture.

Maceration

__ is an imbalance in a client's intake, which can include deficiencies or excesses in nutrients.

Malnutrition

__ is a pigment that determines the color of hair, skin, and eyes.

Melanin

Melanocytes produce __ and are found in the epidermis.

melanin

_____ __ are specialized receptor cells in the epidermis for detection of light touch.

Merkel cells

_____ is a form of dermatitis caused by exposure to irritants.

Moisture-associated skin damage (MASDis a condition characterized by inflammation and damage to the skin due to prolonged exposure to moisture and irritants, leading to redness, erosion, and potential infection.

______ _____ pressure injury is injury to a mucous membrane caused by pressure related to the insertion or placement of a foreign device.

Mucosal membrane pressure injury

______ is the death of body tissue as a result of diminished blood flow.

Necrosis

____ _____ is redness of the skin that does not go away when pressure is applied.

Nonblanchable erythema

_____ ____ are localized damage to the skin and/or the soft underlying tissue, which can be caused by prolonged contact with a firm surface that interferes with circulation to the area.

Pressure injuries

Purulent drainage from a wound is typically or in color.

green/yellow

____ drainage from a wound refers to its bloody color.

Sanguineous

A ___ is an accumulation of serous fluid.

seroma

________ drainage is thin, watery wound drainage mixed with blood.

Serosanguineous

____ refers to thin, watery wound drainage.

Serous

____ is a force that is parallel to the surface of the skin.

Shearing

___ __ refers to skin that is at-risk vulnerable.

Skin frailty

____ ___ are the loss of the top skin layer caused by mechanical forces. The severity of a skin tear is defined by the depth of the skin layer loss.

Skin tears

____ is yellow, stringy nonviable tissue found in the base of the wound.

Slough

___ is a narrow channel extending in any direction from the base of the wound.

Tunneling

___ - an open area extending under skin along the edge of the wound.

Undermining

An ____ ____ injury indicates obscured full-thickness skin and tissue loss injury.

unstageable pressure

_______ is the narrowing of blood vessels due to acute blood loss, pain, and/or __ body temperature.

Vasoconstriction is the narrowing of blood vessels due to acute blood loss, pain, and/or low body temperature.

A _____ is a disruption in the normal composition and performance of the skin and its underlying structures.

wound

To determine ______, a nurse applies light pressure to
the middle of the area of erythema. In skin and tissue
without damage, the area where the pressure was applied
will turn ____; when the pressure is released, the skin will
become red again. With pressure injuries, the skin is
______, meaning it stays red and there is no color
change.

To determine blanching, a nurse applies light pressure to
the middle of the area of erythema. In skin and tissue
without damage, the area where the pressure was applied
will turn white; when the pressure is released, the skin will
become red again. With pressure injuries, the skin is
nonblanchable, meaning it stays red and there is no color
change.

What major risk categories does the Braden Scale focus on?

Sensory perception, moisture, activity, mobility, nutrition, friction/shear

Braden scale - the ____ the score, the higher the risk of developing pressure ulcers. A score of 6 to 9 indicates a very ____ risk, while a score of 15 to 18 indicates a ___ risk.

Braden scale - the lower the score, the higher the risk of developing pressure ulcers. A score of 6 to 9 indicates a very high risk, while a score of 15 to 18 indicates a low risk.

What kinds of ulcers are most often found on the lower
extremities?

Arterial ulcer, venous ulcer, neuropathic ulcer

What are the major types of wounds?

Acute and Chronic

What are the major complication associated with surgical wounds?

Infection, dehiscence, bleeding/hemorrhage, evisceration