Skin Integrity and Wound Care (33)

Abscess

collection of infected fluid that has not drained

Bandages

piece of gauze or other material used to cover a wound

Biofilm

a thick grouping of microorganisms

Debridement

cleaning away devitalized or weakened tissue and foreign matter from a wound

Dehiscence

any separation of the layers of a surgical wound

Dermis

• the second layer of skin.

  • consists of a framework of elastic connective tissue

  • comprised primarily of collagen

  • location of nerves, hair follicles, glands, immune cells, and blood vessels

Desiccation

• the process of drying up.

• cells dehydrate and die in a dry environment.

Dressing

protective covering placed over a wound

Epidermis

The top layer, or outermost portion, of the skin.

Epithelial Cells

• have no blood vessels

• depend on underlying tissues for nourishment and waste removal

• when well nourished, it regenerates easily and quickly.

Epithelialization

• when the epithelial cells form across the surface of a wound.

  • tissue color ranges from the color of “ground glass” to pink

Erythema

redness of the skin

Eschar

• thick, leathery scab or dry crust that is dead

  • must be removed for adequate healing to occur

Evisceration

protrusion or projecting of viscera through an incision

Exudate

• fluid that accumulates in a wound

  • may contain serum, cellular debris, bacteria, and white blood cells

Fistula

• an abnormal passage

  • from an internal organ to the skin.

  • from one internal organ to another.

Friction

when two surfaces rub against each other.

Granulation Tissue

• forms the foundation for scar tissue development.

  • highly vascular, red, and bleeds easily.

Hematoma

localized mass of usually clotted blood

Hypoxia

inadequate amount of oxygen available to cells

Ischemia

deficiency or lack of blood in a particular area

Maceration

overhydration; results from prolonged exposure to moisture.

Necrosis

death of tissue

Negative Pressure Wound Therapy (NPWT)

• a noninvasive medical device.

• uses controlled negative pressure (a vacuum) to pull fluid out of a wound and accelerate healing.

  • decreases bacterial colonization.

  • stimulates increased blood supply and granulation.

Pressure

• disrupts the blood supply to the wound area

• interferes with blood flow to the tissue

• delays healing.

Pressure Injury (Ulcer)

• localized damage to the skin and underlying tissue.

• occurs over a bony prominence.

  • caused by unrelieved, prolonged or intense pressure combined with friction or shear.

  • aka: pressure ulcers

Purulent Drainage

• pus draining from a wound.

• a primary sign of wound infection

• never considered normal.

  • Consistency: thick, milky, or creamy.

  • Color: yellow, green, or brown.

  • Odor: a distinct foul, unpleasant, or malodorous smell.

Sanguineous Drainage

• fresh, bright red bloody fluid leaking from a wound.

  • occurs during the initial inflammatory phase when capillaries are broken open.

  • It is NORMAL.

Scar

connective tissue that fills a wound area

Serosanguineous Drainage

• a thin, watery, pinkish or pale red fluid leaking from a wound.

  • a mixture of serum and red blood cells.

  • most common type of wound fluid.

  • a normal sign of healthy wound healing.

Serous Drainage

• a clear, thin, watery, straw-colored fluid leaking from a wound

  • It is normal & expected in healthy wound healing

  • appears during the inflammatory and proliferative phases.

  • It has NO odor!

Shear

• when one layer of tissue slides over another layer.

  • separating the skin from underlying tissues.

Sinus Tract

• a cavity or channel underneath the wound.

  • has the potential for infection.

Subcutaneous Tissue

• the bottom layer of the skin.

  • consists of adipose tissue and connective tissue.

  • stores fat for energy, preserves heat, and provides cushioning for protection.

  • contains blood and lymph vessels, nerves, and fat cells.

Vasoconstriction

• the narrowing (constriction) of blood vessels

• caused by the tightening of the smooth muscle walls within the arteries and arterioles.

Vasodilation

• the widening of blood vessels.

• caused by the relaxation of smooth muscle walls within the arteries and veins.

  • Increases local blood flow.

  • Increases the supply of oxygen and nutrients to the area

  • Decreases venous congestion

Wound

a break or disruption in the normal structure and continuity of the skin and underlying tissues.