2. Tissue Integrity Glossary

Benchmarking - Comparing results and outcomes to other sources of similarly retrieved data.

blanchable erythema - An area of a reddened skin that temporarily turns white or pale when light pressure is applied. the skin then reddens when pressure is relieved.

Cellulitis - An infection of the superficial layers of skin.

Debridement - The process of surgically removing dead tissue and other debris that can cause infection.

deep tissue pressure injury (DTPI) - Persistent nonblanchable tissue injury of the skin appearing deep red, maroon, or purple color.

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

Dermatitis - A red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates. This type of dermatitis is called an irritant dermatitis.

Dermis - The layer under the epidermis that is composed mainly of connective tissue and provides strength and flexibility of the skin.

Epidermis - The outer most layer of the skin, made of squamous epithelial cells, which provides a barrier against the external environment.

Erythema - Redness of the skin due to dilation of blood vessels.

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

Evisceration - Protrusion of internal organs through a surgical wound which has dehisced or opened.

Exudate - Fluid secreted by the body during the inflammatory stage of healing and is made of plasma.

Friction - The force created when two objects rub together.

granulation tissue - New skin tissue that forms on the surface of the wound.

Hematoma - Accumulation of blood in the body.

Hemorrhage - Bleeding (may be internal or external).

Hypoperfusion - Inadequate supply of blood circulation, which results in low oxygen levels in tissues.

Hypoxia - Below the expected level of oxygen in body tissue.

Keratinocytes - Cells formed in the basal layer of the skin that function to protect the skin from the external environment.

Lacerations - Any tearing of the skin, usually caused by blunt or sharp objects.

Langerhans cells - Cells found in the epidermis that play a role in cutaneous immune system reactions.

Maceration - An irritation of the epidermis caused by moisture.

Malnutrition - Imbalance in a client's intake, which can include deficiencies or excesses in nutrients, vitamins, or calories.

Melanin - A pigment that determines the color of the hair, skin, and eyes.

Melanocytes - Cells that are produced in the epidermis and produce melanin.

Merkel cells - Receptors cells in the epidermis that are specialized for detection of light touch.

moisture-associated skin damage (MASD) - A form of dermatitis; a skin irritation that forms when the skin is exposed to irritants like feces, urine, stoma content, and wound exudates.

mucosal membrane pressure injury - Injury to a mucous membrane caused by the pressure related to the insertion or placement of a foreign device.

Necrosis - Death of body tissue as a result of diminished blood flow.

nonblanchable erythema - Redness of the skin that does not go away when pressure is applied and indicates structural damage has occurred in the small vessels supplying blood to the underlying skin and tissues.

pressure injuries - 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 injury - Localized damage to the skin and/or the soft underlying tissue, which can be caused from prolonged contact with a firm surface that interferes with circulation to the area.

Purulent - Green/yellow wound drainage.

Sanguineous - Bloody wound drainage.

Seroma - Accumulation of serous fluid.

Serosanguineous - Thin, watery wound drainage mixed with blood.

Serous - Thin, watery wound drainage.

Shearing - A force parallel to the surface of the skin.

skin frailty - At-risk vulnerable skin.

skin tears - 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.

Slough - Yellow, stringy nonviable tissue found in the baase of the wound.

Tunneling - A narrow channel or passage way extending in any direction from the base of the wound

Undermining - An open area extending under skin along the edge of the wound.

unstageable pressure injury - Obscured full-thickness skin and tissue loss injury.

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

Wound - A wound is a disruption in the normal composition and performance of the skin and it s underlying structures.