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76 notecards = 19 pages (4 cards per page)

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Foundations: Fundamentals of Nursing, Chapter 48 Skin Integrity and Wound Care

front 1

Abnormal reactive hyperemia

back 1

Excessive vasodilation and induration, skin is bright pink to red, no blanching with fingertip pressure, can last 1 hour to 2 weeks, stage I pressure ulcer;

front 2

Abrasion

back 2

Superficial wound with little bleeding, considered a partial-thickness wound. Often appears "weepy" because of plasma leaking from damaged capillaries;

front 3

Approximated

back 3

Closed;

front 4

Blanching

back 4

When normal red tones of light skinned patients are absent as when pressing a patient's fingertips to test capillary refill - blanching of the skin does not occur in darkly pigmented skin;

front 5

Collagen

back 5

A tough fibrous protein;

front 6

Darkly pigmented skin

back 6

Skin that remains unchanged (does not blanch) when pressure is applied on a bony prominence;

front 7

Debridement

back 7

Removal of nonviable, necrotic tissue;

front 8

Dehiscence

back 8

Partial or total separation of wound layers - this happens when wounds fail to heal properly - occurs before collagen formation;

front 9

Drainage evacuators

back 9

Convenient, portable units that connect to tubular drains lying down within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage;

front 10

Epithelialization

back 10

The natural act of healing by secondary intention, the proliferation, or rapid reproduction, of new epithelium into an area devoid of it but that naturally is covered by it;

front 11

Eschar

back 11

Black or brown necrotic tissue - has to be removed before healing can occur;

front 12

Evisceration

back 12

Protrusion of visceral organs through a wound opening;

front 13

Exudate

back 13

Amount, color, consistency, and odor of wound drainage;

front 14

Fibrin

back 14

Provides a framework for cellular repair. Protein involved in the clotting of blood form a "mesh" that forms a hemostatic plug or clot in conjunction with platelets over a wound site;

front 15

Fistula

back 15

Abnormal passage between two organs or between an organ and the outside of the body - caused by diseases, radiation, and trauma that prevents tissue layers from closing properly allowing a fistula tract to form. Increase risk of infection and fluid and electrolyte imbalances from fluid loss. Chronic drainage of fluids through a fistula all predispose a person to skin breakdown.;

front 16

Friction

back 16

Occurs when skin is dragged across a coarse surface, such as bed linens, usually affecting the top layer of epidermis of skin.;

front 17

Granulation Tissue

back 17

Red, moist tissue composed of new blood vessels which indicated progression toward healing;

front 18

Hematoma

back 18

Localized collection of blood underneath the tissues;

front 19

Hemorrhage

back 19

Bleeding from a wound site;

front 20

Hemostasis

back 20

Injured blood vessel constrict and platelets gather to stop bleeding;

front 21

Induration

back 21

Abnormal firmness or hardness of tissue with margins as a result of edema or inflammation;

front 22

Laceration

back 22

A break or opening in the skin that may be smooth or jagged. Bleed more depending on location and depth.;

front 23

Normal reactive hyperemia

back 23

Redness-localized vasodilation, blanching with fingertip pressure; lasts less than 1 hour;

front 24

Pressure ulcer

back 24

Impaired skin integrity related to unrelieved prolonged pressure;

front 25

Primary intention

back 25

Wound healing with skin edges that are approximated, or closed, risk of infection is low, healing occurs quickly with minimal scar formation as long as infection and secondary breakdown is prevented; similar to a surgical wound;

front 26

Puncture

back 26

Caused by an object piercing the skin and creating a hole, bleeding determined by depth and size, primary dangers are internal bleeding and infection;

front 27

Purulent exudate

back 27

Thick, yellow, green, tan or brown pus or drainage;

front 28

Sanguineous

back 28

Bright red which indicates active bleeding;

front 29

Secondary intention

back 29

Wound is left open until it fills with scar tissue, wound healing takes longer and chance of infection is greater. If scarring s severe often a permanent loss of tissue function occurs, usually burns, pressure ulcers, or severe lacerations;

front 30

Serosanguineous exudate

back 30

Pale, red, watery; mixture of clear and red fluid;

front 31

Serous exudate

back 31

Clear, watery, plasma;

front 32

Shearing force

back 32

Force exerted parallel to skin resulting from both gravity pushing down on the body and resistance, or friction, between the client and a surface. Example: when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of friction with the bed.;

front 33

Slough

back 33

String substance attached to a wound bed - has to be removed before wound can heal properly;

front 34

Sutures

back 34

Threads or metal used to sew body tissues together;

front 35

Tissue ischemia

back 35

When living tissue is deprived of oxygen - depriving tissue of adequate blood flow is the same as depriving tissue of oxygen;

front 36

Vacuum Assisted Closure (VAC)

back 36

Device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together;

front 37

Wound

back 37

Disruption of the integrity and function of tissues in the body;

front 38

Wound contraction

back 38

The shrinkage and spontaneous closure of open skin wounds. Begins almost concurrently with collagen synthesis centripetal movement of wound edges that facilitates closure of a wound, maximal 5 - 15 days after injury;

front 39

Abnormal reactive hyperemia

back 39

Excessive vasodilation and induration, skin is bright pink to red, no blanching with fingertip pressure, can last 1 hour to 2 weeks; stage I pressure ulcer;

front 40

Abrasion

back 40

Superficial wound with little bleeding, considered a partial-thickness wound. Often appears "weepy" because of plasma leaking from damaged capillaries;

front 41

Approximated

back 41

Closed;

front 42

Blanching

back 42

When normal red tones of light skinned patients are absent as when pressing a patient's fingertips to test capillary refill - blanching of the skin does not occur in darkly pigmented skin;

front 43

Collagen

back 43

A tough fibrous protein;

front 44

Darkly pigmented skin

back 44

Skin that remains unchanged (does not blanch) when pressure is applied on a bony prominence;

front 45

Debridement

back 45

Removal of nonviable, necrotic tissue;

front 46

Dehiscence

back 46

Partial or total separation of wound layers - this happens when wounds fail to heal properly - occurs before collagen formation;

front 47

Drainage evacuators

back 47

Convenient, portable units that connect to tubular drains lying down within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage;

front 48

Epithelialization

back 48

The natural act of healing by secondary intention, the proliferation, or rapid reproduction, of new epithelium into an area devoid of it but that naturally is covered by it;

front 49

Eschar

back 49

Black or brown necrotic tissue - has to be removed before healing can occur;

front 50

Evisceration

back 50

Protrusion of visceral organs through a wound opening;

front 51

Exudate

back 51

Amount, color, consistency, and odor of wound drainage;

front 52

Fibrin

back 52

Provides a framework for cellular repair. Protein involved in the clotting of blood form a "mesh" that forms a hemostatic plug or clot in conjunction with platelets over a wound site;

front 53

Fistula

back 53

Abnormal passage between two organs or between an organ and the outside of the body - caused by diseases, radiation, and trauma that prevents tissue layers from closing properly allowing a fistula tract to form. Increase risk of infection and fluid and electrolyte imbalances from fluid loss. Chronic drainage of fluids through a fistula all predispose a person to skin breakdown.;

front 54

Friction

back 54

Occurs when skin is dragged across a coarse surface, such as bed linens, usually affecting the top layer of epidermis of skin.;

front 55

Granulation Tissue

back 55

Red, moist tissue composed of new blood vessels which indicated progression toward healing;

front 56

Hematoma

back 56

Localized collection of blood underneath the tissues;

front 57

Hemorrhage

back 57

Bleeding from a wound site;

front 58

Hemostasis

back 58

Injured blood vessel constrict and platelets gather to stop bleeding;

front 59

Induration

back 59

Abnormal firmness or hardness of tissue with margins as a result of edema or inflammation;

front 60

Laceration

back 60

A break or opening in the skin that may be smooth or jagged. Bleed more depending on location and depth.;

front 61

Normal reactive hyperemia

back 61

Redness-localized vasodilation, blanching with fingertip pressure; lasts less than 1 hour;

front 62

Pressure ulcer

back 62

Impaired skin integrity related to unrelieved prolonged pressure;

front 63

Primary intention

back 63

Wound healing with skin edges that are approximated, or closed, risk of infection is low, healing occurs quickly with minimal scar formation as long as infection and secondary breakdown is prevented, similar to a surgical wound;

front 64

Puncture

back 64

Caused by an object piercing the skin and creating a hole, bleeding determined by depth and size, primary dangers are internal bleeding and infection;

front 65

Purulent exudate

back 65

Thick, yellow, green, tan or brown pus or drainage;

front 66

Sanguineous

back 66

Bright red which indicates active bleeding;

front 67

Secondary intention

back 67

Wound is left open until it fills with scar tissue, wound healing takes longer and chance of infection is greater. If scarring s severe often a permanent loss of tissue function occurs; usually burns, pressure ulcers, or severe lacerations;

front 68

Serosanguineous exudate

back 68

Pale, red, watery, mixture of clear and red fluid;

front 69

Serous exudate

back 69

Clear, watery, plasma;

front 70

Shearing force

back 70

Force exerted parallel to skin resulting from both gravity pushing down on the body and resistance, or friction, between the client and a surface. Example: when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of friction with the bed.;

front 71

Slough

back 71

String substance attached to a wound bed - has to be removed before wound can heal properly;

front 72

Sutures

back 72

Threads or metal used to sew body tissues together;

front 73

Tissue ischemia

back 73

When living tissue is deprived of oxygen - depriving tissue of adequate blood flow is the same as depriving tissue of oxygen;

front 74

Vacuum Assisted Closure (VAC)

back 74

Device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together;

front 75

Wound

back 75

Disruption of the integrity and function of tissues in the body;

front 76

Wound contraction

back 76

The shrinkage and spontaneous closure of open skin wounds. Begins almost concurrently with collagen synthesis centripetal movement of wound edges that facilitates closure of a wound, maximal 5 - 15 days after injury;