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Foundations:FundamentalsofNursing,Chapter48SkinIntegrityandWoundCare
1. Abnormalreactivehyperemia
Excessivevasodilationandinduration,skinisbrightpinktored,noblanchingwithfingertippressure,
canlast1hourto2weeks,stageIpressureulcer
2. Abrasion
Superficialwoundwithlittlebleeding,consideredapartialthicknesswound.Oftenappears"weepy"
becauseofplasmaleakingfromdamagedcapillaries
3. Approximated
Closed
4. Blanching
Whennormalredtonesoflightskinnedpatientsareabsentaswhenpressingapatient'sfingertipstotest
capillaryrefillblanchingoftheskindoesnotoccurindarklypigmentedskin
5. Collagen
Atoughfibrousprotein
6. Darklypigmentedskin
Skinthatremainsunchanged(doesnotblanch)whenpressureisappliedonabonyprominence
7. Debridement
Removalofnonviable,necrotictissue
8. Dehiscence
Partialortotalseparationofwoundlayersthishappenswhenwoundsfailtohealproperlyoccurs
beforecollagenformation
9. Drainageevacuators
Convenient,portableunitsthatconnecttotubulardrainslyingdownwithinawoundbedandexertasafe,
constant,lowpressurevacuumtoremoveandcollectdrainage
10. Epithelialization
Thenaturalactofhealingbysecondaryintention,theproliferation,orrapidreproduction,ofnew
epitheliumintoanareadevoidofitbutthatnaturallyiscoveredbyit
11. Eschar
Blackorbrownnecrotictissuehastoberemovedbeforehealingcanoccur
12. Evisceration
Protrusionofvisceralorgansthroughawoundopening
13. Exudate
Amount,color,consistency,andodorofwounddrainage
14. Fibrin
Providesaframeworkforcellularrepair.Proteininvolvedintheclottingofbloodforma"mesh"that
formsahemostaticplugorclotinconjunctionwithplateletsoverawoundsite
15. Fistula

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Abnormalpassagebetweentwoorgansorbetweenanorganandtheoutsideofthebodycausedby
diseases,radiation,andtraumathatpreventstissuelayersfromclosingproperlyallowingafistulatractto
form.Increaseriskofinfectionandfluidandelectrolyteimbalancesfromfluidloss.Chronicdrainageof
fluidsthroughafistulaallpredisposeapersontoskinbreakdown.
16. Friction
Occurswhenskinisdraggedacrossacoarsesurface,suchasbedlinens,usuallyaffectingthetoplayerof
epidermisofskin.
17. GranulationTissue
Red,moisttissuecomposedofnewbloodvesselswhichindicatedprogressiontowardhealing
18. Hematoma
Localizedcollectionofbloodunderneaththetissues
19. Hemorrhage
Bleedingfromawoundsite
20. Hemostasis
Injuredbloodvesselconstrictandplateletsgathertostopbleeding
21. Induration
Abnormalfirmnessorhardnessoftissuewithmarginsasaresultofedemaorinflammation
22. Laceration
Abreakoropeningintheskinthatmaybesmoothorjagged.Bleedmoredependingonlocationand
depth.
23. Normalreactivehyperemia
Rednesslocalizedvasodilation,blanchingwithfingertippressurelastslessthan1hour
24. Pressureulcer
Impairedskinintegrityrelatedtounrelievedprolongedpressure
25. Primaryintention
Woundhealingwithskinedgesthatareapproximated,orclosed,riskofinfectionislow,healingoccurs
quicklywithminimalscarformationaslongasinfectionandsecondarybreakdownispreventedsimilar
toasurgicalwound
26. Puncture
Causedbyanobjectpiercingtheskinandcreatingahole,bleedingdeterminedbydepthandsize,
primarydangersareinternalbleedingandinfection
27. Purulentexudate
Thick,yellow,green,tanorbrownpusordrainage
28. Sanguineous
Brightredwhichindicatesactivebleeding
29. Secondaryintention
Woundisleftopenuntilitfillswithscartissue,woundhealingtakeslongerandchanceofinfectionis
greater.Ifscarringssevereoftenapermanentlossoftissuefunctionoccurs,usuallyburns,pressure
ulcers,orseverelacerations
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30. Serosanguineousexudate
Pale,red,waterymixtureofclearandredfluid
31. Serousexudate
Clear,watery,plasma
32. Shearingforce
Forceexertedparalleltoskinresultingfrombothgravitypushingdownonthebodyandresistance,or
friction,betweentheclientandasurface.Example:whentheheadofthebediselevatedandthesliding
oftheskeletonstartsbuttheskinisfixedbecauseoffrictionwiththebed.
33. Slough
Stringsubstanceattachedtoawoundbedhastoberemovedbeforewoundcanhealproperly
34. Sutures
Threadsormetalusedtosewbodytissuestogether
35. Tissueischemia
Whenlivingtissueisdeprivedofoxygendeprivingtissueofadequatebloodflowisthesameas
deprivingtissueofoxygen
36. VacuumAssistedClosure(VAC)
Devicethatassistsinwoundclosurebyapplyinglocalizednegativepressuretodrawtheedgesofa
woundtogether
37. Wound
Disruptionoftheintegrityandfunctionoftissuesinthebody
38. Woundcontraction
Theshrinkageandspontaneousclosureofopenskinwounds.Beginsalmostconcurrentlywithcollagen
synthesiscentripetalmovementofwoundedgesthatfacilitatesclosureofawound,maximal515days
afterinjury
39. Abnormalreactivehyperemia
Excessivevasodilationandinduration,skinisbrightpinktored,noblanchingwithfingertippressure,
canlast1hourto2weeksstageIpressureulcer
40. Abrasion
Superficialwoundwithlittlebleeding,consideredapartialthicknesswound.Oftenappears"weepy"
becauseofplasmaleakingfromdamagedcapillaries
41. Approximated
Closed
42. Blanching
Whennormalredtonesoflightskinnedpatientsareabsentaswhenpressingapatient'sfingertipstotest
capillaryrefillblanchingoftheskindoesnotoccurindarklypigmentedskin
43. Collagen
Atoughfibrousprotein
44. Darklypigmentedskin
Skinthatremainsunchanged(doesnotblanch)whenpressureisappliedonabonyprominence
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45. Debridement
Removalofnonviable,necrotictissue
46. Dehiscence
Partialortotalseparationofwoundlayersthishappenswhenwoundsfailtohealproperlyoccurs
beforecollagenformation
47. Drainageevacuators
Convenient,portableunitsthatconnecttotubulardrainslyingdownwithinawoundbedandexertasafe,
constant,lowpressurevacuumtoremoveandcollectdrainage
48. Epithelialization
Thenaturalactofhealingbysecondaryintention,theproliferation,orrapidreproduction,ofnew
epitheliumintoanareadevoidofitbutthatnaturallyiscoveredbyit
49. Eschar
Blackorbrownnecrotictissuehastoberemovedbeforehealingcanoccur
50. Evisceration
Protrusionofvisceralorgansthroughawoundopening
51. Exudate
Amount,color,consistency,andodorofwounddrainage
52. Fibrin
Providesaframeworkforcellularrepair.Proteininvolvedintheclottingofbloodforma"mesh"that
formsahemostaticplugorclotinconjunctionwithplateletsoverawoundsite
53. Fistula
Abnormalpassagebetweentwoorgansorbetweenanorganandtheoutsideofthebodycausedby
diseases,radiation,andtraumathatpreventstissuelayersfromclosingproperlyallowingafistulatractto
form.Increaseriskofinfectionandfluidandelectrolyteimbalancesfromfluidloss.Chronicdrainageof
fluidsthroughafistulaallpredisposeapersontoskinbreakdown.
54. Friction
Occurswhenskinisdraggedacrossacoarsesurface,suchasbedlinens,usuallyaffectingthetoplayerof
epidermisofskin.
55. GranulationTissue
Red,moisttissuecomposedofnewbloodvesselswhichindicatedprogressiontowardhealing
56. Hematoma
Localizedcollectionofbloodunderneaththetissues
57. Hemorrhage
Bleedingfromawoundsite
58. Hemostasis
Injuredbloodvesselconstrictandplateletsgathertostopbleeding
59. Induration
Abnormalfirmnessorhardnessoftissuewithmarginsasaresultofedemaorinflammation

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60. Laceration
Abreakoropeningintheskinthatmaybesmoothorjagged.Bleedmoredependingonlocationand
depth.
61. Normalreactivehyperemia
Rednesslocalizedvasodilation,blanchingwithfingertippressurelastslessthan1hour
62. Pressureulcer
Impairedskinintegrityrelatedtounrelievedprolongedpressure
63. Primaryintention
Woundhealingwithskinedgesthatareapproximated,orclosed,riskofinfectionislow,healingoccurs
quicklywithminimalscarformationaslongasinfectionandsecondarybreakdownisprevented,similar
toasurgicalwound
64. Puncture
Causedbyanobjectpiercingtheskinandcreatingahole,bleedingdeterminedbydepthandsize,
primarydangersareinternalbleedingandinfection
65. Purulentexudate
Thick,yellow,green,tanorbrownpusordrainage
66. Sanguineous
Brightredwhichindicatesactivebleeding
67. Secondaryintention
Woundisleftopenuntilitfillswithscartissue,woundhealingtakeslongerandchanceofinfectionis
greater.Ifscarringssevereoftenapermanentlossoftissuefunctionoccursusuallyburns,pressure
ulcers,orseverelacerations
68. Serosanguineousexudate
Pale,red,watery,mixtureofclearandredfluid
69. Serousexudate
Clear,watery,plasma
70. Shearingforce
Forceexertedparalleltoskinresultingfrombothgravitypushingdownonthebodyandresistance,or
friction,betweentheclientandasurface.Example:whentheheadofthebediselevatedandthesliding
oftheskeletonstartsbuttheskinisfixedbecauseoffrictionwiththebed.
71. Slough
Stringsubstanceattachedtoawoundbedhastoberemovedbeforewoundcanhealproperly
72. Sutures
Threadsormetalusedtosewbodytissuestogether
73. Tissueischemia
Whenlivingtissueisdeprivedofoxygendeprivingtissueofadequatebloodflowisthesameas
deprivingtissueofoxygen
74. VacuumAssistedClosure(VAC)

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Devicethatassistsinwoundclosurebyapplyinglocalizednegativepressuretodrawtheedgesofa
woundtogether
75. Wound
Disruptionoftheintegrityandfunctionoftissuesinthebody
76. Woundcontraction
Theshrinkageandspontaneousclosureofopenskinwounds.Beginsalmostconcurrentlywithcollagen
synthesiscentripetalmovementofwoundedgesthatfacilitatesclosureofawound,maximal515days
afterinjury

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