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(def)

The tough, supple, cutaneous membrane that covers the entire surface of the body
skin (integument)
What is the primary function of skin?
protection
The _________ prevents the entrance of microorganisms.
epidermis
________ removes bacteria from hair follicles.
Sebum
_______ pH further slows bacterial growth.
Acidic
What are the 5 functions of skin?
1. Protection
2. Sensation
3. Temperature Regulation
4. Excretion
5. Secretion
What are 5 issues that may contribute to weakening of the epidermis?
1. scraping/stripping of the surface (razor, tape removal, improper turning/positioning)
2. excessive dryness (causes cracks/breaks in skin mucosa)
3. excessive moisture causes maceration (disrupts dermal integrity which promotes ulcers and bacteria growth)
4. chemical irritation (soaps, detergent, cosmetics, deodorants)
5. neutralizing acid condition of the skin with use of alkaline soaps
The epidermis contains sensory organs for what specific sensations?
touch, pain, heat, cold & pressure
Which status of skin integrity involves a break in the skin or mucosa?
open
Which status of skin integrity involves no break in the skin?
closed
If a wound results from therapy, it is said to be what?
intentional
If a wound occurs accidentally, it is said to be what?
unintentional
What are the (5) depths of tissue disruption?
1. superficial
2. partial thickness
3. full thickness
4. penetrating
5. perforating
How would you describe the depth of a wound that involves only the epidermis?
superficial
How would you describe the depth of a wound that involves on the the epidermis and dermis?
partial thickness
How would you describe the depth of a wound that involves the epidermis, dermis, subcutaneous tissue and possibly muscle and bone?
full thickness (penetrating)

* terms may both be used depending on wound*
How would you describe the depth of a wound that involves the epidermis, dermis, and possibly deeper tissues?
penetrating (full thickness)

* terms may both be used depending on wound*
What term would be used to describe the depth of tissue disruption when a foreign object enters or exits an internal organ?
perforating
What are 4 ways to reduce skin sensation (ex. reduce pain, pressure)?
1. minimize friction
2. remove sources of mechanical irritation
3. prevent injury to client's skin
4. check temperature of water
Which state of cleanliness contains no pathogens and has minimal inflammation?
clean
Which state of cleanliness involves surgical wounds made under aseptic conditions, but involves a body cavity that normally harbors microorganisms; shows no evidence of infection?
clean contaminated
Which state of cleanliness involves open, unintentional wounds, surgery with a major break in aseptic technique, or with major contamination from the GI tract; shows evidence of inflammation?
contaminated
Both clean wounds and contaminated wounds might show signs of inflammation. What is the major difference between the inflammatory responses of these 2 states of cleanliness?
clean - contains no pathogens, minimal inflammation

contaminated- pathogens involved, more severe inflammatory response
The temperature of the skin is controlled by what 4 mechanisms?
1. evaporation
2. conduction
3. convection
4. radiation
What is the primary fluid excreted by the skin and what is the purpose of this excretion?
sweat promotes heat loss by evaporation
What is the purpose of the sebum secreted from the skin?
lubricates the skin and hair
Which state of cleanliness involves wounds that contain pathogens, dead tissue, and evidence of infection (such as purulent drainage)?
Infected
What wound description would you use for tissue torn with jagged, uneven edges?
laceration
What wound description would you use for a wound made with a sharp, cutting edge?
incision
What wound description would you use for a wound that shows signs of damage but is intact; caused by a blow from a hard object?
contusion (bruise)
What wound description would you use for a localized open lesion characterized by sloughing of necrotic tissue or mucosa?
ulceration
What wound description would you use for a wound that results from excessive exposure to thermal, electrical, or chemical agents?
burn
(def)

A wound that heals with minimal tissue loss, with the edges and skin layers approximated
First Intention
(def)

soft, pink to red translucent fleshy projections of tissue that form during the healing process
granulation tissue
What amount of granulation tissue would you expect to see in a wound that is healing by first intention?
minimal granulation tissue
A wound healing by first intention would likely have a ________ (thick or thin) scar.
thin
(def)

a wound heals by filling in with granulation tissue and is described as having extensive tissue loss in which edges cannot or should not be approximated
Secondary intention
First, Secondary, or Third intention:

edges cannot be approximated, slower healing, with more scar tissue
Secondary Intention
First, Secondary, or Third intention:

delay between wound occurrence and the suturing of a wound OR a wound is sutured open and later re-sutured
Third intention
Would you expect a large or small scar with a wound that heals by third intention?
small
First intention is also known by what other 2 names?
primary intention or primary union
Third intention is also known by what other 3 names?
- secondary closure
- delayed primary closure
- tertiary healing
First, Secondary, or Third Intention:

Burns or pressure ulcers
Secondary Intention
In the process of wound healing, what is released by the platelets after initial injury to the skin?
a vasoconstrictive agent
What is the purpose of the vasoconstricting agent that is released by the platelets after injury has occurred?
They cause a retraction (drawing back) of the larger blood vessels that were injured
In the process of wound healing, what is the next step once retraction of the blood vessel that was injured has taken place?
Coagulation factors are released and platelet aggregation occurs at the site of the injury
In the process of wound healing, what is the next step once platelet aggregation has occurred?
polymerized fibrin forms a thrombus (clot) and the bleeding stops
Put the following processes in order:

1. coagulation factors are released
2. injury to the skin
3. polymerized fibrin forms a thrombus
4. retraction occurs in the larger blood vessels that were injured
5. vasoconstrictive agent is released by the platelets
6. bleeding stops
7. platelet aggregation occurs at the site of the injury
2, 5, 4, 1, 7, 3, 6
What are the 3 phases of wound healing?
1. Inflammatory phase
2. Proliferative phase
3. Remodeling
The inflammatory response occurs _______ (before or after) hemostasis?
after (takes place several hours after hemostasis)
What are 5 symptoms associated with the inflammatory response?
1. redness
2. swelling
3. heat
4. pain
5. exudate
How long does the inflammatory phase last?
2-3 days
How would you describe the strength of the wound during the inflammatory phase?
wound strength is low
During which phase of wound healing does phagocytosis occur?
Inflammatory phase
During which phase of wound healing does a scab form?
Inflammatory phase
During which phase of wound healing is collagen deposited?
Proliferative phase (phase 2)
During which phase of wound healing does angiogenesis occur?
Proliferative phase (phase 2)
During the proliferative phase, granulation tissue forms. Where does this formation begin within the wound?
at the base of the wound
What is epithelializtion and what phase of wound healing is this seen in?
Occurs during the proliferative phase of wound healing. Epidermal cells migrate over the wound edges.
How long does the proliferative phase last?
3-21 days
What is the most likely days for wound disruption in the proliferative phase?
between the 5th-8th days of healing
Sutures are usually removed in what phase of wound healing?
the proliferative phase
How long does the remodeling phase of wound healing last?
from 21st day up to weeks, months, or years
Where does the remodeling phase of wound healing take place?
within the scar tissue
What happens to the blood flow to the wound during the remodeling phase?
it decreases
Why does a scar lighten during the remodeling phase of wound healing?
because of a decreased flow of blood to the scar
What happens to the collagen fibers at the wound site during the remodeling phase?
they are broken down and reorganized (contraction)
During the remodeling phase, wound strength does increase. However, it will not be more than ___% of the original tensile strength of intact skin.
70%
True/False:

Scars continue to fade in color and shrink in size for many months or years.
True
What 2 things may influence the body's ability to handle tissue trauma?
1. the extent of the damage
2. the person's general state of health
The body's response to injury is more effective if proper ________ has been maintained.
nutrition
The body responds ____________ to trauma in any of its parts.
systematically
What transports substances to and from injured tissue?
blood
What is the first line of defense against mucous membranes?
intact skin and mucous membranes
What is promoted when the wound is free of foreign bodies, including bacteria?
normal healing
What type of client may have difficulty mounting their cell-mediated defense system?
undernourished clients, those with weakened immune responses
Why are undernourished clients at a higher risk for wound infections?
because some leukocyte functions are diminished in the presence of protein deficiency, therefore undernourished clients are at a higher risk for wound infection
True/False:

Wound healing requires additional energy, therefore you should increase your intake of fats.
False-

Although wound healing does require energy, you would want to increase your protein intake, not fat.
What dietary requirement is needed for collagen synthesis and epithelialization?
Vitamin A
What dietary requirement serves as a co-factor of enzyme reactions needed for healing?
Vitamin B
What dietary supplement is needed for collagen synthesis, capillary formation, and resistance to infection?
Vitamin C
What dietary supplement is needed for the synthesis of prothrombin?
Vitamin K
What (3) minerals assist in collagen synthesis?
Zinc, copper, and iron
What mineral serves as an enzyme activator?
manganese
Arginine, an amino acid, increases what 2 things?
increases collagen deposition and lymphocyte response
Why would a person recovering from a wound want to add arginine to their dietary intake if it is produced already by the body?
During illness, metaboic stress, and growth the production is insufficient to meet the needs of the body
Wounds in compromised tissue are more likely to heal slowly and encounter complications. What are 4 examples of substances that may compromise tissues?
1. foreign objects
2. microorganisms
3. exposure to temperature extremes
4. radiation
How does impaired oxygenation/poor tissue perfusion impair wound healing?
Low arterial oxygen tension (aka- low oxygen levels in the blood) alters the synthesis of collagen and the formation of epithelial cells
True/False:

Although impaired oxygenation will increase the time it takes to heal wounds, it does not have an impact on resistance to infection.
False- impaired oxygenation will do both - increases time to heal and reduces resistance to infection
Why would anemia impair wound healing?
anemia (decreased hemoglobin in blood) reduces arterial oxygen levels in the capillaries. (**oxygen is needed for tissue repair**)
Smoking reduces the amount of functional _________ in the blood.
hemoglobin
In addition to decreasing tissue oxygenation (by reducing hemoglobin), what are 2 additional negative effects of smoking that impair wound healing?
1. causes hypercoagulability (by increasing platelet aggregation)
2. interferes with normal cellular mechanisms that promote oxygen release to tissues
What impact do steroids have on wound healing?
reduce the inflammatory response which increases wound susceptibility to infection AND slows collagen synthesis
Anti-inflammatory drugs suppress what 4 activities in the body that have an effect on wound healing?
1. protein synthesis
2. wound contraction (shrinkage)
3. epithelialization
4. inflammation
Pronlonged use of antibiotics may increase the risk of a _____________.
superinfection
Chemotherapeutic drugs can have what (3) effects on the body that ultimately impair wound healing?
1. depress bone marrow function
2. lower number of lymphocytes
3. impair inflammatory response
Young, healthy people heal quicker than elderly people. What specific changes occur in the body that account for this? (7)
1. vascular changes impair circulation
2. reduced liver function alters synthesis of clotting factors
3. inflammatory process is slowed
4. formation of antibodies and lymphocytes is reduced
5. collagen tissue is less pliable, and deposit of collagen is slowed
6. scar tissue is less elastic
7. cell growth and differentiation in reconstruction are slower in the elderly
Diabetes causes small vessel disease that impairs what?
tissue perfusion
What are 5 factors that impair wound healing in a diabetic patient?
1. small vessel disease
2. poor wound healing (increases risk for infection)
3. wound strength is decreased
4. hemoglobin has a greater affinity to oxygen (fails to release it for tissue repair)
5. collagen synthesis is reduced
What occurs with hyperglycemia that impairs wound healing?
alters the ability of leukocytes to perform phagocytosis and also supports fungal and yeast infections
Which phase of wound healing is affected by poor nutritional status?
all phases are impaired
Stress from burns or severe trauma _______ increases/decreases nutritional requirements.
increases
How does obesity impair wound healing?
fatty tissue lacks adequate blood supply to resist bacterial invasion and deliver nutrients and cellular elements for healing
(def)

refers to the areas within a sutured wound in which the tissue layers on the opposite sides of the wound are not aligned or in contact with each other
dead space
What results in "dead space"?
When large amounts of tissue are removed and interferes with cell migration and tissue perfusion
Extensive tissue loss requires that the wound remain open for a longer time to heal by ________ _________.
secondary intention
What 2 problems eventually develop in irradiated skin layers?
fibrosis and vascular scaring
Due to fibrosis and vascular scarring of irradiated tissue, what happens to the affected tissues?
they become fragile and poorly oxygenated
What effect might vomiting, abdominal distention, and respiratory effort have on a healing wound?
May stress the suture line and disrupt the wound layer
Sudden, unexpected tension on an incision may inhibit the formation of what?
endothelial cell and collagen networks
(def)

excessive loss of blood
hemorrhage
What may result from suture disruption in surgical wounds or inadequate cautery?
hemorrhage
How long after surgery is the risk for hemorrhage greatest?
during the 1st 48 hours
(def)

microbial contamination of a wound at the time it is made or during the healing process
infection
Wound disruption may be minor or very serious. What are 6 types of wound disruptions?
1. dehiscence
2. evisceration
3. fistula
4. ischemia
5. keloids
6. contractures
(def)

separation of the edges of a wound; partial or total rupture of a sutured wound
dehiscence
Dehiscence is most like to occur ___-___ days post-operatively.
4-5 days
(def)

wound separation with the protrusion of an organ/internal viscera through the wound opening
evisceration
(def)

an abnormal passage from an internal organ to the surface or between 2 internal organs
fistula
(def)

a deficient blood supply to the tissue; a decrease supply of oxygenated blood to a body part
ischemia
(def)

a raised, firm thickened scar that results from the deposition of abnormal amounts of collagen into the tissue surrounding the wound
keloid
(def)

pathological shrinkage of a scar causing immobility
contracture
What 7 things should be assessed when observing a wound?
C- color
L- location
O- odor
S- size
E- erythema
D- depth
D- Drainage (drainage and/or closure devices)
What are the 3 goals of wound care?
1. prevent injury
2. prevent complications
3. promote healing
Heat or Cold:

vasodilation
heat
Heat or Cold:

vasoconstriction
cold
Heat or Cold:

increased capillary permeability
heat
Heat or Cold:

decreased capillary permeability
cold
Heat or Cold:

increased cellular metabolism
heat
Heat or Cold:

decreased cellular metabolism
cold
Heat or Cold:

increased inflammation
heat
Heat or Cold:

decreased inflammation
cold
Heat or Cold:

sedative effect
heat
Heat or Cold:

local anesthetic effect
cold
Heat or Cold:

slows bacterial growth
cold
Heat or Cold:

brings oxygen, nutrients, antibiotics & leukocytes with vasodilation
heat
Heat or Cold:

Reduces supply of oxygen & metabolites
cold
Heat or Cold:

promotes soft tissue healing & increased suppuration
heat
Heat or Cold:

decreases removal of wastes
cold
Heat or Cold:

causes an increase in edema with an increase in capillary permeability
heat
Heat or Cold:

produces skin pallor and coolness
cold
Heat or Cold:

used for joint stiffness from arthritis, contractures, and low back pain
heat
Heat or Cold:

prolonged exposure can result in impaired circulation, cell deprivation, and damage to the tissue from lack of oxygen and nutrients
cold
Heat or Cold:

used for sports injuries, sprains, and fractures to decrease post-injury bleeding and edema
cold
What are 4 signs of tissue damage from cold?
1. bluish purple mottled skin
2. numbness
3. occasionally blisters
4. pain
Heat or Cold:

when applied to a large body area it causes vasodilation and a drop in BP
heat
Heat or Cold:

may cause syncope
heat
Heat or Cold:

extensive application causes vasoconstriction & an increase in BP
cold
Heat or Cold:

use with caution in patients with heart or pulmonary disease & circulatory disturbances
heat
What affect would neurosensory impairment have on thermal tolerance?
inability to perceive heat damaging tissues (at risk for burns); inability to perceive discomfort from cold (at risk for tissue damage)
Why is close monitoring needed during heat/cold therapy for clients with impaired mental status?
to ensure safety
Why are clients with impaired circulation (ex. peripheral vascular disease, diabetes & CHF) at risk for tissue damage with thermal therapy?
because these clients lack the normal ability to dissipate heat via circulation which puts them at risk for tissue damage with therapy
Heat or Cold:

increases bleeding & edema
heat
Would you apply heat to a wound immediately after injury or surgery? Why or why not?
No, because heat increases bleeding and edema
Heat or Cold:

decreases blood flow to the area inhibiting healing
cold
Would you apply cold to an open wound? Why or why not?
No, because cold decreases blood flow to the area inhibiting healing
What specific body parts are temperature sensitive? (3)
1. inner aspect of wrist and forearm
2. neck
3. perineal
True/false:

The smaller the area exposed, the lower the tolerance to thermal therapy.
False- the "larger" the area, the lower the tolerance
Which of the following would have a lower tolerance to temperature change:

1. very young & very old clients
2. client with neurosensory impairment
The very young and very old clients have a lower tolerance to temperature change
Which of the following would be at a greater risk for injury due to temperature change:

1. very young & very old clients
2. client with neurosensory impairment
The client with the neurosensory impairment
(def)

tolerance to heat and cold applications over a period of time
adaptive response
True/False:

Injured skin is more sensitive to temperature variations.
True
Describe a thermal receptor's mechanism of adaptation to temperature changes. (3 steps)
1. abrupt temperature change occurs
2. thermal receptors are strongly stimulated at first
3. stimulus declines rapidly over the first few seconds and then more slowly over the next half hour as receptors adapt to the new temperature
You are teaching a client about thermal applications. Why will you advise them NOT to change the temperature of an application after adaptation has occurred?
With heat, a change could result in serious burns. With cold, serious circulatory impairment might occur.
(def)

occurs when maximum therapeutic effect of a hot or cold application is achieved and the opposite effect begins
rebound phenomenon
With heat, vasodilation occurs in ___-___ minutes.
20-30 minutes
With heat, continued application beyond 30-45 minutes brings about what effect?
tissue congestion and blood vessel constriction (for unknown reasons)
A client with back pain tells you that he applies a heating pad in the same location for 45 minutes each night. What information should you provide this client?
You should advise the client that he is at risk for burns due to overexposure (rebound phenomenon).

Reasoning- application beyond 30-45 minutes results in blood vessel constriction and the inability to dissipate heat via circulation.
With cold, maximum vasoconstriction occurs when the skin reaches a temperature of ______ degrees F.
60 degrees F
With cold, an application below 60 degrees F (15C) results in vasodilation. Why does this occur?
it is a protective mechanism of the body to keep tissues from freezing
Thermal applications must be stopped before what begins?
rebound phenomenon
A temperature application with the description of "very cold" falls within what temperature range? What type of application is this?
below 59 F (15 C); ice bags
A temperature application with the description of "cold" falls within what temperature range? What type of application is this?
59-65 F (15-18C); cold pack
A temperature application with the description of "cool" falls within what temperature range? What type of application is this?
65-80 F (18-27C); cold compresses
A temperature application with the description of "tepid" falls within what temperature range? What type of application is this?
80-98 F (27-37C); alcohol sponge bath
A temperature application with the description of "warm" falls within what temperature range? What type of application is this?
98-105 F (37-40C); aquathermia pads (K-pads)
A temperature application with the description of "hot" falls within what temperature range? What type of application is this?
105-115 F (40-46C); hot soaks, irrigations, hot compresses
A temperature application with the description of "very hot" falls within what temperature range? What type of application is this?
above 115 F; hot water bags for adults
Before applying a local application of heat or cold, you should first determine what?
the client's ability to tolerate the treatment AND identify any conditions that may contraindicate treatment
True/False:

In a hospital environment, explanation of heat/cold applications does not need to be explained to the client.
False- you always explain any procedure to a client
What should be assessed before applying local heat/cold?
the skin area
You should instruct the client to report what when applying local heat/cold?
any pain or discomfort
How long after starting a local application of heat/cold should you return to the client to check for adverse effects? What should you do if you notice any problems?
return after 15 minutes; stop application if problems occur
What is the procedure for removal of heat/cold applications?
remove at the designated time and dispose of properly
What is your next action(s) after removal of heat/cold applicators?
reassess the area that received the application and record the client's response
What type of therapy (heat or cold) would be indicated for muscle spasms, inflammation, and/or pain?
Either may be used (remember heat will increase inflammation, cold will decrease it)
What type of therapy (heat or cold) would be used for contractures or joint stiffness?
Heat application only
What type of therapy (heat or cold) would be used for traumatic injury?
Cold application only
What are 5 specific circumstances where heat application would be contraindicated?
1. first 24 hours after traumatic injury
2. active hemorrhage
3. non-inflammatory edema
4. localized malignant tumor
5. skin disorders that cause redness or blisters
What are 3 specific circumstances where cold application would be contraindicated?
1. open wounds
2. impaired circulation
3. allergy or hypersensitivity to cold
(def)

a water-soluble, heat-coagulable protein; the most abundant protein in blood plasma
albumin
(def)

the formation of new blood vessels, a process controlled by chemicals produced in the body that stimulate blood vessels for form new ones
angiogenesis
(def)

the absence of germs
asepsis
(def)

bluish discoloration of an area of skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissue as a result of trauma
ecchymosis
(def)

the abnormal accumulation of fluid in interstitial spaces of tissues
edema
(def)

the regrowth of skin over a wound
epithelialization
(def)

redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries
erythema
(def)

fluid, cells, or other substances that have been slowly discharged from cells or blood vessels through small pores or breaks in cell membranes
exudate
(def)

any soft pink fleshy projections that form during the healing process in a wound that does not heal by primary intention
granulation
(def)

the termination of bleeding by mechanical or chemical means or by the complex coagulation process of the body, which consists of vasoconstriction, platelet aggregation, and thrombin and fibrin synthesis
hemostasis
(def)

hardening of a tissue, particularly the skin, caused by edema, inflammation, or infiltration by a neoplasm
induration
(def)

the protective or destructive response of body tissues to irritation or injury.
inflammation
(def)

a decreased supply of oxygenated blood to a body part
ischemia
(def)

one of the formed elements of the circulating blood system that comprise the cells of immunity and inflammation; 5 types
leukocyte
(def)

the softening and breaking down of skin resulting from prolonged exposure to moisture
maceration
(def)

pertaining to, resembling, or producing edema
serous
(def)

pertaining to blood or containing blood, such as full blooded
sanguineous
(def)

producing or containing pus
purulent