UNIT VIII
Title: Skin Integrity and Wound Care
Overview: Skin Integrity, Pressure Ulcers, and Wounds
Ch 36
Key Terms
1. Aerobic: Culture growing in the presence of oxygen. (With o2)
2. Anaerobic: Culture growing without oxygen. (Without o2)
3. Approximated- (Closed) minimal or no tissue loss. Example, Primary intention healing occurs where the tissues
surfaces have been approximated (closed).
4. Binder: A type of bandage designed for a specific body part; for example, the triangular binder (sling) fits the
arm. Binders are used to support large areas of the body, such as the abdomen or chest. Bonders can be simple
inexpensive and customizable by using plain material such as the triangular sling described below, or they can b
of commercial design. Commercial binders, such as the hook and loop (Velcro) binder, are often easier to use,
more expensive, and slightly less modifiable then customized binders. https://www.youtube.com/watch?
v=2M03cj9j3xo https://www.youtube.com/watch?v=tWLBZKeWEkg ATI information on Binders is below:
Binders provide support to the body area they surround. They are most often used on the abdomen following a surgical
procedure with a large incision. They are made from woven cotton, synthetic, or elastic materials. Most binders require either
Velcro closure or safety pins. If a patient’s girth is too large for the largest binder available, use two or more binders attached
length to length. Keep the underlying skin in mind when applying a binder. Binders can cause irritation or abrasions on the skin
beneath them. Assess and remove binders at prescribed intervals and be sure chest binders do not interfere with the patient’s
ability to move, breathe, or cough effectively. If the binder slips or becomes saturated with any body fluids, replace it.
5. Braden Scale for Predicting Pressure Sore Risk Pg 832 See this page related to sensory perception, moisture,
activity, mobility, nutrition, friction and shear.
6. Collagen: A whitish protein substance that adds tensile strength to the wound. When collagen increases so does
the strength of the wound.
7. Compress: A moist gauze dressing applied to a wound or injury. A compress can be either warm or cold. For hot
compresses, the solution can be heated to the temperature indicated by the order or according to agency
protocol, for example, 40.5 C (105F) When there is break in the skin or when the body part (e.g. an eye) is
vulnerable to microbial invasion, sterile technique is necessary, therefore, sterile gloves are needed to apply
compress and all materials must be sterile.
8. Debridement: Removal of necrotic material. For example, a wound is covered with thick necrotic tissue, or
eschar. Black wounds require debridement.
9. decubitus ulcers: This is a previous name for pressure ulcer. Pressure ulcers were previously called decubitus
ulcer, pressure sores, or bedsores.
10. Dehiscence: Is partial or total rupture of a suture wound. It can involve all wounds but usually involves an
abdominal wound in which the layers below the skin also separate. A number of factors, including obesity, poor
nutrition, multiple trauma, failure of suturing excessive coughing, vomiting, and dehydration increases the risk
for dehiscence.
11. Eschar: If the wound does not close by epithelialization, the area becomes covered with dried plasma protein
and dead cells that occurs if the wound does not close by epithelialization.
12. Evisceration: Is the protrusion of the internal viscera through an incision.
13. Excoriation: Area of loss of the superficial layer of the skin; also known as denuded area.
,14. Exudate: Material that has escaped from the blood vessels during the inflammatory process and is deposited in
the tissue or on tissue surfaces.
15. Fibrin: An insoluble protein formed from fibrinogen during the clotting of blood.
16. Friction: A force acting parrallel to the skin surface.
17. Granulation tissue: Is fragile and bleeds easy. The initial translucent, fragile tissue that forms during the
proliferative phase of wound healing.
18. Hematoma: A localized collection of blood underneath the skin that may appear as reddish-blue swelling.
19. Hemorrhage: Massive bleeding that is abnormal.
20. Hemostasis: Cessation of bleeding results from vasoconstriction of the larger blood vessels in the affected area
retraction (drawing back) of injured blood vessels, the deposition fibrin (connective tissue), and the formation of
blood clots in the area.
, 21. Inflammatory response: Local and nonspecific defensive tissue response to injury or destruction of cells. Starts
right after the injury and last 3 to 6 days. Two major processes occur during this phase: hemostasis and
phagocytosis.
22. Ischemia: A deficiency in the blood supply to the tissue. Pressure ulcers are due localized ischemia.
23. Immobility: Reduction in the amount and control of movement a person has.
24. Keloid: Hypertrophic scar, this is an abnormal amount of collagen laid down on the skin.
25. Lavage: (Irrigation) is the washing out of a body cavity by a stream of water or other fluid that may or may not
be medicated.
Title: Skin Integrity and Wound Care
Overview: Skin Integrity, Pressure Ulcers, and Wounds
Ch 36
Key Terms
1. Aerobic: Culture growing in the presence of oxygen. (With o2)
2. Anaerobic: Culture growing without oxygen. (Without o2)
3. Approximated- (Closed) minimal or no tissue loss. Example, Primary intention healing occurs where the tissues
surfaces have been approximated (closed).
4. Binder: A type of bandage designed for a specific body part; for example, the triangular binder (sling) fits the
arm. Binders are used to support large areas of the body, such as the abdomen or chest. Bonders can be simple
inexpensive and customizable by using plain material such as the triangular sling described below, or they can b
of commercial design. Commercial binders, such as the hook and loop (Velcro) binder, are often easier to use,
more expensive, and slightly less modifiable then customized binders. https://www.youtube.com/watch?
v=2M03cj9j3xo https://www.youtube.com/watch?v=tWLBZKeWEkg ATI information on Binders is below:
Binders provide support to the body area they surround. They are most often used on the abdomen following a surgical
procedure with a large incision. They are made from woven cotton, synthetic, or elastic materials. Most binders require either
Velcro closure or safety pins. If a patient’s girth is too large for the largest binder available, use two or more binders attached
length to length. Keep the underlying skin in mind when applying a binder. Binders can cause irritation or abrasions on the skin
beneath them. Assess and remove binders at prescribed intervals and be sure chest binders do not interfere with the patient’s
ability to move, breathe, or cough effectively. If the binder slips or becomes saturated with any body fluids, replace it.
5. Braden Scale for Predicting Pressure Sore Risk Pg 832 See this page related to sensory perception, moisture,
activity, mobility, nutrition, friction and shear.
6. Collagen: A whitish protein substance that adds tensile strength to the wound. When collagen increases so does
the strength of the wound.
7. Compress: A moist gauze dressing applied to a wound or injury. A compress can be either warm or cold. For hot
compresses, the solution can be heated to the temperature indicated by the order or according to agency
protocol, for example, 40.5 C (105F) When there is break in the skin or when the body part (e.g. an eye) is
vulnerable to microbial invasion, sterile technique is necessary, therefore, sterile gloves are needed to apply
compress and all materials must be sterile.
8. Debridement: Removal of necrotic material. For example, a wound is covered with thick necrotic tissue, or
eschar. Black wounds require debridement.
9. decubitus ulcers: This is a previous name for pressure ulcer. Pressure ulcers were previously called decubitus
ulcer, pressure sores, or bedsores.
10. Dehiscence: Is partial or total rupture of a suture wound. It can involve all wounds but usually involves an
abdominal wound in which the layers below the skin also separate. A number of factors, including obesity, poor
nutrition, multiple trauma, failure of suturing excessive coughing, vomiting, and dehydration increases the risk
for dehiscence.
11. Eschar: If the wound does not close by epithelialization, the area becomes covered with dried plasma protein
and dead cells that occurs if the wound does not close by epithelialization.
12. Evisceration: Is the protrusion of the internal viscera through an incision.
13. Excoriation: Area of loss of the superficial layer of the skin; also known as denuded area.
,14. Exudate: Material that has escaped from the blood vessels during the inflammatory process and is deposited in
the tissue or on tissue surfaces.
15. Fibrin: An insoluble protein formed from fibrinogen during the clotting of blood.
16. Friction: A force acting parrallel to the skin surface.
17. Granulation tissue: Is fragile and bleeds easy. The initial translucent, fragile tissue that forms during the
proliferative phase of wound healing.
18. Hematoma: A localized collection of blood underneath the skin that may appear as reddish-blue swelling.
19. Hemorrhage: Massive bleeding that is abnormal.
20. Hemostasis: Cessation of bleeding results from vasoconstriction of the larger blood vessels in the affected area
retraction (drawing back) of injured blood vessels, the deposition fibrin (connective tissue), and the formation of
blood clots in the area.
, 21. Inflammatory response: Local and nonspecific defensive tissue response to injury or destruction of cells. Starts
right after the injury and last 3 to 6 days. Two major processes occur during this phase: hemostasis and
phagocytosis.
22. Ischemia: A deficiency in the blood supply to the tissue. Pressure ulcers are due localized ischemia.
23. Immobility: Reduction in the amount and control of movement a person has.
24. Keloid: Hypertrophic scar, this is an abnormal amount of collagen laid down on the skin.
25. Lavage: (Irrigation) is the washing out of a body cavity by a stream of water or other fluid that may or may not
be medicated.
