Telangiectasia Lesion due to permanently enlarged and dilated blood vessels that are visible
ex. rosacea, spider veins
Purpura Multiple pinpoint hemorrhages and accumulation of blood under the skin
Petechiae Pinpoint purple or red spots from minute hemorrhages under the skin
Fissure Linear crack in the epidermis; may be moist or dry
Scale Heaped-up keratinized cells
Flaky skin; irregular
Hemosiderin Brownish discoloration caused by breakdown of hemolobin from leaking
vessels in chronic venous insufficiency
Lipodermatosclerosis Hyperpigmentation and accompanying erythema, induration, and
plaque-like structural changes due to long-standing venous insufficiency
Atrophie blanche dermal sclerosis , dilated abnormal vasculature, ivory-white plaques on
the ankle or foot and hemosiderin pigmented borders
,Granulation New vascularized tissue in a healing wound
Appears beefy red, velvety, cobbled in appearance
Hypergranulation Overgrowth of tissue beyond the surface of the wound
Light red or dark pink in color, tissue bleeds easily
Epithelialization Process of epithelial cells migrating from wound margin or hair follicles
Appears pink or lavender
Slough Non-viable tissue that is soft, moist, and pale in color
May be loose or firmly adherent
Eschar Non-viable tissue that is black or brown, hard or soft or soggy
May be loose or firmly adherent
Epibole Rolled edges of prematurely closing wound
Health belief model Addresses the relationship between a person's beliefs and behaviors;
consider's a persons beliefs re: susceptibility, severity, benefits, barriers, and self-efficacy
, Clinical guidelines Systematically developed statements that summarize state of the art care
for specific healthcare issues
Functions of the hypodermis Cushions, insulates, and helps regulate temperature
Muscle Soft tissue with the highest metabolic rate and is therefore most susceptible to
pressure injury
Risk factors associated with peristomal MASD Pouch system leakage (exposure to urine,
stool)
Stoma protrusion
Mucocutaneous junction separation
Alkaline chemical irritants
Mechanical injury
Risk factors associated with periwound MASD Type of wound (acute v chronic wounds)
Type and volume of exudate
Effectiveness of periwound skin protection
Location of wound
Presence of infection
Purulent Exudate most likely to caused periwound MASD....