| A | B |
|---|
| Tissue integrity | The body’s ability to maintain homeostasis of the mucous membrane, integumentary system and subcutaneous tissue |
| Primary Intention Healing | If the wound surfaces can be brought together where the edges of the wound line up and can be held in place; minimal amount of scar tissue formation or deformity; sutures or staples |
| Secondary Intention Healing | Edges cannot be brought together; body fills in space with scar tissue; takes longer to heal; Pressure ulcers and abrasions heal this way |
| Tertiary Intention Healing | occurs when a wound has to be left open to resolve an infection or contamination |
| Risks for altered tissue integrity | infections; radiation, temperature changes, pollution; impaired mobility; altered elimination; decreased perfusion; fluid/electrolyte imbalances; altered metabolism; loss of envirornmental protection (shelter) |
| Abrasion | A wound caused by the scraping or erosion of tissue. |
| Contusion | An area of tissue where blood capillaries have ruptured. Also known as a bruise |
| Incision | The medical term for a surgical laceration or cut made in the skin. |
| Laceration | A deep cut or tear in the skin. |
| Ulcer | A wound caused by lack of blood flow and oxygenation to a region of tissue. |
| Complications of altered tissue integrity | deformity; tissue death; infection; poor healing; pain; circulation issues; wound irritation |
| Factors that delay wound healing | Age; poor nutrition; dehydration; anemia; circulation problems; chronic conditions (Diabetes); cancer; irritation; infection; chemotherapy; gluccocorticoids |
| Factors that promote wound healing | Age; good nutrition (vitamin A &C); adequate hemoglobin; effective circulation; clean wound; no infection or trauma to area |
| Pressure Ulcer | when there is a breakdown in the skin related to repeated force and pressure on a specific area of the skin. |
| Pressure Ulcer Risk Factors | Poor circulation; age; anemia; edema; loss of sensation; immobility; mechanical irritation; friction; excessive moisture; poor hygiene; inadequate nutrition; cognition alterations (dementia); trauma; chronic conditions (DM) |
| Stage 1 Pressure Ulcer | Nonblancable redness; skin is discolored |
| Stage 2 Pressure Ulcer | superficial damage; top layer of the skin is lost; looks like a blister. |
| Stage 3 Pressure Ulcer | damage is deeper, extending to the adipose layer of the skin. |
| Stage 4 Pressure Ulcer | skin is severely damaged, extending to the muscles and bones. |
| Unstageable Pressure Ulcer | Full-thickness skin loss occurs and the exposure is covered by slough or eschar |
| Macule | Small, flat, circumscribed lesion of a different color than the normal skin |
| Papule | Small, firm, elevated lesion |
| Pustule | Elevated, erythematous lesion, usually containing purulent exudate |
| Vesicle | Elevated, thin-walled lesion containing clear fluid (blister) |
| Plaque | Large, slightly elevated lesion with flat surface, often topped by scale |
| Fissure | Small, deep, linear crack or tear in skin |
| Ulcer | Cavity with loss of tissue from the epidermis and dermis, often weeping or bleeding |
| Pruritis | Itching |
| Contact Dermatitis | inflammation of the skin caused by the direct contact of an allergen or irritant |
| Urticaria | Hives; raised, itchy welts on the skin |
| Shingles | is a viral infection; results in painful blisters that extend over a dermatome; vesicular rash develops in a line; causes burning, tingling, painful blisters |
| Atopic Dermatitis | chronic inflammation results from response to allergens; itchy, dry skin that can appear thickened and cracked |
