Hygiene, Skin Integrity, Wound Care, and Activity

thermal wound

High or low temperatures; cellular necrosis as a possible result

abrasion wound

Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded

cyanosis

bluish or grayish discoloration in response to inadequate oxygenation

abduct

Lateral movement of a body part away from the midline of the body. Example: A person's arm is abducted when it is moved away from the body.

pressure injury

(1) localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is related to the use of a (medical or other) device; (2) any lesion caused by unrelieved pressure that results in damage to underlying tissue; formerly known as pressure ulcer

How would you individualize your teaching about needed supplies, wound care, and resources for the following patients?

-A homeless man admitted to the hospital for gangrene of the big toe; the toe has been amputated. -A teenage gang member treated in the emergency department for a superficial (but long) knife wound. -An infant who has had abdominal surgery and is now having diarrhea. -A frail, 80-year-old man who needs daily dressing changes on a draining wound and lives with his blind wife.

Describe the nursing interventions you would include in a care plan to prevent pressure injuries in the following patients:

-A middle-aged woman, 70 lb over normal body weight, who has a fractured femur and is recovering at home (she lives alone). -A 90-year-old man with cognitive impairment who is confined to bed. -A 17-year-old girl who is paralyzed from the waist down after a diving accident and is wheelchair dependent.

contusion wound

Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma

incision wound

Cutting or sharp instrument; wound edges in close approximation and aligned

wheals

Elevated mass with transient borders that is often irregular. Size and color vary. Caused by movement of serous fluid into the dermis; it does not contain free fluid in a cavity (e.g., vesicle). Examples include urticaria (hives, pictured below) and insect bites.

venous ulcer

Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction. edema, pain, erythema, warmth

diabetic ulcer

Injury and underlying diabetic neuropathy, dry mucus membranes, poor skin tugor

erosion

Loss of superficial epidermis that does not extend to the dermis. It is a depressed, moist area. Examples include rupture vesicle, scratch mark, and aphthous ulcer (aphthous stomatitis, commonly called a canker sore, pictured below).

macule and patch

Small, flat, nonpalpable skin color change (skin color may be brown, white, tan, purple, red). Macules are less than 1 cm with a circumscribed border, whereas patches are greater than 1 cm, and may have an irregular border. Examples include freckles, flat moles, petechiae, rubella (pictured below), vitiligo, port wine stains, and ecchymosis.

avulsion wound

Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

chemical wound

Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis

irradiation wound

Ultraviolet light or radiation exposure

ecchymosis

a collection of blood in subcutaneous tissues causing purplish discoloration

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? A. "I can expect to have more discomfort in the area where the cold is applied." B. "I should expect more drainage from the incision after the ice has been in place." C. "I should see less swelling and redness with the cold treatment." D. "My incision may bleed more when the ice is first applied."

c. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.

debridement

cleaning away devitalized tissue and foreign matter from a wound

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury? A. Keeping the head of the bed elevated as often as possible B. Massaging over bony prominences C. Repositioning bed-bound patients every 4 hours D. Using a mild cleansing agent when cleansing the skin

d. To prevent pressure injuries, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.

necrosis

death of cells and tissue

ischemia

deficiency of blood in a particular area

desiccation

dehydration; the process of being rendered free from moisture

gliding joint

flat surfaces of the bone slide over one another; flexion-extension and abduction-adduction can occur (e.g., carpal bones of wrist and tarsal bones of feet).

stage 2 pressure ulcer

partial skin loss with exposed dermis. wound is viable, pink or red, moist and intact or ruptured serum-filled blister. adipose and deeper tissues are not visible. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD) including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

bandage

piece of gauze or other material used to cover a wound

dressing

protective covering placed over a wound

erythema

redness of the skin

opposition

rotation of the thumb around its long access (movement of the thumb across the palm to touch each fingertip of the same hand).

proximal

situated nearer to the center of the body or the point of attachment. closer to the core

petechiae

small hemorrhagic spots caused by capillary bleeding.

maceration

softening through liquid; overhydration

epithelialization

stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of "ground glass" to pink

epidermis

superficial layer of the skin

pronation

the assumption of the prone position. Example: A person is in the prone position when lying on the abdomen; a person's palm is prone when the forearm is turned so that the palm faces downward.

supination

the assumption of the supine position. Example: A person is in the supine position when lying on the back; a person's palm is supine when the forearm is turned so that the palm faces upward.

ball-and-socket joint

the oval head of one bone fits into a shallow cavity of another bone; flexion-extension and abduction-adduction can occur (e.g., wrist joint and joints connecting fingers to palm).

hematoma

A localized collection of blood creating an elevated ecchymosis. It is associated with trauma.

laceration wound

Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue

puncture wound

Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental

vesicle

Circumscribed elevated, palpable mass containing serous fluid. Vesicles are less than 0.5 cm; bullas are greater than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox, pictured below), poison ivy, and second-degree burn. Examples of bulla include pemphigus, contact dermatitis, large burn blisters, poison ivy, and bullous impetigo.

papule

Elevated, palpable, solid mass. Papules have a circumscribed border and are less than 0.5 cm; plaques are greater than 0.5 cm and may be coalesced papules with a flat top. Examples of papules include elevated nevi, warts, and lichen planus. Examples of plaques include psoriasis (psoriasis vulgaris pictured below) and actinic keratosis.

nodule and tumor

Elevated, solid, palpable mass that extends deeper into dermis than a papule. Nodules are 0.5-2 cm and circumscribed; tumors are greater than 1-2 cm and do not always have sharp borders. Examples of nodules include keloid (pictured below), lipoma, squamous cell carcinoma, poorly absorbed injection, and dermatofibroma. Examples of tumors include larger lipoma and carcinoma.

cyst

Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis. Examples include sebaceous cyst and epidermoid cyst (pictured below).

dehiscence

Figure A. separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound

evisceration

Figure B. protrusion of viscera through an incision

penetrating wound

Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues

arterial ulcer

Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis. intermittent claudication, diminished pulses, no hair on legs, cool pale mottled skin

adduct

Lateral movement of a body part toward the midline of the body. Example: A person's arm is adducted when it is moved from an outstretched position to a position alongside the body.

fissure

Linear crack in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete's foot. Interdigital tinea pedis with fissures and maceration is pictured below.

stage 1 pressure ulcer

Nonblanchable Erythema of Intact Skin. Intact skin with a localized area of nonblanchable erythema. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.

stage 4 pressure ulcer

Obscured Full-Thickness Skin and Tissue Loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

deep tissue pressure ulcer

Persistent Nonblanchable Deep Red, Maroon, or Purple Discoloration. Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury (unstageable, stage 3, or stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

pustule

Pus-filled vesicle or bulla. Examples include acne (pictured below), impetigo, furuncles, and carbuncles.

ulcer

Skin loss extending past epidermis, with necrotic tissue loss. Bleeding and scarring are possible. Examples include stasis ulcer of venous insufficiency (stasis dermatitis with venous stasis ulcer, pictured below) and pressure ulcer.

scar

Skin mark left after healing of wound or lesion that represents replacement by connective tissue of the injured tissue. Young scars are red or purple, whereas mature scars (pictured below) are white or glistening. Examples include healed wound and healed surgical incision.

prone position

The patient lies flat on the abdomen with the head turned to one side. It is used to assess the hip joint and the posterior thorax.

supine position

The patient lies flat on the back with legs extended and knees slightly flexed. It facilitates abdominal muscle relaxation and is used to assess vital signs and the head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses.

Sim's position

The patient lies on either side with the lower arm below the body and the upper arm flexed at the shoulder and elbow. Both knees are flexed, with the upper leg more acutely flexed. It is used to assess the rectum or vagina.

dorsal recumbent

The patient lies on the back with legs separated, knees flexed, and soles of the feet on the bed. It is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. It should not be used for abdominal assessment because it causes contraction of the abdominal muscles.

Fowler's position

This position is often used to promote cardiac and respiratory functioning because abdominal organs drop in this position, providing maximal space in the thoracic cavity. This is also the position of choice for eating, conversation, and urinary and intestinal elimination. Variations of Fowler's position include high-Fowler's and low-Fowler's, or semi-Fowler's position. In the high-Fowler's position, the head of the bed is elevated 90 degrees. When a bedside table with a pillow on top of it is placed in front of the patient in high-Fowler's position, the patient can lean forward and rest the arms on the pillow, assuming a posture that allows for maximal lung expansion. In low-Fowler's or semi-Fowler's position, the head of the bed is elevated only 30 degrees.

circumduct

Turning in a circular motion; combines abduction, adduction, extension, and flexion. Example: Circling the arm at the shoulder, as in bowling or a serve in tennis.

pivot joint

a ring-like structure that turns on a pivot; movement is limited to rotation (e.g., joints between the atlas and axis of the neck and between the proximal ends of the radius and the ulna at the wrist).

hinge joint

a spool-like (rounded) surface of one bone fits into a concave surface of another bone; only flexion-extension can occur (e.g., elbow, knee, ankle joints).

biofilm

a thick grouping of microorganisms

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. A. Serous drainage is composed of the clear portion of the blood and serous membranes. B. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. C. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. D. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. E. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. F. Serosanguineous drainage can be dark yellow or green depending on the causative organism.

a, b, c, d. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. A. Use standard precautions or transmission-based precautions when indicated. B. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. C. Clean the wound in full or half circles beginning on the outside and working toward the center. D. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. E. Clean to at least 1 in beyond the end of the new dressing if one is being applied. F. Clean to at least 3 in beyond the wound if a new dressing is not being applied.

a, b, e. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least 1 in beyond the end of the new dressing, and (6) clean to at least 2 in beyond the wound margins if a dressing is not being applied.

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. A. Hemostasis occurs immediately after the initial injury. B. A liquid called exudate is formed during the proliferation phase. C. White blood cells move to the wound in the inflammatory phase. D. Granulation tissue forms in the inflammatory phase. E. During the inflammatory phase, the patient has generalized body response. F. A scar forms during the proliferation phase.

a, c, e. Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood components out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? A. Document the findings and continue to monitor the patient. B. Administer antipyretics, as prescribed. C. Increase the frequency of assessment to every hour and notify the patient's primary care provider. D. Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.

a. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? A. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. B. Draw the shape of the wound and describe how deep it appears in centimeters. C. Gently insert a sterile applicator into the wound and move it in a clockwise direction. D. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.

a. To measure the depth of a wound, the nurse should perform hand hygiene and put on gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin; and remove the swab and measure the depth with a ruler.

negative pressure wound therapy (NPWT)

activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid

fistula

an abnormal passage from an internal organ to the skin or from one internal organ to another. Rectovaginal is most common

lesions

areas of diseased or injured tissue such as bruises, scratches, cuts, burns, insect bites, and wounds.

caudal

at or near the tail or the posterior part of the body

A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply. A. The patient takes time to think about responses to questions. B. The patient is 86 years old. C. The patient reports inability to control urine. D. The patient is scheduled for a hip arthroplasty. E. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL). F. The patient reports increased pain in right hip when repositioning in bed or chair.

b, c, d, f. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure injury development. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development.

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as: A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

b. A stage 2 pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister.

The nurse uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound? A. Irrigate the wound. B. Provide gentle cleansing of the wound. C. Debride the wound. D. Change the dressing frequently.

b. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires debridement (removal) before the wound can heal.

dorsiflexion

backward bending of the hand or foot. Example: A person's foot is in dorsiflexion when the toes are brought up as though to point them at the knee.

saddle joint

bone surfaces are convex on one side and concave on the other; movements include flexion-extension, adduction-abduction, circumduction, and opposition (e.g., joint between the trapezium and metacarpal of the thumb).

A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. A. Notify the health care provider of the situation. B. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. C. Place the patient in the low Fowler's position.

c, b, a. Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position (to prevent further physical damage), cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). Note that the interprofessional team may be completing the activities simultaneously in the clinical setting, but the priority identified above is important to understand.

The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. A. Enhanced healing due to the presence of sugars and proteins B. Delayed healing due to dead tissue present in the wound C. Decreased effectiveness of antibiotics against the bacteria D. Impaired skin integrity due to overhydration of the cells of the wound E. Delayed healing due to cells dehydrating and dying F. Decreased effectiveness of the patient's normal immune process

c, f. Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Baranoski & Ayello, 2016; Hess, 2013). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? A. The therapy is used to collect excess blood loss and prevent the formation of a scab. B. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. C. The therapy provides a moist environment and stimulates blood flow to the wound. D. The therapy irrigates the wound to keep it free from debris and excess wound fluid.

c. Negative pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.

A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? A. Pain B. Impaired Skin Integrity C. Disturbed Body Image D. Disturbed Thought Processes

c. Wounds cause emotional as well as physical stress.

Hemovac drain

closed drain. portable negative pressure suction device that drains blood and fluid after abdominal or orthopedic surgery.

JP (Jackson-Pratt) drain

closed drainage system. Drains blood and fluid. ex. after breast surgery or mastectomy, abdominal surgery

abscess

collection of infected fluid that has not drained

serous drainage

composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery.

purulent drainage

comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.

sanguineous drainage

consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding.

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? A. Using sterile dressing supplies B. Suggesting dietary supplements C. Applying antibiotic ointment D. Performing careful hand hygiene

d. Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.

plantar flexion

flexion of the foot. Example: A person's foot is in plantar flexion in the footdrop position.

exudate

fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells

shear

force created when layers of tissue move on one another

stage 3 pressure ulcer

full thickness skin loss with visible fat. granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. depth of tissue varies by location. undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.

cephalad cranial?

in a direction towards the head, in a. direction towards the front end of the body, or in a. direction away from the tail or ends.

anterior

in front of, on the frontal plane

wound

injury that results in a disruption in the normal continuity of a body tissue

dermis

layer of the skin below the epidermis

lateral or side-lying position

many people routinely fall asleep in the side-lying position, this is a comfortable alternative to the supine position for the patient on bed rest. Although it relieves pressure on the scapulae, sacrum, and heels and allows the legs and feet to be comfortably flexed, support pillows are needed for correct positioning

serosanguineous drainage

mixture of serum and red blood cells. It is light pink to blood tinged.

inversion

movement of the sole of the foot inward (occurs at the ankle)

eversion

movement of the sole of the foot outward (occurs at the ankle)

granulation tissue

new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

friction

occurs when two surfaces rub against each other; the resulting injury resembles an abrasion and can also damage superficial blood vessels directly under the skin

pallor

palness of skin resulting from a decrease in circulating blood.

condyloid joint

the oval head of one bone fits into a shallow cavity of another bone; flexion-extension and abduction-adduction can occur (e.g., wrist joint and joints connecting fingers to palm).

flexion

the state of being bent. Example: A person's cervical spine is flexed when the head is bent forward, chin to chest.

extension

the state of being in a straight line. Example: A person's cervical spine is extended when the head is held straight on the spinal column.

hyperextension

the state of exaggerated extension. It often results in an angle greater than 180 degrees. Example: A person's cervical spine is hyperextended when looking overhead, toward the ceiling.

eschar

thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur

medial

toward the midline

rotation

turning on an axis; the turning of a body part on the axis provided by its joint. Example: A thumb is rotated when it is moved to make a circle.

subcutaneous tissue

underlying layer that anchors the skin layers to the underlying tissues of the body

jaundice

yellow coloring resulting from elevated amounts to bilirubin in the blood associated with gallbladder disease, anemia, and excessive hemolysis