TERM ABRIEVIATION DEFINITION PICTURE/DIAGRAM

Transcription

1 Abrasion Wearing away of the skin through some mechanical process (friction or trauma) Abscess Localized collection of pus in any part of the body. Acute Wound Albumin A wound induced by surgery or trauma in an otherwise health individual. Plasma protein. Normal levels are at least 3.5mg/dl Alginates Absorptive wound dressing made from brown seaweed Angiogenesis Ankle-Brachial Index Autolytic Debridement Avascular ABI Formation of new blood vessels. Indirect measure of peripheral perfusion, calculated as the systolic pressure of the ankle divided by the systolic pressure of the brachium. Normally Disintegration or liquefaction of tissue or of cells by the body's own mechanisms, such as leukocytes and enzymes. Lacking in blood supply

2 Avoidable Pressure Ulcer Bactericidal Bacteriostatic Means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors, define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice, monitor and evaluate the impact of the interventions, or revise the interventions as appropriate. Agent that detroys bacteria Agent that is capable of inhibiting the growth or multiplication of bacteria Basement Membranes Thin acellular layer separating the epidermis from the dermis. Biofilms A complex aggregation of microorganisms marked by the excretion of a protective and adhesive matrix. Biological Debridement The use of sterile maggots to debride a wound. Blanching Becoming white: maximum pallor.

3 Body Mass Index BMI A number calculated from a person's weight and height. BMI provides a reliable indicator of body mass for most people and is used to screen for weight categories that may lead to health problems. Bottoming Out The caregiver can determine whether the resident has "bottomed out" by placing an outstretched hand (palm up) under the support surface below the part of the body at risk for developing a pressure ulcer, if less than an inch of support material is felt, the resident has "bottomed out" and the support surface in inadequate. Bulla A fluid filled blister more than 5mm in diameter with thin walls. Callous A common, usually painless thickening of the skin at locations of pressure or friction. Candidiasis An infection caused by a yeast like fungus called Candida. Capillary Closing Pressure Amount of external pressure that must be applied to prohibit capillary blood flow, generally 13-32mm Hg

4 Cellulitis Inflammation of connective tissue: infection in, or close to the skin. Charcot Foot Neuropathic fracture/dislocation found in patient with diabetes, most commonly resulting in a "rockerbottom" foot deformity. Chronic Wound Collagen Colonized A wound, induced by various causes, whose progression through the phases of wound healing is prolonged or arrested due to underlying conditions. Fibrous protein that provides strength to dermis. Presence of bacteria that cause no local or systemic signs or symptoms. Composite Dressings Multilayer dressing made from a combination of wound dressing categories. Contact Layer Dressings Single layers of a woven net that acts as a lowadherence material when placed in contact with the wound bed. These require a secondary dressing. Contamination The soiling by contact or introduction of organisms on to a wound.

5 C-Reactive Protein Crust Dead Space Debridement A protein found in the blood, levels will rise in response to infection within the body Dried blood, pus, or skin fluids on the surface of the skin The space remaining in a wound, leaving this open without packing allows for the accumulation of blood or debris which can result in delayed healing, or infection The removal of necrotic tissue, foreign material, and/or debris from wound bed. Dehiscence Separation of wound edges Denuded Loss of epidermis Dermatitis Inflammation of the skin associated with itching, redness, and open lesions. Dermis Inner layer of skin in which hair follicles and sweat glands originate: involved in Stages II to IV pressure ulcers

6 Desiccation an excessive loss of moisture, the process of drying out Doppler Ultrasound Instrument used to assess arterial or venous flow. Dry Gangrene This is caused by a reduction of blood flow through the arteries. It appears gradually and progresses slowly. The tissue becoumes cold and black, begins to dry and the area eventually sloughs off. Duplex Scanning Noninvasive medical test to assess peripheral blood flow, velocity, and turbulence. Ecchymosis A small hemorrhagic spot in the skin or mucous membrane, larger than petechia, forming a nonelevated, rounded or irregular blue or purplish area

7 Edema Presence of abnormally large amounts of fluid in the interstitial space. Enzymatic Debridement Epibole Form of debridement using topically applied exogenous enzymes to remove devitalized tissue, requires a physicians prescription. Edges of top layers of epidermis have rolled down to cover lower edges of epidermis, including basement membrane, so that epithelial cells cannot migrate from wound edges: also described as closed wound edges. Epidermis Outer cellular layer of skin. Epithelialization Regeneration of the epidermis across a wound surface

8 Erosion Wearing away or gradual destruction of a surface caused by inflammation, injury, or other causes. Erythema Redness of the skin surface produced by vasodilatation. Eschar Thick, leathery necrotic tissue: devitalized tissue, can be soft or hard. Excoriation Exudate Fascia Fibroblasts Destruction of the skin by mechanical means, which appear in the forms of a scratch or abrasion of the skin. Accumulation of fluid in a wound: may contain serum, cellular debris, bacteria, and leukocytes. Can be described as bloody, purulent, serosanguineous, or serous. Connective tissue that surrounds muscles, groups of muscles, blood vessels, and nerves, binding structures together A cell or corpuscle from which connective tissue is developed. Fissure A crack in the skin that is usually narrow but deep. Fistula An abnormal passage from an internal organ to the body surface or between two internal organs.

9 Foam Moisture-retentive wound dressing consisting of a polyurethane foam with or without an adhesive back Friction Full Thickness Gangrene Surface damage caused by skin rubbing against another surface. Tissue destruction extending through the dermis to involve the subcutaneous layer and possibly muscle and bone. Dead tissue that is dry, dark, cold, and contracted, removal requires surgical intervention. See Dry gangrene, wet gangrene and gas gangrene. Gas Gangrene A type of wet gangrene caused by Clostridia bacteria. This bacteria causes infection, and grows only in the absence of oxygen. As the bacteria grows, it produces poisonous toxins and gas. This progresses quickly and has a mortality rate of 20-25%. Granulation Tissue Temporary structure composed of vascularized connective tissue that fills the wound void. Heel Flotation Use of pillow or other device to completely off load the pressure on the heels while.

10 Hemosederin Staining Occurs when the by-product of the breakdown of red blood cells is forced into the interstitial area by venous hypertension. Hemostasis Occurs immediately after the initial injury. The platelet is the key cell responsible for this function, which forms a clot to prevent further bleeding. This phase is followed by the inflammation phase. Hydrocolloid Moisture-retentive occlusive wound dressing consisting of gelatin, pectin, and carboxymethycellulose hydrophilic particles with an adhesive back. Hydrogel Wound dressing that is 80%-90% water or glycerin based, available in sheets and as an amorphous gel. Hydrophilic Hydrophobic Attracting moisture. Repelling moisture.

11 Hyperbaric Oxygen HBO Modality used to enhance wound healing by having patient breathe 100% oxygen at 2.0 to 2.5 Atm. Hyperemia Presence of excess blood in the vessels, engorgement. Hyperkeratosis Excess growth of keratin resulting in thickening of skin, typical appearance is white/gray in color and is firm to touch Incontinence Associated Dermatitis IAD An inflammation of the skin that occurs when urine or stool comes into contact with perineal skin, this can cause the skin to appear macerated, reddened with partial skin loss in diffuse patterns Induration Abnormal firmness of tissue with a definite margin. Infection Invasion and multiplication of microorganisms within body tissues, wound culture reveals greater than 10₅ microbes per gram of tissue

12 Inflammation The second phase of wound healing, also known as the defensive or reactive phase. This phase lasts 4-6 days. In this phase, macrophages work to destroy bacteria, and cleanse the wound of cellular debris. Characteristics of this phase include, pain, warmth, redness, and edema. Intertrigo An inflammatory process that occurs on opposing skin surfaces as a result of friction and moisture: characterized by erythema, superficial linear erosions at the base of the skin fold, or circular erosion between the buttocks. Ischemia Deficiency of blood flow caused by functional constriction or obstruction of a blood vessel. Keloid Scar due to the overproduction of collagen which extends beyond the confines of the original wound. Kennedy Terminal Ulcer KTU A subset of pressure ulcers, that occurs in residents as they are dying. They usually appear suddenly on the sacrum in the shape of a pear, butterfly, or horseshoe with irregular wound edges. They start out larger then other pressure ulcers, and are usually more superficial initially but develop rapidly in size and depth.

13 Lower Extremity Arterial Ulcers LEAD Ulcers that are a result of inadequate blood supply that compromises circulation. These ulcers are usually located on the foot or toes. Ulcers have a "punched out" appearance, with dry wound bed. Lower Extremity Vascular Ulcers LEVD These ulcers are a result of venous congestion. Ulcers are usually located below the knee and above the ankle, wound edges are irregular, and ulcers are shallow with significant drainage. Periwound skin may appear shiny and tight due to edema. Low-intensity Laser Therapy Light amplification by stimulated emission of radiation, modality that may enhance healing in chronic wounds. Maceration Skin that is white, friable, over hydrated, and sometimes wrinkled. Macule A flat area of discoloration that is less than 10mm. This area does not include changes in skin texture or thickness.

14 Maturation The final phase of wound healing, and is also known as the remodeling phase. This phase can last from 21 days to years. During this phase collagen fibers remodel and mature, but only 80% of the skin's original tensile strength is regained. Mechanical Debridement Form of debridement using force to remove devitalized tissue, foreign material, and debris from a wound bed. Musculocutaneous Flap Closure Surgical procedure used to close Stage III and IV pressure ulcers by rotating a muscle and overlying tissue along with the blood supply to fill the wound defect. Necrotic Tissue Dead, avascular, devitalized tissue adhered to the wound bed. Negative Pressure Wound Therapy NPWT Modality that uses negative pressure to enhance wound healing. Sometimes referred to as vacuumassisted closure (VAC)

15 Neuropathic Ulcers Ulcer due to insensitivity as in a diabetic ulcer Neuropathy Dysfunction of sensory nerves leading to altered or decreased sensation. Nodule Similar to a papule, but larger than 10mm in width and depth, and is centered in the dermis or subcutaneous tissue. Osteomyelitis Pallor Inflammation of bone and marrow, usually caused by pathogens that enter the bone during an injury or surgery. Lack of natural color, paleness Pannus A hanging apron of excess abdominal skin Papule A solid elevation of discolored skin with no visible fluid less than 10mm at widest point.

16 Paresthesia Abnormal neurologic sensations described as "pins and needles," "electric-like", "numb, aching feet", or "as if my feet have been in ice water", : "knifelike", or shooting pains. Partial Thickness Periwound Pillow Bridging Plaque Pliable Pre-Albumin Pressure Ulcer Loss of epidermis and possible partial loss of dermis. The area immediately around the wound. see heel floatation An elevated, plateau-like lesion that is greater in its diameter than in its depth. Supple, flexible. Transport protein used as an indicator of nutritional status. Normal levels are 16-40mg/dl A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers: the significance of these factors is yet to be elucidated. Pressure Ulcer - Stage I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching: its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons.

17 Pressure Ulcer - Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serumfilled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation. *Bruising indicates deep tissue injury Pressure Ulcer - Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable Pressure Ulcer - Stage IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis likely to occur. Exposed bone/muscle is visible or directly palpable.

18 Pressure Ulcer - Suspected Deep Tissue Injury sdti Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, wormer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include thin blister over a dark wound bed. The wound may further evolve and become covere by thin eschar. Evolution may be rapid exposing additional layers of tissue ever with optimal treatment. Pressure Ulcer - Unstageable Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determinined: but it will be either a Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. Pressure Ulcer Scale for Healing PUSH Developed by the NPUAP, as a tool to monitor the change in pressure ulcer status over time. This tool helps assign a numerical value to pressure ulcers, in order to simply plot graph status. can be found at Primary Closure Wound closure immediately following the injury and prior to the formation of granulation tissue The third phase of wound healing and known as the regenerative phase. This phase lasts several weeks. During this phase granulation tissue fills the wound site which leads to epithelialization. Proliferation

19 Pulsed Magnetic Therapy Field Puritis PEMF A therapeutic device that generates wave-like charges called electromagnetic fields. When used in wound care it is to stimulate wound healing. Severe itching Purpura Bleeding beneath the skin or mucous membranes: it causes black and blue spots (ecchymosis) or pinpoint bleeding. Pus Thick fluid indicative of infection containing leukocytes, bacteria and celluar debris. Pustule A small elevation of the skin containing cloudy or purulent material usually consisting of necrotic inflammatory cells Revascularization Secondary Closure Secondary Dressing Sharp (Surgical) Debridement Shear A surgical procedure for the provision of a new, additional or augmented blood supply to a body part or organ. This refers to allowing wounds to heal on their own without surgical closure. Wound dressing placed over the primary dressing that provides increased protection, cushioning, absorption, and/or occlusion. Form of selective debridement using scissors or scalpel to cut along the lines of demarcation between viable and nonviable tissue. Trauma caused by tissue layers sliding against each other that results in disruption or angulation of blood vessels.

20 Sinus Tract Course or pathway that can extend in any direction from the wound surface: results in dead space with potential for abscess formation. Skin Tear A traumatic injury resulting in the separation of the dermis and the epidermis. Skin Tear - Grade 1 A skin tear without the loss of tissue Skin Tear - Grade 2 Scant loss of tissue, maximum 25% loss of tissue flap lost. Skin Tear - Grade 3 Skin tear that involves the loss of the entire skin flap. Slough Soft, moist avascular (necrotic/devitalized) tissue: it may be white, yellow, tan, or green: it may be loose, stringy, or firmly adherent. Specialty Absorptives Multilayered dressings that consist of highly absorptive layers of fibers, such as cellulose, cotton, or rayon.

21 Stasis Subcutaneous Tissue Support Surfaces Tertiary Closure Tissue Interface Pressure Total Protein Stagnation of blood caused by venous congestion Composed of adipose tissue and fascia, located beneath the dermis, helps support the skin. A therapeutic means to manage pressure, friction, and shear on tissues. May also assist in controlling moisture, and inhibiting bacterial growth. They are for use in chairs, beds, OR tables, gurneys etc. They can be static or dynamic, replacement or overlay. This refers to the approach of having the patient return in 3-4 days after the initial wound cleansing and dressing for wound closure. Also known as delayed primary wound closure. The amount of pressure between a body part and support surface. Responsible for the growth and maintenance of tissue, fluid balance, and antibody formations. Can be influenced by stress, hormones, infection, and organ dysfunction. Normal levels 5-9 g/dl. Transferrin Is responsible for transporting dietary iron from the intestine to the bone marrow so that it can be used by the hemoglobin. Reference range is mg/dl Transparent Film Moisture-retentive wound dressing consisting of a transparent polyurethane sheet with an adhesive backing: impermeable to bacteria and water. Tunneling A narrow passageway within a wound bed.

22 Unavoidable Pressure Ulcer Means that the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors, defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice. Undermining Tissue destruction to underlying intact skin along wound margins. Vasoconstriction Constriction of the blood vessels. Vasodilatation Dilatation of blood vessels, especially small arteries and arterioles. Vesicle A circumscribed, fluid containing epidermal elevation generally considered less than 10mm in diameter at the widest point.

23 Wet Gangrene Wet or moist gangrene develops as a complication of an untreated infected wound. Swelling from the bacterial infection causes a sudden stoppage of blood flow which facilitates bacterial invasion of muscles. The bacteria grows quickly due to the fact WBC's cannot reach the affected area because of the blockage of blood flow. Wheal A rounded or flat topped pale red papule or plaque that is characteristically evanescent, disappearing within hours. Wound Base Wound Contracture Wound Fillers Wound Margin Uppermost viable tissue layer of the wound: may be covered with slough or eschar. Process by which myofibroblasts pull wound margins closer together thereby decreasing the size of the defect. Agents that are provided in a variety of forms including pastes, granules, powders, beads, and gels. The provide a moist healing environment, absorb exudate, and help debride the wound bed by softening the necrotic tissue. Rim or border of wound. Xerosis Abnormal dryness of the skin or mucus membranes. The skin is dry, scaly, itchy, and red. Fine cracks may appear on the skin.