Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
BIRMINGHAM PRIMARY CARE TRUSTS -TISSUE VIABILITY GUIDELINES/NURSING HOMES Glossary Abrasion A break in the skin integrity through some mechanical process such as friction or trauma. Abscess Accumulation of pus enclosed anywhere in the body which can evacuate to reveal extensive damage Antimicrobials A term used to describe a substance that destroys microbial bacteria or prevents them multiplying. Arterial insufficiency The lumen of the artery becomes smaller due to atherosclerosis, resulting in less blood being delivered to the lower extremities of the body. Arterial ulcers Ulcers that are formed on the lower extremities as a result of arterial insufficiency. Blanching hyperaemia An area of erythema that turns white under finger pressure Cellulitis Inflammation and infection of the cells associated with redness, heat, swelling and pain. Common bacterial agents are staphyloccus aureus and streptococcus. Clinical infection The presence of multiplying bacteria in a localised wound environment Collagen Main protein involved in wound healing that provides strength and structure to tissues Colonisation Multiplication of bacterial organisms without a host reaction. Contamination Organisms present in a wound, not multiplying or causing a host reaction. Debridement Removal of devitalised or contaminated tissue Dermis The skin layer between the epidermis and the subcutaneous tissue Emollient Used to moisturise the skin. A mixture of water, oil and emulsifiers. Epidermis Outermost layer of the skin Epithelialisation End stage of wound healing, epithelial cells migrate across the wound surface to close the wound. Pink/pale mauve in colour. EPUAP European Pressure Ulcer Advisory Panel Erythema Redness of the skin in relation to either inflammation, infection or prolonged pressure to tissue. Eschar Non viable, devitalised tissue characterised by a thick black crust 101 BIRMINGHAM PRIMARY CARE TRUSTS -TISSUE VIABILITY GUIDELINES/NURSING HOMES Excoriation A superficial loss of the outermost layer of skin by scratching, trauma, chemicals in contact with the skin surface Exudate Serous fluid that passes through damaged or over extended veins. Consistency changes according to the state of the wound bed. Some exudate is required in a wound to achieve the optimum wound environment. Friction The resistance of one surface to another that moves over it characterised by a blister. Full thickness Tissue destruction extending down through the dermis and subcutaneous tissue and fascia to muscle and bone. Granulation The growth of new tissue. The appearance will be pink/ red in colour with lumps over the surface. The lumps are as a result of new capillaries growing through the wound matrix. Indolent Static, lazy wound Infection Overgrowth of micro organisms in sufficient quantities to over whelm the body’s immune system Inflammation A physiological response of the body’s immune system to injury, lasting for approximately 3 days, as a result of the release of chemical mediators to fight off invading bacteria. Lipodermatosclerosis A clinical feature of venous leg ulceration, the adipose tissue becomes hard, fibrosed and woody. Lipoedema Bilateral enlargement of the legs due to oedema in the subcutaneous fat layer. Maceration The softening of tissue that has had prolonged moisture on it. The skin becomes white and ‘soggy’. Maturation The final stage of wound healing involving wound contraction, full epithelialisation and reorganisation of the cellular matrix. Microcirculation Small vessels that carry oxygen and nutrients to the tissues and waste products away. Necrosis Death of a tissue or organ in response to lack of blood flow, trauma or infection Non blanching hyperaemia An area of reddened skin that does not turn white under finger pressure. Indicative of microcirculation damage as a result of unrelieved pressure. Requires immediate intervention. Oedema An accumulation of fluid within the interstitial spaces of tissues. 102 BIRMINGHAM PRIMARY CARE TRUSTS -TISSUE VIABILITY GUIDELINES/NURSING HOMES Overgranulation Granulation tissue fills the wound and becomes proud of the surface preventing the migrating epithelial cells from closing the wound. Can be as a result of chronic infection. Papillomatosis Upward projections of dermis into the epidermis of the skin. Appear as wart like growths. Peri-wound The outer margins of a wound Pressure reduction Redistribution of pressure over a larger surface to spread the pressure load, this in turn reduces the force on a bony prominence. Pressure relief Removal of the source of pressure, achieved through repositioning the body surface. Prevalence An epidemiological term that describes the proportion of a population that has a specific condition at one point in time. Primary dressing A dressing that is placed in direct contact with the wound bed. Proliferation Rapid multiplication of cells or the second stage of wound healing. Reactive hyperaemia Red flushing of the tissues followed by a period of ischaemia, occurs as a result of microcirculatory damage. Secondary dressing Used to secure a primary dressing and to increase the absorptive capacity. Shear A force that acts on the body from one direction and can cause distortion and twisting of the underlying tissue. Slough A mixture of dead white cells, dead bacteria, rehydrated necrotic tissue and fibrous tissue. Can be soft or fibrous. If present in large quantities it needs to be removed through a form of debridement. Strike through Evidence of wound exudate appearing on the outer surface of the wound dressing, indicating a need to change the dressing Thirty degree tilt Places the patient at a slight angle with the use of pillows reducing the direct pressure on bony prominences. Tissue Viability An umbrella term for the management, prevention and treatment of wounds Ulcer A lesion to the skin, a non healing chronic wound Undermine Edges of a wound that have lost supporting tissues under intact skin Vasculitis Inflammation of blood vessels Venous hypertension 103 BIRMINGHAM PRIMARY CARE TRUSTS -TISSUE VIABILITY GUIDELINES/NURSING HOMES The veins become engorged with blood as a result of the inability of damaged valves in the veins to return the blood back up to the heart. The excess fluid creates high pressure within the lumen of the vein. Venous insufficiency The valves in the superficial veins become inadequate as a result of trauma, DVT, pregnancy or long periods of standing Venous return The ability of the circulatory system to return blood back up to the heart. Wound bed preparation An umbrella term for the clinical measures taken to remove any barriers to wound healing. For example, the management of infection, control of exudate and debridement of unhealthy tissue. 104