Skin Integrity and Wound Care

Flashcards covering key concepts related to skin integrity and wound care.

Pressure Injury

Localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device.

Blanching

The lighter color of the skin after pressure is relieved, indicating transient hyperemia.

Stage 1 Pressure Injury

Non-blanchable erythema of intact skin, may appear differently in darkly pigmented skin.

Stage 2 Pressure Injury

Partial-thickness skin loss with exposed dermis; the wound bed is viable, pink or red, and moist.

Stage 3 Pressure Injury

Full-thickness skin loss where adipose is visible, granulation tissue, and epibole may occur.

Stage 4 Pressure Injury

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, or bone.

Deep Tissue Pressure Injury

Persistent nonblanchable deep red, maroon, or purple discoloration of intact or nonintact skin.

Unstageable Pressure Injury

Full-thickness skin and tissue loss wherein the extent of tissue damage cannot be confirmed due to slough or eschar.

Primary Intention Healing

Wound healing that occurs with clean surgical incisions where edges are approximated, leading to minimal scarring.

Secondary Intention Healing

Wound healing that involves extensive tissue loss and should not be closed; heals from inner layer to surface.

Nutritional Factors in Wound Healing

Essential nutrients like protein and vitamin C are crucial for skin repair and maintaining hydration.

Braden Scale

A tool used to predict pressure injury risk based on sensory perception, moisture, activity, mobility, nutrition, and friction.

Maceration

The softening of skin due to prolonged exposure to moisture.

Friction

The force of two surfaces moving across one another, which can damage the skin.

Shear

The sliding movement of skin and subcutaneous tissue while the underlying muscle and bone remain stationary.

Exudate

Fluid emitted by a wound, which may vary in color and consistency, indicating the healing process or infection.

Debridement

The removal of dead tissue to promote healing and prevent infection.

Granulation Tissue

New connective tissue formed during the healing process, typically red and moist.

Epithelialization

The phase in wound healing where epithelial cells migrate to cover the wound surface.

Eschar

Necrotic tissue that is black or brown and can obscure the extent of tissue damage in a wound.

Sign of Wound Infection

Indicators include erythema, swelling, warmth, pain, fever, and foul odor around the wound.