Skin Integrity Key Terms

Abrasion

Superficial wound involving scraping or rubbing away of outermost layer of skin (epidermis)

Approximated

Clean, straight, and brought closely together // typically seen from surgical incision healing

Blanchable Hyperemia

Redness of skin that temporarily turns white/pale when light pressure is applied and returns to red when released // indicates intact capillary blood flow and vasodilation

Blanching

Temporary whitening of normal skin color when pressure is applied, reflecting normal microvascular responsiveness

Debridement

Medical removal of nonviable, devitalized, or necrotic tissue (like slough or eschar) from a wound bed to promote healing and clear infection

Dehiscence

Partial or total separation of previously apprx. wound layers

Epithelialization

Phase of wound healing where new epithelial cells migrate across granulation bed to resurface and restore intact skin

Eschar

Thick, dry, black, brown, or tan necrotic, nonviable tissue covering a wound that must typically be debrided before healing can occur // hard, crusty, dead skin

Evisceration

Total separation of wound layers accompanied by protrusion of visceral organs (Wound is open and smth comes out through opening)

Exudate

Fluid, cells, or vascular discharge that slowly leaks out of blood vessels into a wound or tissue bed as part of the inflammatory process

Fluctulance

Soft, boggy, or wave-like feeling detected during wound or tissue palpation, indicating underlying fluid accumulation (such as pus or abscess)

Friction

Effects of rubbing or resistance that a moving body meets from surface when it moves, affecting the epidermal layer

Granulation Tissue

Soft, red, most, highly vascularized new tissue forming during wound healing, consisting of newly formed capillaries and connective tissue

Hemostasis

Cessation of bleeding via blood clotting, vasoconstriction, and platelet aggregation during intial stage of wound repair

Induration

Abnormal firmness or hardening of soft tissue surrounding a wound or pressure area caused by edema or inflammation

Laceration

A torn or jagged wound in the skin and soft tissues caused by sharp trauma or tearing

Medical Adhesive - Related Skin Injury (MARSI)

When attachment btwn skin and adhesive is stronger than skin cells, causing surface epidermal layer to detach from underlying layers (from repeated removal of adhesives)

Medical Device-Related Pressure Injury (MDRPI)

Skin or underlying tissue subjected to sustained pressure or shear over nonbony locations from medical device (eg. oxygen tubing)

Negative-Pressure Wound Therapy (NPWT)

Application of controlled vacuum pressure to a wound bed via specialized dressing to draw edges together, remove exudate, and stimulate granulation tissue growth

Nonblanchable Erythema

Redness of intact skin that doesn’t turn white/pale when pressure is applied — Indicates localized tissue ischemia and Stage 1 pressure injury

Pressure Injury

Localized dmg to skin and/or underlying soft tissue, usually over bony prominence or under medical device, resulting from intense or prolonged pressure or pressure combined w/ shear and friction

Primary Intention

Healing of a clean wound with well-approximated edges that heals quickly with minimal scar tissue and granulation

Puncture Wound

Deep, narrow wound caused by sharp object penetrating through skin layers into underlying tissues

Purulent

Thick opaque, yellow, green, tan, or brown wound drainage containing pus, dead white blood cells, and bacteria, indicating infection (smells bad)

Reactive Hyperemia

Transient increase in blood flow to tissues following brief period of ischemia or pressure relief

Sanguineous

Bright red, fresh blood drainage from a wound, indicating active bleeding

Secondary Intention

Healing of a wound involving tissue loss where edges cannot be approximated

Serosanguinous

Pale, pinkish, watery wound drainage comprised of mixture of clear serous fluid and red sanguineous fluid

Serous

Clear, thin, watery fluid or plasma drainage from a wound

Shearing Force

Sliding mvmt of skin and SubQ tissue while underlying muscle/bone are stationary

Slough

Soft, moist, stringy yellow, tan, gray, or green nonviable tissue present on a wound bed

Tertiary Intention

Delayed primary closure of wound left open intentionally for several days to allow infection or edema to resolve before surgically closing the apprx edges

Tissue ischemia

Deficiency of blood supply to tissues caused by sustained external mechanical pressure by exceeding capillary pressure

Wound

Disruption of normal anatomical structure and function of skin and underlying tissues

Wound Drainage Evacuators

Closed or open portable vacuum suction drainage systems placed in or near a wound to continuously pull exudate and fluid away from tissue beds (by gravity)