Skin Integrity and Wound Healing

Comprehensive vocabulary flashcards covering skin integrity, wound classification, healing mechanisms, pressure injury staging, and nursing interventions from Chapter 32.

1. protection

2. barrier from pathogens

3. insulation

4. sensory perception

5. control of heat regulation

6. aesthetic function

7. synthesis of vitamin D

functions of skin 7

Skin Integrity

maintenance of all layers of skin (intact)

• age

• impaired mobility

• nutrition

• diminished sensation

• cognition

• impaired circulation

• meds

• moisture

• infection

• fever

• lifestyle

What are factors that affect skin integrity? 11

Epidermis

outermost layer of the skin

Dermis

connective tissue layer beneath the epidermis containing blood vessels

Hypodermis (Subcutaneous Tissue)

The layer of adipose and connective tissue located beneath the dermis that provides insulation, physical cushioning, and vascular connections to underlying muscle and bone.

Age-Related Skin Changes in Older Adults

Decreased activity of sebaceous and sweat glands, diminished lean body mass and subcutaneous fat, decreased elasticity, and pre-existing chronic diseases that heighten skin vulnerability.

wounds

disruption in normal skin integrity; may be intentional or unintentional

• length of time wound has existed

• condition of wound

• depth

What are wounds classified according to? 3

Closed Wound

A wound characterized by no break or disruption in the skin surface, ex: contusion (bruise), tissue swelling from fracture

Open Wound

A wound characterized by a break in the skin or mucous membranes, such as an abrasion, laceration, puncture, or surgical incision.

Abrasion

A scrape of the superficial layers of the skin; usually unintentional (can be intentional)

Abscess

A localized cavity of pus beneath the skin resulting from pathogens, which must be opened and drained to heal.

Contusion

A closed wound resulting from blunt trauma (bruise)

Crushing

A wound caused by force leading to compression (fracture); usually closed

Excoriation

A superficial wound due to excessive scratching

Incision

An intentional, open wound caused by a sharp instrument

Laceration

skin torn open, resulting in jagged margins

Penetrating

An open wound in which an agent causing wound lodges in tissue

Puncture

open wound caused by sharp object

Tunnel

wound with an entrance and exit site

strip and inspect them

What can nurses do with JP drains?

Undermining

Tissue erosion occurring beneath the intact wound margins, resulting in an open pocket or overhang beneath the skin edge.

Hematoma

A localized extravasation and collection of blood, often clotted, trapped within tissues or body spaces beneath intact skin.

Acute Wound

A wound of short duration; in healthy pts wounds heal spontaneously

Chronic Wound

A wound that exceeds the expected length of recovery (failing to heal within 2 to 4 weeks) due to stalled healing phases, lasting from months to years.

pressure injury

• one of the most common chronic wounds

• caused by pressure, shear, and friction

• coccyx, sacrum, heels, elbow, spine

• can be SERIOUS tissue damage

Superficial Wound

A wound that involves only the epidermal layer of the skin, commonly resulting from shearing, friction, or burns.

Partial-Thickness Wound

A wound extending completely through the epidermis and into, but not through, the dermal layer of the skin.

Full-Thickness Wound

A wound that extends completely through the epidermis and dermis into the subcutaneous tissue and potentially deeper structures such as bone, tendon, or muscle.

Primary Intention Healing

• Healing occurring in wounds with minimal or no tissue loss

• well-approximated edges (closed)

• low risk of infection

• little scarring; heals quickly

• top layer cells migrate/epithealize within 72 hrs

• ex: clean surgical incision

Secondary Intention Healing

1. Healing that occurs when extensive tissue loss; prevents edge approximation (coming together)

2. should not be closed due to infection (left open); heals from the inner layer to surface with beefy red granulation tissue (good bloody supply); RISK FOR INFECTION; scarring

Tertiary Intention Healing (Delayed Primary Closure)

• AKA delayed primary closure

• occurs when 2 surfaces of granulation tissue are brought together

• initially wound heals by secondary intention

• when there is no edema or infection, edges are closed by bringing together granulation tissue and suturing surface

• require strict ASEPTIC technique w dressing changes

• less scarring

• increased age

• overall wellness

• infection

• medications

• nutrition

• tissue perfusion

• obesity

• systemic (diabetes mellitus)

• smoking

What are 9 factors of wound healing

primary and tertiary intention wounds

What 2 types of wounds would be closed with wound closures?

Adhesive Strips (Steri-Strips/butterfly strips)

for superficial low tension wounds, for additional support after suture/staples removed

Absorbent Sutures

Surgical threads used in deep tissues; no need to remove

Nonabsorbent Sutures

Surgical sutures placed superficially in the skin that do not dissolve and must be manually removed by a nurse once healing occurs.

Surgical Staples

Lightweight titanium fasteners used for fast and easy wound closure on the arms, legs, abdomen, back, scalp, or bowel; require removal by a nurse.

Surgical Glue (Dermabond)

A topical liquid adhesive used to approximate clean, low-tension skin edges without the need for needles or traditional closures.

Hyperbaric Oxygen Therapy (HBOT)

A collaborative medical treatment administering 100% oxygen under elevated atmospheric pressure to wound site to increase tissue oxygen concentratoin and stimulate new blood vessel growth.

Extensive Debridement

The surgical or mechanical removal of devitalized, necrotic tissue or foreign matter from a chronic wound bed to promote the development of viable granulation tissue.

Flap Technique

A reconstructive surgical procedure in which a section of healthy tissue with its original vascular supply is detached and positioned over a deep tissue defect.

Exudate

Fluid drainage accumulating in wounds that is produced by the inflammatory response and microvascular leakage.

• exudate

• amount

• color

• consistency

• odor

What are you looking for when assessing drainage? 5

Serous Exudate

Thin, watery, straw-colored wound drainage containing serum and minimal cellular components, typically produced by clean, non-infected wounds.

Sanguineous Exudate

Fresh or old bloody wound drainage that indicates disruption or damage to capillaries.

Serosanguineous Exudate

A light pink drainage composed of a mixture of clear serous fluid and red blood cells, commonly seen in newly healing wounds.

Purulent Exudate

Thick, opaque, malodorous pus that is typically yellow or can be blue-green, often from pus-forming bacteria such as staphylococcus or streptococcus infecting the wound

Purosanguineous Exudate

Red-tinged pus drainage indicating a concurrent bacterial wound infection and localized capillary rupture.

• hemorrhage

• infection

• dehiscence

• evisceration

• fistulas

What are 5 complications of wound healing?

1. localized edema

2. erythema

3. pain

4. fever (temp >100.4)

5. change in exudate color

What are 6 signs of infection?

Dehiscence

The rupture or separation of one or more skin layers of a wound, most likely to occur in the inflammatory phase before collagen deposition; RISK for draining wounds within 5-7 days after surgery

1. poor nutrition

2. inadequate muscle closure

3. wound infection

4. increased tension on suture line from coughing or lifting

5. OBESITY

What are common causes for dehiscence? 5

Dehiscence

• usually associated w abd wounds

• pts report “pop” or tear

• often w coughing, straining, vomiting, changing positions

• Maintain strict bedrest with head of bed elevated to 20 degrees and knees flexed

• apply an abdominal binder to support the incision and prevent evisceration

• immediately alert the healthcare provider.

Nursing Interventions for Dehiscence 3

Evisceration

A rare surgical emergency characterized by the total separation of all wound layers accompanied by protrusion of internal viscera through the open incision.

• Immediately cover the protruding organs with sterile towels or dressings soaked in sterile saline

• keep the patient in bed with knees bent

• do NOT apply a binder

• immediately contact the healthcare provider.

Nursing Interventions for Evisceration 4

pressure

external force contributing to pressure injuries that compresses small blood vessels, hindering blood flow and nutrient supply = ischemia

Shear Force

external force contributing to pressure injuries where one layer of tissue slides horizontally over another, deforming adipose and muscle tissue; often occurs when pt slides down in bed

Friction Force

external force contributing to pressure injuries that occurs when pt is moved up in bed

Moisture

external force contributing to pressure injuries that results from urine, feces, diaphoresis macerate the skin

braden scale

• Risk assessment tool for pressure injuries

• use it to assess the patient’s level of risk for development of pressure ulcers

1. sensory perception

2. moisture

3. activity

4. mobility

5. nutrition

6. friction/shear

What are the 6 subscales of braden scale?

• each category is graded from 1-4

• total scores are from 6-23

• LOWER numbers indicate a HIGHER risk for pressure injury development

How does the grading scale in braden scale work?

THOROUGHLY ASSESS YOUR PATIENTS! and document any pressure injuries through a Braden scale

As the nurse, you are responsible for prediction and preventing pressure ulcers so you need to…

Blanching Assessment

The application of light digital fingertip pressure to a reddened skin site to determine whether microvascular blood flow temporarily pales and returns.

Nonblanchable Erythema

Persistent redness of intact skin over a pressure point that fails to turn pale when light fingertip pressure is applied, indicating microvascular damage.

stage 1 pressure injury

intact skin with nonblanchable redness

Stage II Pressure Injury

Partial-thickness loss of skin with involving epidermis, dermis, or both

Stage III Pressure Injury

Full-thickness tissue loss with visible adipose (subcutaneous fat) tissue in the wound bed; muscle, tendon, and bone are not exposed.

Stage IV Pressure Injury

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

Unstageable Pressure Injury

Ulcer which cannot be staged due to eschar or slough obscuring wound

Suspected Deep Tissue Injury (DTI)

deep discoloration of intact skin in a pressure area

• turn q2h

• reduce shearing/friction

• specialty mattress/wheelchair cushion

• skin barriers

• float heels

• joint protectors

• ASSESS

• BE PROACTIVE

What can I do to prevent pressure injuries?

• history

• mobility and activity level

• PAIN

• all areas of skin

• blanching

What are 5 cues to assess for pressure injuries?

• location

• size (length, width, depth)

• type of wound

• type of closure

When assessing wounds, what traits are important to note?

undermining

tissue under wound edge erodes = pocket beneath skin at wound’s edge

tunneling

passageway extending through tissue = dead space and potential for abscess formation

erythema

redness → possible infection

edema

swelling → possible infection

Slough

Soft, stringy, yellow necrotic tissue

Eschar

Thick, black or brown necrotic tissue

Maceration

The pruning, pale discoloration, and breakdown of skin caused by prolonged exposure to moisture, such as wound exudate or bodily fluids.

Crepitus

A crackling or bubbling sensation palpable in the periwound skin caused by gas produced by bacteria trappedunder skin

wound base

• reveals severity of wound; treatment options; healing

• viable tissue MUST be distinguished from nonviable tissue

granulation tissue

what is evidence of healing

pale or dry tissue

what is evidence of delayed healing

necrotic tissue

delayed healing; must be removed!

Red Wound Classification

A wound characterized by healthy, moist granulation tissue and new capillary beds; the nursing goal is gentle cleansing and protection.

Yellow Wound Classification

A wound bed covered with soft, stringy slough or purulent tissue; the nursing goal is to debride and cleanse the nonviable tissue.

Black Wound Classification

A wound bed covered with thick, leathery, dark necrotic eschar; the nursing goal is debridement to enable granulation and healing.

Wound Culture

The diagnostic collection technique of swabbing viable wound tissue to identify infecting bacterial species; must be executed before starting antibiotics.

NO

Can you delegate initial assessment and ongoing evaluation of a wound requiring treatment

YES, report any disturbing signs to RN

Can you delegate a UAP to inspect skin and note any disturbing signs?

YES

Can you delegate UAP to turn and reposition pt if RN provides turning schedule?

1. remove necrotic tissue

2. prevent, eliminate, or control infection

3. absorb drainage

4. maintain a moist wound environment

5. protect the wound from further injury

6. protect the surrounding skin

What are the 6 goals for wound care

• from the cleanest area outward

• gently pat wound w gauze soaked with ordered med

• be careful w granulation tissue

to cleanse a wound: 3

antiseptic solutions

• cleanse per order

• can be harmful to tissue

normal saline

• isotonic solution

• safe

• bottle should be used within 24 hrs of opening

• LABEL