MED-SURG NURSING — Tissue Integrity, Wounds, Burns & Skin Conditions Flashcards

A vocabulary-style study guide focusing on tissue integrity, wound classification, healing phases, pressure injury staging, burn management, and common skin conditions based on the NUR 113 visual guide.

Tissue Integrity

State of structurally intact and physiologically functioning epithelial tissues (skin and mucous membranes).

Wound

A complete or incomplete disruption in the continuity of bone or soft-tissue structure.

Debridement

Removal of necrotic or devitalized tissue using autolytic, chemical, or mechanical means.

Granulation Tissue

New tissue formed during proliferative healing phase consisting of fibroblasts, new collagen, and new blood vessels; described as pink/red and moist.

Epithelialization

Process of new epithelial cells migrating over a wound surface to close it.

Exudate

Fluid that leaks from blood vessels into wound tissue during inflammation.

Eschar

Hard, leathery, black/brown necrotic (dead) tissue that must often be removed before healing can occur.

Slough

Soft, yellow/tan/grey necrotic tissue which indicates infection or poor healing.

Dehiscence

Partial or complete separation of wound edges.

Evisceration

Protrusion of internal organs through an open wound; considered a SURGICAL EMERGENCY.

Fistula

An abnormal tunnel connecting two body cavities or a body cavity to the skin.

TBSA

Total Body Surface Area; the percentage of the body that is burned.

Maceration

Softening and breakdown of skin resulting from prolonged moisture exposure.

Undermining

Tissue destruction extending under intact skin along wound edges.

Tunneling

A narrow passage or channel through wound tissue.

Epidermis

The outermost waterproof barrier containing melanocytes and keratinocytes; it is avascular and renews approximately every $28$ days.

Dermis

Deeper skin layer containing collagen, blood vessels, nerves, hair follicles, and sweat glands where most wound healing occurs.

Acute Wound

A wound that heals on schedule, such as a surgical incision.

Chronic Wound

A wound stuck in inflammation for $> 3$ months, such as a diabetic ulcer.

Incision

A clean cut with straight edges, typically surgical.

Laceration

An irregular tear with jagged edges resulting from trauma.

Abrasion

Scraping of the skin surface, often referred to as road rash.

Puncture

A small entry but deep wound carries a HIGH infection risk.

Contusion

A closed wound with blood under intact skin caused by blunt force; a bruise.

Avulsion

The forceful tearing away of tissue.

Ulcer

Tissue loss resulting from disease, such as pressure, venous, arterial, or diabetic causes.

Hemostasis Phase

The first phase of healing (minutes to hours) involving vasoconstriction, platelet plug formation, and the creation of a fibrin clot (scab).

Inflammatory Phase

Healing phase (Days $1-4$) characterized by vasodilation, migration of WBCs (neutrophils and macrophages), and cardinal signs: redness, warmth, swelling, pain, and loss of function.

Proliferative Phase

Healing phase (Days $4-21$) involving granulation (fibroblasts and angiogenesis), contraction (myofibroblasts), and epithelialization.

Maturation / Remodeling Phase

Final healing phase ($21$ days to $2$ years) where collagen fibers reorganize; maximum strength reaches approximately $80\%$ of original.

Primary Intention

Healing where wound edges are brought together and closed, typically used for clean surgical incisions.

Secondary Intention

Healing where the wound is left open and heals from the base up by granulation and epithelialization; used for infected wounds or large tissue loss.

Tertiary (Delayed Primary) Intention

Wound is initially left open to control infection and then sutured later.

MEASURE Framework

Assessment tool for wounds: Location, Size ($Length \times Width \times Depth$ in $cm$), Wound Bed Tissue, Exudate, Surrounding Skin, Reassessment, and Edge.

Serous Exudate

Clear, watery fluid; normal early drainage in small amounts.

Serosanguineous Exudate

Pink/pale red, watery mix of serum and blood; common in early postop.

Sanguineous Exudate

Bright red, bloody drainage indicating active bleeding.

Purulent Exudate

Yellow, green, tan, or cloudy thick fluid with foul odor; indicates INFECTION.

REEDA

Wound infection assessment acronym: Redness, Edema, Ecchymosis, Discharge (Purulent), and Approximation.

Evisceration Nursing Action

Call for help, stay with patient, cover organs with STERILE SALINE-SOAKED gauze, position SUPINE with KNEES BENT, and maintain NPO.

Hematoma

A collection of blood within a wound causing swelling, firmness, and bluish discoloration.

Wound Irrigation Pressure

Ideal pressure is $8-15\,psi$ using a $35\,mL$ syringe with a $19$-gauge needle.

Transparent Film (Tegaderm)

Dressing for Stage $1-2$ pressure injuries or IV sites; allows $O_2$ exchange and is waterproof.

Hydrocolloid (DuoDerm)

Occlusive dressing for Stage $2-3$ wounds; forms gel with wound fluid and promotes autolytic debridement.

Alginate Dressing

Seaweed-based, highly absorbent dressing used for heavy exudate or bleeding (hemostatic) wounds.

Hydrogel Dressing

Soothing/cooling dressing that ADDS moisture; used for dry wounds, burns, or radiation skin reactions.

Wet-to-Dry Gauze

Mechanical debridement used ONLY for wounds with necrotic tissue/slough; contraindicated for clean granulating wounds.

Autolytic Debridement

Slowest but most selective method using the body's own enzymes to dissolve necrotic tissue under moist dressings.

Stable Heel Eschar

Dry, black eschar on the heel without infection signs that should NOT be debrided; acts as a natural protective cover.

Stage 1 Pressure Injury

Intact skin with NON-BLANCHABLE redness; may feel warm, firm, soft, or painful.

Stage 2 Pressure Injury

Partial-thickness skin loss; shallow open wound with pink/red bed or an intact/ruptured serum-filled BLISTER.

Stage 3 Pressure Injury

Full-thickness skin loss where SUBCUTANEOUS FAT is visible, but no bone, tendon, or muscle is exposed.

Stage 4 Pressure Injury

Full-thickness tissue loss with EXPOSED BONE, TENDON, or MUSCLE; high risk for osteomyelitis.

Unstageable Pressure Injury

Wound bed covered by slough or eschar such that depth cannot be determined until debrided.

Deep Tissue Injury (DTI)

Intact or non-intact skin with DEEP PURPLE/MAROON discoloration; may feel boggy or firm and can rapidly deteriorate.

Braden Scale

Risk assessment tool where a LOWER score indicates HIGHER risk; a total score of $18$ or below indicates the patient is at risk.

Braden Scale Categories

Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction & Shear.

Pressure Injury Prevention

Reposition every $2$ hours, $30$-degree lateral tilt, FLOAT heels, and keep HOB at $30$ degrees or less.

Superficial (1st Degree) Burn

Epidermis only; red, dry, NO blisters; painful; blanches; heals in $3-5$ days.

Superficial Partial-Thickness (2nd Degree) Burn

Epidermis and superficial dermis; red, moist, blisters; VERY painful; blanches.

Full-Thickness (3rd Degree) Burn

Through entire dermis; white, brown, or black and LEATHERY; PAINLESS because nerve endings are destroyed; requires grafting.

Rule of Nines — Adult Chest (Anterior Trunk)

$18\%$ ($9\%$ chest + $9\%$ abdomen).

Rule of Nines — Each Arm

$9\%$ total ($4.5\%$ front + $4.5\%$ back).

Parkland Formula

$4\,mL \times \text{weight (kg)} \times \%TBSA = \text{total LR fluid in 24 hours}$; give half in the first $8$ hours (from time of burn).

Inhalation Injury Signs

Singed nasal hairs, hoarseness, stridor, soot in mouth, and carbonaceous sputum; requires early intubation.

Cellulitis

Bacterial infection of skin and subcutaneous tissue; red, warm, swollen with POORLY DEFINED edges.

Herpes Zoster (Shingles)

Reactivation of dormant varicella-zoster virus; unilateral DERMATOMAL rash of vesicles that DOES NOT CROSS MIDLINE.

Melanoma ABCDE Rule

Asymmetry, Border, Color variation, Diameter $> 6\,mm$, and Evolution.

Psoriasis

Chronic autoimmune condition with accelerated cell turnover causing silvery-white scales on red plaques.