Wound Care and Tissue Integrity

These flashcards cover the vocabulary and key concepts of wound care, including tissue integrity definitions, phases of wound healing, drainage types, dressing selections, and pressure ulcer staging as presented in the lecture notes.

Tissue Integrity

The condition of the skin and underlying tissues being intact and healthy, meaning there are no injuries, wounds, pressure ulcers, or damage disrupting normal function.

Inflammation Phase

The second phase of wound repair, a physiologic defense occurring immediately after tissue injury and lasting $2$ to $5$ days, involving swelling, redness, warmth, pain, and decreased function.

Phagocytosis

A process by which neutrophils and monocytes (macrophages) emigrate from blood vessels to consume pathogens, coagulated blood, and cellular debris.

Proliferation Phase

A period occurring $2$ days to $3$ weeks after the inflammatory phase, during which new cells fill and seal a wound through resolution, regeneration, and scar formation.

Remodeling Phase

The final period of wound repair, lasting $6$ months to $2$ years, during which the wound undergoes maturation, the wound contracts, and the scar shrinks.

DIDN'T HEAL

A mnemonic for factors affecting wound healing: Diabetes, Infection, Drugs, Nutritional problems, Tissue necrosis, Hypoxia, Extensive tension, Another wound, and Low temperatures.

Maceration

An irritation of the epidermis caused by moisture.

Dermatitis

A red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound secretions.

Skin tears

Loss of the top layer of the skin caused by mechanical forces and tissue trauma.

Hydrofiber dressing

A high-absorbency dressing used for moderate and highly exudative wounds that can stay in the wound for several days.

Hydrogel dressing

A dressing used for the debridement of necrotizing tissue in dry wounds.

Hydrocolloid dressing

A dressing that should not be used in infected or tunneling wounds because it can cause contact dermatitis and trap bacteria.

Polymeric membrane dressing

A dressing used to treat wounds with a small amount of exudate.

Gauze dressings

Dressings ideal for covering fresh wounds likely to bleed or wounds that exude drainage.

Transparent dressings

Dressings used to cover peripheral and central IV insertion sites; also effective for Stage 1 pressure injuries.

Serous Drainage

Wound drainage that is clear, pale yellow, thin, and watery, consisting of blood plasma low in proteins.

Sanguineous Drainage

Wound drainage consisting mainly of blood that is bright red and thin initially before darkening and thickening; has a coppery smell.

Serosanguineous Drainage

Wound drainage that is thin, light pink, and odorless, containing both serum and blood.

Purulent Drainage

Thick, pus-like wound drainage that is brown, gray, yellow, or green; contains bacteria, dead tissue, and WBCs, and always indicates infection.

Sharp debridement

The removal of dead tissue using sterile scissors, forceps, or other instruments.

Enzymatic debridement

The removal of dead tissue through the use of chemical substances.

Autolytic debridement

A natural physiologic process where moisture-retentive dressings (like hydrogels or hydrocolloids) trap body enzymes and fluids to liquefy necrotic tissue.

Hemoglobin

A part of the red blood cell that transports oxygen in the blood throughout the body.

Decubitus ulcers

Also known as pressure ulcers, these appear over bony prominences (sacrum, hips, heels) where pressure is unrelieved.

Stage 1 Pressure Ulcer

Intact skin with localized, non-blanchable erythema (redness); may include warmth, edema, hardness, or pain.

Stage 2 Pressure Ulcer

Partial-thickness skin loss involving the epidermis and dermis, presenting as a blister or shallow open ulcer without slough or bruising.

Stage 3 Pressure Ulcer

Full-thickness skin loss extending into subcutaneous tissue where fat is visible, but bone, tendon, and muscle are not; slough or tunneling may be present.

Stage IV Pressure Ulcer

Full-thickness tissue loss with exposed bone, muscle, or tendon; undermining and tunneling are common, and slough or eschar may be present.

Lateral oblique position

A recommended side-lying position for the prevention of pressure ulcers.