Skin Integrity and Wound Care

What are some ways wounds can be classified?

By underlying cause, skin integrity (open vs. closed), wound depth, and presence of infection.

What does an open wound mean?

There is an actual break in the skin’s surface.

What does a closed wound mean?

The skin remains intact (e.g., bruise).

What does infection in a wound mean?

Contamination in the wound; can be acute or chronic.

What layer of skin does a superficial wound involve?

Only the epidermis.

What layers of skin does a partial-thickness wound involve?

The epidermis and dermis, but not through the dermis to the subcutaneous layer.

What layers does a full-thickness wound involve?

Extends through the dermis to the subcutaneous layer and may reach muscle, bone, or other underlying structures.

What is a clean wound?

A wound with no infection and a low risk for infection.

What is a clean-contaminated wound?

A wound similar to a clean wound, but involving organ systems likely to contain bacteria, so the infection risk is greater.

What is a contaminated wound?

A wound that results from a break in sterile technique during surgery.

What is an infected wound?

A wound with clinical signs of infection, such as redness, warmth, and increased drainage (which may or may not be purulent).

What is a colonized wound?

A wound with organisms present on the surface, but no overt signs of infection in the tissue below (swab culture positive, but no infection).

What is an acute wound?

A wound that progresses through the phases of wound healing in a rapid, uncomplicated manner.

What are examples of acute wounds?

Surgical incisions or traumatic wounds with edges that can be approximated (brought together).

How do acute wounds usually heal?

By primary intention — healing quickly with minimal scar formation.

What is a chronic wound?

A wound that fails to progress to healing in a timely manner, often staying open for an extended period.

How do chronic wounds usually heal?

By secondary intention — new tissue must fill in from the bottom and sides until the wound bed is filled.

What does tertiary intention healing mean?

Healing that occurs when a wound is left open for a period after injury and then closed later.

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What happens during the inflammatory phase of wound healing?

It begins as the body’s initial response to skin wounding and lasts about 3 days.

What happens during the proliferative phase of wound healing?

Repair of the defect, filling of the wound bed with granulation tissue, and resurfacing with skin (Day 3–24).

What is granulation tissue?

New tissue that fills the wound; it appears beefy red due to many new blood vessels.

What is the maturation phase of wound healing?

The last phase, also called the remodeling phase, which can last up to a year.

What happens during the maturation phase?

Collagen continues to be deposited and remodeled, and scar tissue is formed and strengthened.

What is scar tissue?

A avascular mass of collagen that provides strength to the repaired wound.

What are the main factors that affect wound healing?

Disease processes, nutrition, age, and infection.

What is dehiscence?

Partial or complete separation of tissue layers during healing, usually with surgical incisions.

What is evisceration?

Total separation of tissue layers, with protrusion of visceral organs through the incision.

What is a healing ridge?

A 1-cm-wide area of induration next to the incision line, indicating new collagen is being laid down and the wound is healing properly.

What is a fistula?

An abnormal connection between two internal organs or between an internal organ and the outside of the body through the skin.

What is a pressure ulcer?

A localized injury to the skin and/or underlying tissue, usually over a bony prominence, caused by pressure or pressure combined with shear.

What is capillary closing pressure or critical closing pressure?

The minimum pressure required to collapse a capillary, generally 12–32 mm Hg.

How does pressure over time affect skin and tissue?

Low pressure over long periods can be as damaging as high pressure over a short period.

What is friction in the context of skin injuries?

The rubbing of two surfaces, such as the skin against a bed or other surface.

What is shear?

When a body slides against a surface, the skin sticks due to friction while the body’s weight pulls downward, causing tissue injury.

The nursing assistant asks you the difference between a wound that heals by
primary or secondary intention. You will reply that a wound heals by primary
intention when the skin edges:
A. Are approximated.
B. Migrate across the incision.
C. Appear slightly pink.
D. Slightly overlap each other.

A

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Which patients are at increased risk for developing pressure ulcers?

Those who are unable to feel pain, unable to respond appropriately, or limited in their ability to move or maintain position independently.

What is maceration?

A condition in which excessive moisture softens the skin.

What characterizes a Stage I pressure ulcer?

Intact, nonblistered skin with nonblanchable erythema (persistent redness) in an area exposed to pressure.

What is abnormal reactive hyperemia?

Redness due to excessive vasodilation caused by pressure.

What is a Stage II pressure ulcer?

A partial-thickness wound involving the epidermis and/or dermis but not extending below the dermis.

What does a Stage II pressure ulcer look like?

Shallow and superficial with a pink wound bed; intact or ruptured pressure blisters are also considered Stage II.

What is a Stage III pressure ulcer?

A full-thickness wound that extends into the subcutaneous tissue but does not go through the fascia to muscle, bone, or connective tissue.

What is undermining in a wound?

Tissue loss under intact skin, usually along the edges, forming a “lip” around the wound.

What is a tunnel or sinus tract in a wound?

A narrow passageway extending outward from the edge of the wound, similar to undermining but narrower.

What is a Stage IV pressure ulcer?

A wound deeper than Stage III that exposes muscle, bone, or connective tissue (e.g., tendons or cartilage).

Why is a Stage IV pressure ulcer particularly concerning?

Because bone may be exposed, making osteomyelitis (bone infection) likely.

What is an unstageable pressure ulcer?

A full-thickness wound with so much necrotic tissue (eschar) that the depth or involvement of underlying structures cannot be assessed.

When can an unstageable pressure ulcer be properly staged?

After the necrotic tissue is removed (debrided), allowing assessment of the wound depth and structures involved.

What is a suspected deep tissue injury?

An area of intact skin that is purple or maroon, or presents as a blood-filled blister.

Why are suspected deep tissue injuries challenging to detect?

They may be hard to see in darker-skinned individuals, and the true depth of tissue damage is not apparent initially.

How can suspected deep tissue injuries progress?

They can worsen rapidly, exposing deeper tissue layers even with prompt treatment.

How can chronic wounds affect people across the lifespan?

They can cause loss of independence, inability to work, and create significant financial burdens due to treatment costs.

What permanent changes can occur in full-thickness wounds healing by secondary intention?

Loss of epidermal structures like hair follicles, sweat glands, and melanocytes; in people of color, this may result in loss of skin pigmentation.

Which populations are more prone to keloids and pigment changes?

African Americans are more likely to develop keloids, hypopigmentation, and hyperpigmentation.

Which patients with disabilities are at higher risk for pressure ulcers?

Patients with mobility or sensory perception difficulties, such as those with spinal cord injuries, peripheral neuropathies, or neuromuscular disorders.

How does obesity affect wound healing?

Obesity increases the risk of poor wound healing because adipose tissue is poorly vascularized, mechanical forces on wound edges are higher, and individuals may have difficulty repositioning. Nutritional deficiencies may also be present despite body weight.

What general questions can be asked to assess a patient’s skin?

• How would you describe your overall skin condition?

• Have you had skin problems? What kind, where, and when?

• Describe your usual skin care routine.

• Describe your diet and any recent unintended weight loss.

• Have you ever been incontinent of urine or stool?

• Have you been told you have diabetes or circulation problems?

• Do you smoke?

• Have you noticed numbness or tingling in your feet?

• Has it ever taken a long time for a wound to heal?

What questions are important for a focused wound assessment?

• How long has the wound been present? Suspected cause? Previous similar wounds?

• How is the wound cared for at home? Cleaning method? Topical treatments?

• Have there been changes in the wound or surrounding skin?

• Amount, color, or odor of drainage? Frequency of bandage changes?

• Do you live alone or have help at home?

• Is the cost of wound care difficult to manage?

Why are pressure ulcer risk assessment tools used?

To identify individuals at risk for pressure ulcers and guide preventive strategies.

Do risk assessment tools directly reduce pressure ulcer incidence?

Not directly, but accurate and timely assessment helps implement prevention for those at greatest risk.

Why is early identification of risk factors important?

It allows healthcare facilities to focus resources on patients most likely to develop pressure ulcers.

Why is measuring a wound important?

Wound size changes over time and can indicate healing progress or negative progression.

Can wound measurement be delegated to UAP?

No, it is considered an assessment and must be done by a licensed nurse.

How should a wound be measured?

Using the metric system with a facility-provided ruler (cm or mm); sterile cotton-tip applicators can measure wound depth.

What should be documented when measuring a wound?

• Color of the wound bed and periwound area

• Amount, color, consistency, and odor of drainage

• Type of tissue present (granulation, slough, eschar, subcutaneous, muscle, bone, ligament)

• Signs or symptoms of infection

• Changes in surrounding skin (redness, breakdown)

How should wound measurements be recorded?

By width, length, depth, and undermining depth in metric units (cm or mm), including the location of undermining measurements.

What additional documentation methods may be used for wounds?

Drawings or photographs to document the shape, and noting any patient pain or discomfort during measurement.

What is serous drainage?

Clear, watery fluid from plasma.

What is serosanguinous drainage?

Pink to pale red fluid containing a mix of serous and red, bloody fluid.

What is sanguinous drainage?

Bright red fluid that usually indicates bleeding.

What is purulent drainage?

Thick fluid that usually indicates infection; can be yellow, greenish, or beige.

What are some ways to manage wound-related pain?

• Select appropriate dressings

• Protect surrounding tissue from irritating drainage or dressing materials

• Aggressively treat infection

• Position patient to avoid pressure on the wound

• Use binders or devices to splint wound edges

• Premedicate before turning, dressing changes, or debridement

Can assessment and evaluation of a patient’s skin and wounds be delegated to UAP?

No, it is the nurse’s responsibility and cannot be delegated.

Why is collaboration important in managing chronic wounds?

Chronic wound patients are complex and require input from surgery, infectious disease, PT/OT, social work, nutrition, and nursing for optimal outcomes.

When should collaboration with a wound care or incontinence specialist be considered?

When caring for at-risk individuals to improve wound management.

Why involve nurses and families in selecting wound care products?

Nurses help select appropriate products for care; families help with home care and insurance-based product selection, easing financial concerns.

How is the development of a pressure ulcer viewed ethically and legally?

It is often seen as neglect or inadequate care, reflecting poorly on the facility and caregivers, and may lead to patient suffering and costly litigation.

Who should decide how aggressively chronic wounds are treated?

The patient, in collaboration with family and healthcare providers.

What are common barriers to good wound care?

Lack of knowledge, inconsistent healthcare access, lifestyle choices, and financial constraints at patient and facility levels, leading to disparities in care and outcomes.

A postoperative patient arrives at an ambulatory care center and states, “I
am not feeling good.” Upon assessment, you note an elevated temperature.
An indication that the wound is infected would be:
A. It has no odor.
B. A culture is negative.
C. The edges reveal the presence of fluid.
D. It shows purulent drainage coming from the
incision site.

D

How should nurses select wound care interventions?

Based on the strength of available evidence, research findings, and evidence-based guidelines.

What responsibilities do nurses have regarding evidence-based wound care?

Scrutinize their practice, analyze research, use research-based guidelines, and help develop and implement protocols.

What are some key resources for current wound care evidence?

• National Pressure Ulcer Advisory Panel (NPUAP)

• Joanna Briggs Institute

• Agency for Healthcare Research and Quality (AHRQ)

• Cochrane Library

Why is regular skin cleansing important in nursing care?

It helps maintain skin integrity and timely response to incontinence prevents skin breakdown.

Why should soaps and hot water be used cautiously?

They can remove natural oils from the skin, leading to excessive dryness.

What type of cleansers are recommended for bathing and incontinence care?

Mild, pH-neutral soaps or cleansers that combine a moisturizer with the cleanser; use with warm water instead of hot.

What is the purpose of wound irrigation?

• Clean the wound

• Apply heat to promote healing

• Apply medications (e.g., antibiotics)

• Remove debris and exudates

• Remove bacterial colonization

• Prevent skin from closing over a deeper wound that must remain open

Can wound irrigation be delegated to UAP?

No, it must be performed by a nurse.

How can UAP assist during wound irrigation?

By transporting specimens and providing patient positioning, comfort, and support.

Who provides orders for wound irrigation?

The primary care provider (PCP), which are then carried out by the nurse and other personnel.

Which professionals might collaborate during wound irrigation?

Wound care nurse specialists and infection control nurses.

What might a wound care nurse specialist do in collaboration for wound irrigation?

May perform the procedure and coordinate assessment and timing with other procedures.

What might an infection control nurse do during wound irrigation?

Document confirmed infections, place the patient on isolation precautions, and consult with the PCP for appropriate actions.

What equipment is recommended for wound irrigation?

A 30- to 50-mL syringe and an 18-gauge catheter.

Why is a 30- to 50-mL syringe with an 18-gauge catheter preferred over a standard bulb syringe?

It delivers an irrigation force within the recommended 4–15 psi, whereas a standard bulb syringe delivers only about 1 psi.

Can tap water be used to cleanse a wound?

Yes, as long as the water is drinkable, it has not been shown to increase infection rates.

How does tap water compare to sterile water or normal saline for wound cleansing?

Tap water has been shown to be just as effective in cleansing wounds.

Why is the use of tap water significant in wound care?

It is cost-effective, readily available, and useful for home care and emergency situations.

What is debridement?

The removal of necrotic tissue to promote wound healing, prevent prolonged inflammation, and reduce bacterial reservoirs.

Why is debridement necessary for wound assessment?

It allows proper evaluation of viable tissue and accurate staging of pressure ulcers.