Tissue Intergrity

Tissue Integrity

The ability of the human body to regenerate and maintain normal physiologic functioning of the skin, cornea, subcutaneous tissue, and mucous membranes.

Epidermis

The outermost layer of the skin composed mainly of keratinocytes, melanocytes, Merkel cells, and Langerhans cells.

Dermis

The middle layer of skin containing collagen, elastin, nerves, capillaries, and fibroblasts in papillary and reticular regions.

Subcutaneous Tissue

The innermost skin layer composed mostly of adipose tissue that insulates the body, absorbs shock, pads internal organs, and assists in thermoregulation.

Fibroblasts

Connective tissue cells in the dermis that synthesize hyaluronic acid, fibronectin, and collagen to build and repair the wound bed.

Hyaluronic Acid

A hydrophilic glycosaminoglycan secreted by dermal fibroblasts that retains moisture and facilitates cell migration in the wound bed.

Fibronectin

An extracellular matrix glycoprotein released by dermal fibroblasts that acts as a structural scaffold for cell adhesion during early wound repair.

Erythema

Redness of the skin caused by the dilation of superficial blood vessels.

Blanchable Erythema

Redness of the skin that temporarily turns white or pale when pressure is applied and returns to red when released, indicating intact capillaries.

Nonblanchable Erythema

Redness of the skin that does not turn pale when pressure is applied, indicating structural vascular damage.

Pallor

Loss of healthy red Undertones in light skin, or an ashen-gray discoloration noticeable in mucous membranes of dark skin tones.

Cyanosis

Bluish, gray, or dark discoloration of skin, nail beds, lips, or oral mucosa caused by reduced oxygen saturation.

Jaundice

Yellow-to-orange skin and scleral discoloration caused by elevated serum bilirubin levels.

Skin Frailty

Vulnerable, at-risk skin predisposed to skin tears, pressure injuries, and breakdown due to age, immobility, or chronic illness.

Maceration

Softening, wrinkling, and weakening of the skin caused by prolonged exposure to excess moisture.

Dermatitis

Inflammation and redness of the skin resulting from exposure to irritants such as urine, feces, stoma effluent, or chemical secretions.

Skin Tears

Separation of the epidermal layer from the underlying dermis caused by mechanical friction, shear, or adhesive tape removal.

TIME Mnemonic

Clinical framework for wound assessment: T=Tissue Integrity, I=Inflammation/Infection, M=Moisture, E=Edge of wound.

DIDN'T HEAL Mnemonic

Systemic factors impairing wound healing: Diabetes, Infection, Drugs (steroids), Nutritional deficits, Tissue necrosis, Hypoxia, Extensive tension, Another wound/Age, Low temperature.

Pressure Injury

Localized damage to the skin and underlying soft tissue resulting from intense or prolonged pressure, or pressure in combination with shear.

Stage 1 Pressure Injury

Intact skin with a localized area of persistent nonblanchable erythema.

Stage 2 Pressure Injury

Partial-thickness skin loss with exposed dermis, presenting as a viable, moist, pink/red wound bed or an intact/ruptured serum-filled blister.

Stage 3 Pressure Injury

Full-thickness skin loss with visible adipose (fat) tissue and granulation tissue; muscle, tendon, and bone are NOT visible.

Stage 4 Pressure Injury

Full-thickness skin and tissue loss with directly visible or palpable fascia, muscle, tendon, ligament, cartilage, or bone.

Unstageable Pressure Injury

Full-thickness skin and tissue loss in which the extent of tissue damage is completely obscured by slough or eschar.

Deep Tissue Pressure Injury (DTPI)

Intact or non-intact skin with localized, persistent nonblanchable deep red, maroon, or purple discoloration, or a dark blood-filled blister.

Medical Device-Related Pressure Injury (MDRPI)

Pressure injury resulting from continuous pressure exerted by diagnostic or therapeutic medical devices, mirroring the shape of the device.

Mucosal Membrane Pressure Injury

Pressure injury on mucous membranes caused by medical devices (e.g., ET tubes, catheters) that cannot be staged numerically due to lack of cutaneous skin layers.

Hospital-Acquired Pressure Injury (HAPI)

A pressure injury that develops during a client's hospitalization.

Slough

Nonviable, stringy yellow, tan, gray, or green inflammatory tissue found in the wound bed.

Eschar

Hard, nonviable black or brown necrotic tissue covering a wound bed.

Undermining

Tissue destruction extending underneath intact skin along the margins of a wound.

Tunneling

A narrow channel or passageway extending in any direction from the base of a wound into deeper tissue.

Friction

Mechanical force created when two surfaces rub against each other, causing superficial epidermal abrasions.

Shearing Force

Force exerted parallel to the skin when the skeleton slides downward while the outer skin remains stationary, stretching and tearing deep blood vessels.

Braden Scale

Standardized assessment tool measuring pressure injury risk using 6 subscales with a score range of 6 to 23 (scores <= 16 indicate risk).

Sensory Perception (Braden)

Braden Scale subscale evaluating a client's capacity to respond meaningfully to pressure-related discomfort (scored 1 to 4).

Moisture (Braden)

Braden Scale subscale evaluating the degree to which skin is exposed to perspiration, urine, or exudate (scored 1 to 4).

Activity (Braden)

Braden Scale subscale evaluating the degree of physical activity (1=Bedfast, 2=Chairfast, 3=Walks Occasionally, 4=Walks Frequently).

Mobility (Braden)

Braden Scale subscale evaluating the ability to change and control body position (1=Completely Immobile to 4=No Limitations).

Nutrition (Braden)

Braden Scale subscale evaluating usual food intake pattern, protein servings, or NPO/IV fluid status (scored 1 to 4).

Friction and Shear (Braden)

Braden Scale subscale evaluating mechanical forces during movement (scored 1=Problem, 2=Potential Problem, 3=No Apparent Problem).

Acute Wound

A wound resulting from trauma or surgery that progresses through an orderly, timely healing process.

Chronic Wound

A wound that fails to progress through the normal phases of healing in a timely manner due to underlying pathology.

Clean Wound

Uninfected surgical wound with minimal bacterial load where GI, respiratory, or GU tracts are NOT entered.

Clean-Contaminated Wound

Surgical wound in which the GI, respiratory, genital, or urinary tract IS entered under controlled conditions without unusual contamination.

Contaminated Wound

Fresh, accidental traumatic wound or surgical procedure with major breaks in sterile technique or gross GI spillage.

Dirty or Infected Wound

Wound with pre-existing clinical infection, perforated viscera, or retained devitalized tissue.

Moisture-Associated Skin Damage (MASD)

Inflammation and erosion of the epidermal barrier caused by prolonged exposure to bodily fluids like urine, stool, sweat, or exudate.

Arterial (Ischemic) Ulcer

Distal, "punched-out" leg ulcer caused by severe peripheral arterial hypoperfusion; painful, pale wound bed with weak/absent pulses.

Venous Insufficiency Ulcer

Shallow leg ulcer located on the medial malleolus with irregular borders, beefy red base, heavy exudate, and surrounding hemosiderin staining.

Diabetic Neuropathic Ulcer

Painless ulcer occurring on plantar weight-bearing pressure points of the foot surrounded by a thick callus, carrying high risk for osteomyelitis.

Hemostatic / Inflammatory Phase

Initial phase of wound healing (days 0 to 3-6) featuring clot formation, vasodilation, leukocyte infiltration, and phagocytosis.

Proliferative Phase

Second phase of wound healing (days 3 to 24) characterized by angiogenesis, collagen synthesis, granulation tissue growth, and re-epithelialization.

Remodeling / Maturation Phase

Final phase of wound healing (day 21 to 1+ year) where disorganized collagen is reorganized into stronger fibers to increase scar tensile strength.

Granulation Tissue

Beefy red, highly vascular new connective tissue formed by fibroblasts and capillaries in the wound bed during proliferation.

Angiogenesis

Growth of new capillary blood vessels into the wound bed during the proliferative phase.

Re-epithelialization

Migration of keratinocytes from wound margins across the granulating wound bed to restore epidermal closure.

Primary Healing (First Intention)

Healing of clean, closely approximated wound edges closed with sutures, staples, or adhesive, resulting in minimal scar formation.

Secondary Healing (Second Intention)

Healing process for open wounds with significant tissue loss that fill in from the bottom upward with granulation tissue.

Delayed Primary Closure (Tertiary Intention)

Healing technique where a contaminated wound is left open for 5 to 10 days to resolve infection before being surgically sutured closed.

Debridement

The medical removal of nonviable tissue, slough, eschar, microorganisms, and biofilm from a wound bed.

Surgical (Sharp) Debridement

Physical removal of dead tissue and biofilm using sterile instruments like scalpel or scissors by a trained provider.

Biological Debridement

Use of medical-grade sterile larvae (maggots) that secrete enzymes to liquefy and ingest necrotic tissue while sparing healthy tissue.

Mechanical Debridement

Non-selective removal of tissue using wet-to-dry gauze packing that adheres to and strips away both dead and healthy granulation tissue upon removal.

Autolytic Debridement

Use of the body's own enzymes trapped under moisture-retaining dressings (hydrogels/hydrocolloids) to rehydrate and dissolve nonviable tissue.

Biofilm

An accumulated layer of bacterial debris and microorganisms embedded in a self-produced matrix on the wound bed.

Transparent Film Dressing

Self-adhesive semipermeable polyurethane dressing that traps moisture and allows oxygen exchange for superficial wounds with minimal exudate.

Hydrocolloid Dressing

Gel-forming occlusive dressing for shallow wounds that traps moisture and produces a yellow, foul-smelling gelatinous mass as an expected finding.

Alginate Dressing

Highly absorbent seaweed-based dressing that converts to a hydrophilic gel upon contact with moderate to heavy exudate; requires a secondary dressing.

Hydrofiber Dressing

High-absorbency synthetic dressing that draws fluid vertically upward to protect surrounding skin from maceration.

Foam Dressing

Absorbent silicone or polyurethane pad used for mild to moderate exudate and applied to sacrum/heels to prevent pressure injuries.

Hydrogel Dressing

Water- or glycerin-based gel or sheet that donates moisture to rehydrate dry wound beds and black eschar for autolytic debridement.

Antimicrobial Dressing

Dressing impregnated with silver, iodine, or honey used to reduce bacterial burden and treat infected wounds.

Negative Pressure Wound Therapy (NPWT)

Sealed occlusive dressing connected to vacuum suction that reduces edema, evacuates fluid, pulls wound edges together, and stimulates granulation.

Penrose Drain

Flat, pliable open passive rubber drain that uses gravity to evacuate fluid directly onto a perforated gauze dressing.

Jackson-Pratt (JP) Drain

Closed active drainage system utilizing a squeezable suction bulb that creates low negative pressure to collect wound exudate.

Hemovac Drain

Closed active drainage system containing an internal spring that creates continuous low vacuum suction as it expands.

Exudate

Fluid consisting of plasma and cells secreted by the body into a wound during the inflammatory phase.

Serous Exudate

Clear, watery blood serum exudate with few cells.

Sanguineous Exudate

Bright red fluid containing abundant red blood cells, indicating active capillary damage.

Serosanguineous Exudate

Pink, watery drainage composed of a mixture of clear serum and red blood cells.

Purulent Exudate

Thick, opaque pus containing leukocytes, dead tissue debris, and bacteria, indicating wound infection.

Dehiscence

Partial or total separation of sutured wound margins, often preceded by a gush of serosanguineous drainage on post-op days 5 to 8.

Evisceration

Complete separation of all surgical wound layers with protrusion of internal visceral organs through the incision—a life-threatening emergency.

Hemorrhage

Severe internal or external bleeding resulting from vessel rupture or clotting failure.

Hematoma

A localized collection of extravasated blood beneath the skin or suture line that can cause tissue ischemia and infection.

Seroma

A localized collection of serum fluid beneath a surgical incision.

Cellulitis

A spreading bacterial infection of the superficial and subcutaneous skin layers characterized by redness, edema, warmth, and pain.