Skin Integrity, Wound Healing, and Wound Care

Comprehensive vocabulary flashcards covering skin integrity, pressure injury stages, types of debridement, wound healing phases, complications, dressing types, drains, irrigation, and neurovascular assessment.

Medical Asepsis (Clean Technique)

Procedures and practices designed to reduce the number and transfer of pathogens, preventing or reducing the spread of microorganisms.

Surgical Asepsis (Sterile Technique)

Practices that render and keep objects and areas completely free from all microorganisms.

Disinfection

A process that eliminates many or all pathogenic microorganisms, with the exception of bacterial spores, from inanimate objects.

Antisepsis

The practice of using antiseptic agents to eliminate or inhibit many germs on living tissue or skin surfaces.

Normal WBC Range

The standard reference range for white blood cell count in circulating blood, which is $4,500\text{--}11,000\,/\mu\text{L}$.

Stage I Pressure Injury

Intact skin presenting with a localized area of persistent, non-blanchable erythema (redness).

Stage II Pressure Injury

Partial-thickness loss of skin with exposed dermis; typically presents as a shallow open ulcer, an abrasion, or an intact or ruptured serum-filled blister.

Stage III Pressure Injury

Full-thickness loss of skin in which subcutaneous fat is visible, often presenting as a deep crater; bone, tendon, and muscle are not exposed.

Stage IV Pressure Injury

Full-thickness skin and tissue loss with extensive destruction, tissue necrosis, or exposed/directly palpable fascia, muscle, tendon, ligament, cartilage, or bone.

Slough

Non-viable, devitalized tissue that is yellow, tan, gray, green, or brown, which often covers the base of a chronic wound bed.

Eschar

Thick, leathery, necrotic non-viable tissue that is typically dark brown or black and crust-like.

Unstageable Pressure Injury

Full-thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough or eschar in the wound bed, requiring debridement before it can be staged.

Suspected Deep Tissue Injury (SDTI)

A persistent, localized area of discolored intact skin that appears purple or maroon, caused by underlying soft tissue damage from pressure and/or shear.

Autolytic Debridement

A selective method of debridement using occlusive or semi-occlusive dressings (such as hydrocolloids or foams) that allows the body's own endogenous enzymes to loosen and liquefy necrotic tissue.

Bio-surgical Debridement

The application of sterile, medical-grade fly larvae (maggots) to an open wound to secrete enzymes that digest necrotic tissue while consuming bacteria and debris.

Enzymatic Debridement

The topical application of commercially prepared exogenous enzymatic ointments prescribed by a healthcare provider to break down necrotic wound tissue.

Mechanical Debridement

Non-selective removal of dead tissue using external physical force, such as wet-to-dry gauze dressings, wound irrigation, or hydrogen peroxide ($H_2O_2$).

Hemostasis Phase

The initial phase of wound healing occurring immediately after injury, characterized by vasoconstriction, platelet aggregation, exudate production, and blood clot formation.

Inflammatory Phase

The second phase of wound healing lasting $4\text{--}6\text{ days}$, marked by vasodilation, phagocytosis by leukocytes and macrophages, and localized signs of inflammation (erythema, heat, edema, pain).

Proliferation Phase

The regenerative phase of wound healing lasting from $3\text{--}24\text{ days}$, where fibroblasts synthesize collagen and new blood vessels form to build granulation tissue and fill the wound space.

Maturation Phase

The final remodeling phase of wound healing that can continue for up to $2\text{ years}$, during which collagen fibers are reorganized and mature scar tissue is formed.

Primary Intention

Healing that occurs in clean surgical wounds where the tissue edges are neatly approximated with sutures, staples, or adhesive tape, resulting in minimal tissue loss and a fine "hairline" scar.

Secondary Intention

Healing that occurs in large, gaping, or irregular wounds with extensive tissue loss; heals from the bottom up via granulation, wound contraction, and epithelialization, leaving a larger scar.

Tertiary Intention (Delayed Closure)

Healing that occurs when a contaminated wound is deliberately left open to resolve edema or infection, allowed to granulate, and later closed surgically.

Maceration

The softening and skin breakdown resulting from continuous, prolonged exposure to moisture, such as from urinary or fecal incontinence, perspiration, or wound exudate.

Desiccation

The dehydration or localized drying up of cells within a wound bed, which impedes cell migration and delays healing.

Biofilm

A complex, organized community of microorganisms encased in a self-secreted polysaccharide slime/glue that adheres to wound surfaces, conferring high resistance to antibiotics and the host immune system.

Dehiscence

The partial or complete separation of the outer layers of an approximated surgical incision along the suture line.

Evisceration

A surgical emergency characterized by the complete separation of wound layers accompanied by the protrusion of internal visceral organs (such as bowel loops) through the incision.

Fistula

An abnormal, unintended passage or tract connecting two internal organs or connecting an internal hollow organ directly to the external body surface.

Hematoma

A localized collection of extravasated blood, often clotted, that accumulates within an organ, space, or tissue and presents as a visible or palpable swelling.

Serous Drainage

Clear, watery, pale yellow wound fluid composed primarily of serum, similar in appearance to fluid inside a blister.

Sanguineous Drainage

Thick, opaque, bright red wound drainage consisting predominantly of red blood cells, indicative of active fresh capillary bleeding.

Sero-Sanguineous Drainage

A light pink to blood-tinged watery wound exudate composed of a mixture of serum and red blood cells; thinner than sanguineous but thicker than serous fluid.

Purulent Drainage

Thick, opaque drainage that ranges from milky white to pale yellow or green, containing white blood cells, liquefied dead tissue debris, and bacteria, signaling infection.

Chlorhexidine Gluconate (CHG)

A broad-spectrum antiseptic skin cleanser (e.g., Hibiclens) effective against bacteria, fungi, viruses, and spores; toxic to newly forming granulation tissue in full-strength applications.

Negative Pressure Wound Therapy (Wound VAC)

An advanced wound care therapy utilizing controlled sub-atmospheric suction to draw wound margins together, reduce interstitial edema, stimulate blood flow, and accelerate granulation tissue formation.

Hydrocolloid Dressing

An occlusive, wafer-type dressing (such as Duoderm) that absorbs small to moderate amounts of drainage, maintains a moist healing environment, facilitates autolytic debridement, and can stay in place for $5\text{--}7\text{ days}$.

Transparent Dressing

A moisture- and vapor-permeable, semi-permeable adhesive film (e.g., Tegaderm, OpSite) used over superficial wounds or intravenous catheter sites that permits continuous visual inspection.

ABD Pad (Combine Pad)

A thick, highly absorbent multi-layered secondary dressing used over primary dressings to capture heavy drainage and provide mechanical padding.

Jackson-Pratt (JP) Drain

A closed, active portable drainage system that relies on manual compression of an elastic, bulb-shaped reservoir to generate constant low-pressure suction.

Hemovac Drain

A closed suction active drainage collector containing an internal spring mechanism that, when compressed, exerts continuous negative pressure to evacuate wound drainage.

Penrose Drain

A soft, flexible, open latex rubber drain that promotes passive capillary drainage into overlying dressings without active suction; commonly secured with a sterile safety pin to prevent inward retraction.

The 5 P's of Neurovascular Assessment

A systematic clinical check performed distal to an applied wrap, bandage, or brace to evaluate circulation and nerve function: Pallor, Paresthesia, Pain, Pulselessness, and Paralysis.

Abdominal Binder

A wide, elastic or cloth support garment wrapped around the torso to support the abdominal wall, splint incisional sites, reduce tension, and alleviate discomfort during coughing or mobilization.

Medical Asepsis

Clean technique utilized to reduce or prevent the spread of microorganisms.

Surgical Asepsis

Sterile technique utilized to completely eliminate all microorganisms from an object or area.

Clean

The mechanical removal of all soil and organic matter from an object or surface.

Disinfection

The elimination of many or most disease-causing microorganisms from inanimate objects.

Antisepsis

The elimination of many or most disease-producing microorganisms from living tissue or skin surfaces.

Sterilization

The total destruction and elimination of all microbial life and spores from inanimate objects.

Normal WBC Range

The reference range for white blood cells in a healthy individual, which is $4,500\text{--}11,000/\mu L$.

Leukocytosis

An elevated white blood cell count exceeding normal physiological limits, typically indicating infection or acute inflammation.

Neutropenia

An abnormally low concentration of neutrophils in the blood, placing the patient at increased vulnerability to infection.

Pressure Injury

Localized damage to the skin and underlying soft tissue resulting from prolonged pressure intensity and duration; also referred to as a decubitus ulcer or bedsore.

Shear

A mechanical force exerted parallel to the skin surface when gravity pushes the body downward while tissue resistance adheres to a surface, commonly occurring when a patient slides down in bed.

Stage I Pressure Injury

An area of intact skin with localized, non-blanchable erythema, typically over a bony prominence.

Stage II Pressure Injury

Partial-thickness skin loss with exposed dermis, presenting clinically as a shallow open ulcer, abrasion, or intact/ruptured serum-filled blister.

Stage III Pressure Injury

Full-thickness skin loss with visible damage or necrosis of subcutaneous adipose tissue, presenting as a deep crater without exposed bone, tendon, or muscle.

Stage IV Pressure Injury

Full-thickness skin and tissue loss featuring extensive destruction, necrosis, or directly visible and palpable muscle, tendon, or bone.

Slough

Non-viable, devitalized soft necrotic tissue that presents as yellow, tan, gray, green, or brown in a wound bed.

Eschar

Thick, hard, crust-like, non-viable necrotic tissue that is dark brown or black in color.

Unstageable Pressure Injury

Full-thickness tissue loss in which the actual depth and base of the wound cannot be assessed because it is obscured by slough or eschar.

Suspected Deep Tissue Injury (SDTI)

A localized, persistent purple or maroon area of intact skin or a blood-filled blister caused by underlying soft tissue damage from pressure and shear.

Autolytic Debridement

The use of moisture-retentive dressings (such as hydrocolloids or foams) to allow the body's own endogenous enzymes to loosen and liquefy necrotic tissue.

Bio-surgical Debridement

The application of sterile, surgical-grade fly larvae (maggots) that secrete proteolytic enzymes to dissolve necrotic material and consume bacteria.

Enzymatic Debridement

The topical application of commercially prepared, provider-prescribed exogenous chemical enzymes to break down necrotic tissue.

Mechanical Debridement

The physical removal of necrotic debris using external force such as wet-to-dry dressings, wound irrigation, or hydrogen peroxide; typically painful.

Sharp Debridement

The surgical removal of non-viable tissue using a scalpel, curette, or scissors, performed exclusively by physicians and advanced practice registered nurses.

Hemostasis

The initial phase of wound healing occurring immediately post-injury, characterized by transient vasoconstriction, exudate production, platelet aggregation, and clot formation.

Inflammatory Phase

The second phase of wound healing, lasting $4\text{--}6\text{ days}$, marked by vasodilation, phagocytosis by macrophages and leukocytes, and localized signs of inflammation.

Proliferative Phase

The regenerative phase of wound healing lasting $3\text{--}24\text{ days}$, in which fibroblasts synthesize collagen and new capillaries form granulation tissue to fill the wound defect.

Maturation Phase

The final stage of wound healing, which begins around day $21$ and may continue for up to $2\text{ years}$, involving collagen remodeling and scar tissue maturation.

Granulation Tissue

Healthy, highly vascular connective tissue that is beefy red or deep pink with a moist, granular appearance that fills the wound base during proliferation.

Primary Intention Healing

Healing of a surgical incision or clean wound with well-approximated edges joined by sutures, staples, or adhesive, resulting in minimal tissue loss and a hairline scar.

Secondary Intention Healing

Healing of gaping, irregular wounds with extensive tissue loss that remain open to heal from the base upward via granulation, contraction, and epithelialization, leaving a larger scar.

Tertiary Intention Healing

Delayed primary closure where a contaminated or heavily edematous wound is deliberately left open to resolve infection before being surgically sutured closed later.

Desiccation

The excessive drying out or dehydration of a wound bed, which inhibits cell migration and slows wound healing.

Maceration

The softening, wrinkling, and breakdown of peri-wound skin caused by excessive, prolonged exposure to moisture such as wound exudate or incontinence.

Biofilm

A structured community of bacterial cells enclosed in a self-produced sugary protective slime matrix that adheres to surfaces and exhibits high resistance to antibiotics and immune defense.

Hematoma

A localized collection of extravasated blood trapped within soft tissue or a body space, presenting clinically as an elevated swelling or mass with discoloration.

Wound Dehiscence

The partial or total disruption and accidental separation of closed wound or surgical incision margins.

Wound Evisceration

The complete separation of all layers of a surgical wound accompanied by the protrusion of internal visceral organs through the open incision; a surgical emergency.

Fistula

An abnormal, unintended passage or tract formed between two internal hollow organs or leading from an organ to the exterior surface of the body.

Signs of Localized Infection

The five clinical manifestations indicating local wound infection: redness (erythema), heat, edema (swelling), pain, and altered function.

Serous Drainage

Clear, watery, pale yellow wound exudate derived primarily from the serum portion of blood.

Sanguineous Drainage

Bright red, thick, non-transparent wound drainage containing high numbers of red blood cells, indicating active capillary disruption or bleeding.

Serosanguineous Drainage

Pale pink to light red, watery drainage composed of a mixture of clear serum and red blood cells; thinner than sanguineous drainage and thicker than serous fluid.

Purulent Drainage

Thick, opaque wound drainage ranging in color from pale yellow to dark green, containing white blood cells, liquefied dead tissue, and bacteria, indicating infection.

Hemovac Drain

A closed, portable, spring-activated self-suction device that collects blood and exudate postoperatively into an internal accordion-style circular canister.

Jackson-Pratt (JP) Drain

A closed, bulb-activated self-suction drainage unit that maintains continuous gentle negative pressure when its flexible bulb is compressed.

Penrose Drain

A flat, flexible, open latex tube providing passive capillary drainage directly onto an absorbent gauze dressing, secured with a sterile safety pin to prevent internal migration.

Negative Pressure Wound Therapy (NPWT)

A therapeutic wound care technique (e.g., Wound VAC) using continuous or intermittent negative sub-atmospheric pressure to draw wound margins together, decrease edema, and reduce bacterial load.

Hydrocolloid Dressing

An occlusive or semi-occlusive adhesive wafer (e.g., DuoDERM) that absorbs light drainage, maintains a moist healing environment, facilitates autolysis, and remains intact for $5\text{--}7\text{ days}$.

Non-Adherent Dressing

A specially coated dressing pad (e.g., Telfa) placed directly on the wound bed to absorb exudate without adhering to or disrupting newly formed granulation tissue upon removal.

Transparent Film Dressing

A semi-permeable adhesive membrane (e.g., Tegaderm, OpSite) that allows oxygen and moisture vapor exchange while acting as an impermeable barrier to external liquids and bacteria.

ABD Pad

A large, highly absorbent combine dressing placed over primary gauze to absorb heavy drainage and provide mechanical padding.

Chlorhexidine Gluconate (CHG)

A broad-spectrum antiseptic solution (e.g., Hibiclens, ChloraPrep) that eradicates bacteria, viruses, and fungi, frequently used preoperatively but cytotoxic to delicate granulation tissue.

Hydrogen Peroxide ($H_2O_2$)

An effervescent oxidizing cleansing agent used for mechanical debridement of superficial clotted wounds, avoided in full-strength and contraindicated in deep tunneling tracts due to healthy tissue trauma.

The 5 P's

The clinical parameters of a neurovascular assessment checked distal to a bandage or wrap: Pallor, Paresthesia, Pain, Pulselessness, and Paralysis.