Skin Integrity & Wound Care

Vocabulary flashcards covering core terms, stages, devices, and processes related to skin integrity and wound care as presented in the lecture notes.

Skin Integrity

The skin’s structural and functional wholeness that protects underlying tissues from trauma, bacteria, and fluid loss.

Skin assessments

Health history

Physical assessment

Color

Texture & turgid

Moisture

Temperature

Lesions

Braden Scale

Wound Healing: Hemostasis

Immediate phase in which blood vessels constrict and clotting begins to stop bleeding.

Wound Healing: Proliferation

Phase where granulation tissue, collagen, and new blood vessels form to fill the wound.

Wound Healing: Remodeling (Maturation)

Final phase in which collagen is reorganized and the wound gains tensile strength.

Functions of Skin

Protection, fluid & electrolyte balance, sensory perception, temperature regulation, vitamin D synthesis, and wound repair.

Risk Factors for Skin Breakdown

Age, immobility, poor nutrition/hydration, impaired sensation, poor circulation, medications, moisture, fever, infection, lifestyle.

Braden Scale

Standardized tool that predicts pressure-injury risk by scoring sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Braden scale “Mild risk“

Braden Scale 15-18

Braden Scale “Moderate risk”

Braden scale 13-14

Braden Scale “High risk”

Braden Scale 10-12

Braden "Severe Risk" Score

Total Braden score ≤9 indicates severe risk of developing pressure injuries.

Pressure Injury (Pressure Ulcer, pressure sore, decubitus ulcer, bed sore)

Localized damage to skin and underlying tissue over a bony prominence due to pressure or pressure combined with shear.

Pressure intensity, pressure duration, tissue tolerance, Hospital acquired pressure ulcers

Blanching

Temporary whitening of skin when pressure is applied, indicating vascular response; non-blanchable redness signals Stage I injury.

Tissue ischemia

Inadequate blood flow and nutrition to a specific tissue or organ.

Stage I Pressure Injury

Intact skin with non-blanchable erythema over a bony prominence; may feel firm, painful, warmer or cooler than adjacent tissue.

Stage II Pressure Injury

Partial-thickness skin loss of dermis presenting as a shallow open ulcer or intact/ruptured serum-filled blister.

Stage III Pressure Injury

Full-thickness tissue loss with visible subcutaneous fat; may have slough, undermining, or sinus tracts but no exposed bone, tendon, or muscle.

Stage IV Pressure Injury

Full-thickness tissue loss with exposed bone, tendon, or muscle; often includes undermining and sinus tracts.

Suspected Deep Tissue Injury (SDTI)

Intact skin that is purple/maroon or a blood-filled blister indicating underlying soft-tissue damage from pressure or shear.

Unstageable Pressure Injury

Full-thickness skin/tissue loss in which wound bed is obscured by slough or eschar, preventing accurate staging.

Management of pressure injuries

Debridement (removal of necrotic tissue): mechanical, automatic, chemical, surgical

Education

Nutritional status

Protein status

Hemoglobin

Wound Assessments

Wound appearance

Abrasion

Laceration

Puncture wounds

Wound drainage

Drains

Wind Closures

Palpation of wound

Wound culture

Laceration

Deep cut or tear in skin or flesh, usually by sharp objects or blunt forced traumas

Abrasion

Superficial wound caused by friction or scraping, shallow wound

Nursing diagnosis for wounds

Risk for infection

Imbalanced nutrition

Acute or chronic pain

Impaired physical mobility

Impaired skin integrity

Risk for impaired skin integrity

Ineffective peripheral tissue perfusion

Primary Intention Healing

Wound edges are approximated (e.g., surgical incision with sutures) and minimal scarring occurs.

Secondary Intention Healing

Wound edges are not approximated; healing occurs by granulation, contraction, and epithelialization, leaving a larger scar.

Debridement

Removal of nonviable, necrotic tissue to promote wound healing.

Mechanical Debridement

Physical removal of dead tissue (e.g., wet-to-dry dressings, irrigation).

Autolytic Debridement

Use of moisture-retentive dressings to allow the body’s enzymes to liquefy necrotic tissue.

Chemical (Enzymatic) Debridement

Topical application of proteolytic agents to break down necrotic tissue.

Wound care implementation

Health promotion

Topical skin care and incontinence management

Protect bony prominences, skin barriers for incontinence

Positioning: Turn every 1 to 2 hours as indicated

Support surfaces- decrease amount of pressure

Surgical Debridement

Use of scalpel or scissors by a qualified provider to excise devitalized tissue.

Dry gauze

Plain, sterile gauze applied to clean, dry wound as a secondary dressing

Moist gauze

Gauze that is dampened with sterile saline to help maintain a moist environment. Supports healing in open wounds

Hydrocolloid Dressing

Moisture-retentive dressing that is made of gel-forming agents on contact with wound exudate, protecting from surface bacteria contamination.

Hydrogel Dressing

Water-based or glycerin dressing that maintains a moist environment to support healing of dry wounds.

Film Dressing

Transparent adhesive sheet that protects against friction and bacteria while allowing oxygen exchange.

Complications of Wounds

Infection

Bleeding

Dehiscence

Evisceration

Fistula development (tunneling)

Wound VAC (Negative-Pressure Therapy)

Device that applies continuous or intermittent negative pressure via foam dressing to remove exudate and promote granulation.

Jackson-Pratt (JP) Drain

Closed-suction bulb drain used post-surgically to remove fluid from wound cavities.

Hemovac Drain

Spring-loaded closed-suction device that collects larger volumes of wound drainage.

Dehiscence

Partial or total separation of previously approximated wound edges.

Evisceration

Protrusion of visceral organs through a wound opening following dehiscence.

Fistula

Abnormal passage “tunneling” between two organs or between an organ and the skin, often resulting from infection or poor healing.

Shearing Force

Skin layers slide against each other while deeper tissues remain stationary, compromising blood flow and causing injury.

Protein and Wound Healing

Adequate dietary protein supplies amino acids necessary for collagen synthesis and tissue repair.

Friction

Surface resistance between skin and another surface that can abrade the epidermis, contributing to pressure-injury risk.