Tissue Integrity Part 1 Lecture NURN 153 Exam 3

What infection control practices should the nurse use when caring for wounds?

Perform hand hygiene before and after care, use appropriate PPE, prevent contamination of supplies, follow ordered wound-care technique, and dispose of contaminated dressings properly.

How should the nurse prevent infection when caring for a surgical wound?

Use appropriate aseptic technique, assess the incision for infection, cleanse and change dressings as ordered, and protect the wound from contamination.

How should the nurse prevent infection in chronic wounds and pressure injuries?

1. Hand hygiene , gloves

2. Asses, then relieve pressure

3. Cleanse wound properly

4. Appropriate dressing

5. Protect surrounding skin from moisture

6. Monitor for infection.

Why is normal saline commonly used for wound cleansing?

It is gentle on healing tissue and removes debris without unnecessarily damaging healthy cells. [Reading]

What findings suggest a wound is becoming infected?

Increased redness, swelling, pain, purulent or increased drainage, fever, elevated WBCs, malaise, confusion, or decreased function.

What are the three types of wound healing by intention?

Primary: Wound edges are closed together. Secondary: Wound fills in from the bottom upward. Tertiary: Wound is left open initially and closed later.

When does primary intention wound healing occur?

When wound edges are approximated using sutures, staples, or another closure method, such as a clean surgical incision.

When does secondary intention wound healing occur?

When wound edges cannot be brought together and granulation tissue fills the wound from the bottom upward, such as with pressure injuries.

When does tertiary intention wound healing occur?

When a wound is initially left open because of infection or swelling and is closed after the problem improves. Cards 7–9 expand the healing types named in the PowerPoint using the linked Fundamentals reading. Nursing Fundamentals 2e

What are the four phases of wound healing, in order?

Hemostasis → Inflammatory → Proliferation → Maturation (remodeling).

What happens during hemostasis?

The immediate first phase: blood vessels constrict and clotting begins to stop bleeding.

Then inflammation: Subsequent vessel dilation increases perfusion, warmth, redness, edema, and pain.

What happens during the inflammatory phase?

WBCs move to the wound to defend against infection. Local findings include pain, heat, redness, and swelling. Systemic findings can include fever, leukocytosis, and malaise.

What happens during the proliferation phase?

Granulation tissue develops

Scar tissue forms (early)

Systemic symptoms disappear.

What happens during the maturation/remodeling phase?

Collagen is remodeled, strengthening the healed area, and scar tissue becomes more uniform with surrounding skin.

What local factors can delay wound healing?

Pressure, desiccation (excessive dryness), maceration (excessive moisture), trauma, edema, infection, bleeding, necrosis, and biofilm.

What systemic factors can delay wound healing?

Advanced age, poor circulation or oxygenation, diabetes, inadequate nutrition, medications, immunosuppression, obesity, and poor treatment adherence.

Why does diabetes increase the risk of wounds and delayed healing?

Diabetes can impair circulation, sensation, and the body's ability to fight infection, increasing tissue damage and slowing wound repair. [Reading]

Why are older adults at greater risk for impaired skin integrity and infection?

Their skin becomes thinner and less elastic, making injury more likely. Altered inflammatory responses and nutritional problems may also delay healing. [Reading] Nursing Fundamentals 2e

How do moisture and dry skin affect skin integrity?

Excess moisture causes maceration and skin breakdown. Excessive dryness can cause cracking, which damages the protective barrier and increases infection risk.

Why should the nurse assess nutrition, circulation, mobility, and social circumstances in a patient with a chronic wound?

Wound healing depends on adequate nutrients, blood flow, pressure relief, and the patient's ability to follow the treatment plan. These factors help explain delayed healing and guide interventions.

What causes a pressure injury?

Prolonged pressure, especially over bony prominences, reduces blood flow and damages skin and underlying tissue. Shear and friction also contribute.

What is the difference between friction and shear?

Friction: Skin rubs against another surface. Shear: Skin remains in place while deeper tissues move, stretching and damaging blood vessels.

Which patients have the greatest risk for developing pressure injuries?

Patients with limited mobility, poor nutrition or hydration, moisture exposure, reduced sensation, advanced age, diabetes, poor cognition, or previous pressure injuries.

How does the nurse identify a Stage 1 pressure injury?

Skin is intact with persistent nonblanchable redness or discoloration. On darker skin, assess temperature, firmness, tenderness, and color changes. [Reading]

How does the nurse identify a Stage 2 pressure injury?

Partial-thickness skin loss with exposed dermis. Usually a shallow wound or blister, without exposed fat.

How does the nurse identify a Stage 3 pressure injury?

Full-thickness skin loss with visible subcutaneous fat, but no exposed muscle, tendon, or bone.

How does the nurse identify a Stage 4 pressure injury?

Full-thickness skin and tissue loss with exposed or directly palpable deeper structures, such as muscle, tendon, or bone.

What is an unstageable pressure injury?

Full-thickness tissue loss where slough or eschar covers the wound bed, preventing the nurse from determining its depth. [Reading]

What is a deep tissue pressure injury?

Persistent deep red, purple, or maroon discoloration, sometimes with a blood-filled blister, caused by damage beneath the skin. Staging descriptions are supported by the PowerPoint's visual slides and its linked Fundamentals reading. Nursing Fundamentals 2e +1

Damaged tissue loss.

What nursing interventions help prevent pressure injuries in an immobile patient?

Reposition regularly, offload bony prominences, reduce friction and shear, keep skin clean and dry, assess skin, and support nutrition and hydration. [Reading]

A nurse discovers intact, nonblanchable redness on a patient's heel. What is the priority action?

Relieve pressure from the heel and reassess the skin. This suggests a Stage 1 pressure injury that may worsen without intervention.

What are the signs of hemorrhage in a patient with a wound?

Bleeding from the wound or development of a hematoma (collection of blood within tissues).

What is the difference between wound dehiscence and evisceration?

Dehiscence: A previously closed wound separates. Evisceration: Internal structures protrude through the separation; this is an emergency.

What should the nurse do if a surgical wound develops evisceration?

Stay with the patient, obtain emergency assistance, protect exposed tissue with a sterile saline-moistened dressing, and notify the provider. Do not attempt to push tissue back inside. [Reading]

What is fistula formation?

An abnormal passage connecting an internal organ or vessel to the skin or another internal structure. Infection is a primary cause of accidental fistulas.

What should the nurse assess when evaluating a wound?

Location, type, tissue damage, wound bed, size, edges, surrounding skin, drainage, pain, infection signs, and closure devices.

How can the nurse differentiate the four common types of wound drainage?

Serous: Clear or pale-yellow fluid. Serosanguineous: Thin, pinkish fluid. Sanguineous: Bloody drainage. Purulent: Thick, cloudy drainage suggesting infection. Drainage names are listed in the PowerPoint; their visual descriptions are supplemented from the wound-care reading.

What should the nurse document after assessing or caring for a wound?

Wound location, size, tissue appearance, surrounding skin, drainage type and amount, pain, infection signs, treatment performed, and patient response.

A surgical wound develops increased pain, redness, purulent drainage, and fever. What should the nurse prioritize?

Recognize possible infection, assess vital signs and the wound, clean and dry the wound, use appropriate dressing, promptly notify the provider, and document the findings.

dont rub wound

How does the nurse apply the Clinical Judgment Model to wound care?

Recognize wound cues → Analyze risks → Prioritize infection or tissue damage → Plan interventions → Implement care → Reassess healing and patient response.

What factors determine which wound dressing is appropriate?

Wound size, depth, location, type, drainage amount, surrounding skin, and need for moisture balance or protection.

What is the difference between primary and secondary wound dressings?

Primary: Directly contacts the wound. Secondary: Covers and supports the primary dressing.

What is dry gauze used for?

Absorbing drainage, covering and protecting wounds, or packing when appropriate. It is available in different sizes, such as 2×2 and 4×4.

not for severe drainage it can soak through quickly.

When should the nurse choose a nonadherent dressing?

When the wound needs protection without the dressing sticking to healing tissue. Examples include Telfa and petroleum gauze; the slide specifies Telfa shiny side down.

What are abdominal (ABD) pads used for?

Absorbing wound drainage and providing protection, a barrier, and padding over the wound.

What is a transparent film dressing, and when is it appropriate?

A waterproof, adhesive, semipermeable dressing, such as Tegaderm, commonly used for dry wounds or wounds with minimal drainage. [Reading].

Secondary dressing.