Skin Integrity & Wound Care

Medical adhesive-related Skin injuries (MARSIs)

When superficial layers of skin are removed by medical adhesive

Moisture-associated Skin damage (MASD)

Skin erosion caused by prolonged exposure to a source of moisture

Maceration

White, wrinkled, water-logged skin prone to tears or breakdown

Dermatitis

Inflammation of the skin

Excoriation

Red, scaly areas with surface loss of skin tissue; top layer damaged or rubbed off

Open wound

A break in the skin

Closed wound

Wound with intact skin

Acute wound

Wound with faster healing time

Chronic wound

Wound with a longer healing time

Abrasion

Open wound; scraping injury where outer skin layer is scraped off

Laceration

Open wound; tear or cut in skin and underlying tissue

Contusion

A bruise of the tissue

Avulsion

Open wound where tissue is forcibly torn away or separated

Superficial wound

Only the superficial layer of skin is involved

Partial-thickness wound

Extends through epidermis and dermis, but not subcutaneous tissue

Full-thickness wound

Extends into subcutaneous tissue and beyond; likely to become chronic

Clean wound

No infection; typical of surgical wounds

Clean-contaminated wound

Involves organ systems likely to contain bacteria (GI, respiratory, urinary)

Contaminated wound

Results from a break in sterile technique; high infection risk

Infected wound

Shows clinical signs of infection and a positive culture

Primary healing

Edges approximated to heal quickly

Secondary healing

Cannot approximate edges; extended timeline and larger scar

Tertiary healing

Delayed closure; left open for observation then closed later

Inflammatory phase

Occurs within minutes of injury with increased blood flow

Proliferative phase

Begins 3-4 days post-injury with new granulation tissue formation

Maturation phase

Occurs weeks later; involves scar formation and tissue remodeling

Tunnelling

Narrow passageway extending outward from the wound edge

Undermining

Tissue loss underneath intact skin edges

Serous drainage

Watery drainage, usually seen in clean wounds

Serosanguineous drainage

Blood mixed with serous or clear drainage, usually in new wounds

Purulent drainage

Thick drainage containing pus, indicates infection

Sanguineous drainage

Bloody, red drainage

Montgomery straps

Adhesive strips applied on either side of a dressing with ties to hold it

Dehiscence

Partial or complete separation of tissue layers

Fistula

An abnormal tunnel connecting two body parts

Evisceration

Total separation of tissue layers allowing organs to protrude

Wound drainage system - Gravity

Fluid drains passively into dressing without suctioning: e.g. Pinrose

Wound drainage system - Closed suction

Drains or Hemovac/JP drains attached to a suction device

Wound drainage system - VAC

Uses negative pressure to remove excess wound fluid

Gauze dressing

Absorbs wound drainage

Non-adherent dressing

Does not stick to the skin

Transparent dressing

Allows visual inspection of the wound site

Hydrocolloid dressing

Helps healing by allowing granulation; left for 3-5 days

Hydrogel dressing

Water-infused dressing providing a moist wound bed

Alginate dressing

Non-adherent, good for packing wound, and absorbs fluid

Collagen dressing

Controls bleeding and helps healing

Pressure injury

Localized injury to skin and underlying tissue over bony prominences

Wound color - Red

Cover the wound

Wound color - Yellow

Clean the wound

Wound color - Black

Debride the wound

Crepitus

A crackling sensation in tissue

Erythema

Redness of the skin

Epibole

wound edges heal downward instead of across

Slough

Soft, stringy, pale yellow-gray tissue (attached to wound; requires debridement)

Eschar

Dry, thick, hard, black-brown necrotic tissue requiring debridement

Granulation tissue

Healthy, healing tissue

Necrotic tissue

Dead tissue that must be removed because it hinders healing

Erythrocyte Sedimentation Rate (ESR)

Lab value altered in inflammatory and necrotic processes

Hyperemia

Increased blood flow causing tissue erythema

Pressure injury Stage 1

Localized intact skin with non-blanchable redness lasting over 30 minutes

Pressure injury Stage 2

Partial-thickness dermal loss with a shallow pink-red wound bed

Pressure injury Stage 3

Deep, full-thickness skin loss with visible adipose subcutaneous tissue

Pressure injury Stage 4

Full-thickness loss with exposed bone, tendon, or muscle; slough/eschar possible

Deep tissue injury (DTI)

Intact skin with purple/deep red discoloration or boggy blister

Sharp debridement

Use of sterile, sharp instruments to remove tissue

Mechanical debridement

Performed via lavage, wet-dry dressings, or hydrotherapy

Wet-dry dressing

Saline-moistened gauze packed in wound and removed when dry

Hydrotherapy

mechanical debridement therapy treatment using whirlpools

Enzymatic debridement

Uses proteolytic agents to break down necrotic tissue safely

Autolytic debridement

Uses occlusive dressings and body's own enzymes to break down necrotic tissue

Biotherapy debridement

Uses medical-grade larvae to dissolve dead and infected tissue

Isotonic solution

Solution similar to the body to prevent injury to healing tissue

Non-hemolytic

Property that helps prevent bleeding

Diphenhydramine

An antihistamine medication

Hydrocortisone

Topical corticosteroid to alleviate dermatitis and local inflammation

Zinc oxide

Topical barrier ointment to prevent moisture-related skin breakdown

Pyogenic

Pus-forming or pus-producing

Purosanguineous drainage

Drainage containing both pus and blood

Xerosis

severely dry skin

Exudate

Drainage

serum protein, albumin, and prealbumin

used to monitor wound healing

Pressure injury: unstageable

Involves full-thickness skin loss. Base of wound is obscured by slough or eschar