Skin Integrity and Wound Care Flashcards

A set of vocabulary flashcards covering the structure of the skin, wound healing phases, classification of pressure injuries, and clinical assessment tools based on NUR 155/156 Unit 6 notes.

Epidermis

The outermost layer of skin which regenerates every 4-6 weeks and contains five sub layers.

Dermis

A layer thicker than the epidermis containing sebaceous glands, sweat glands, hair and nail follicles, nerves, and lymphatics.

Subcutaneous layer

The skin layer composed of adipose tissue.

Medical adhesive-related skin injuries (MARSI)

Injuries that occur when superficial layers of skin are removed by medical adhesive.

Inflammatory phase

The phase of wound healing lasting 3 days and involving the coagulation cascade.

Proliferative phase

The phase of wound healing occurring over several weeks characterized by the formation of granulation tissue.

Maturation phase

The final phase of wound healing lasting up to 1 year that results in the development of scar tissue.

Dehiscence and evisceration

Two major complications associated with the wound healing process.

Stage 1 pressure injury

Intact skin with non-blanchable erythema that may be painful and differ in firmness or temperature from surrounding tissue.

Stage 2 pressure injury

Partial-thickness skin loss with exposed dermis and may include intact or ruptured blisters.

Stage 3 pressure injury

Full-thickness skin loss that may include undermining and tunneling.

Stage 4 pressure injury

Full-thickness skin and tissue loss which may involve osteomyelitis.

Unstageable pressure injury

Obscured full-thickness skin and tissue loss that cannot be assessed until necrotic tissue (eschar) in the wound bed is removed.

Deep tissue pressure injury

A persistent non-blanchable deep red, maroon, or purple discoloration of the skin.

Norton Scale

A risk assessment tool for pressure injuries that evaluates parameters including physical condition, mental state, activity, mobility, and continence.

Norton Scale High Risk Score

A total score of 10 or below.

Braden Scale

A scale for predicting pressure sore risk using six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

Pressure Sore Status Tool (PSST)

One of the specific tools used for the assessment of wound healing.

Pressure Ulcer Scale for Healing (PUSH)

An assessment tool designed specifically for monitoring the healing of pressure ulcers.

Albumin

A biochemical indicator of nutritional status; a level of $2.5\,g/dL$ is used as supporting data for impaired skin integrity in the provided nursing diagnosis example.

Prealbumin

A biochemical indicator of nutritional status; a level of $15\,mg/dL$ is used as supporting data for impaired skin integrity in the provided nursing diagnosis example.

Debridement

The removal of damaged or dead tissue through sharp, mechanical, enzymatic, autolytic, or biologic methods.

Negative-pressure wound therapy

A specialized intervention related to wound care used to manage healing and drainage.

Alginates

A specific type of dressing used in wound care interventions.

Secondary intention

The healing process for full-thickness wounds which involves the formation of granulation tissue.

Types of wound dressing

Various materials used for protecting and healing wounds, including but not limited to gauze, hydrocolloids, alginates, foam dressings, film dressings, and negative-pressure wound therapy.