Skin Integrity & Wound Care Fundamentals of Nursing

These flashcards cover key concepts and vocabulary related to skin integrity and wound care fundamentals.

Epidermis

The superficial top layer of skin that consists of epithelial cells, has no blood vessels, and provides a protective and waterproof barrier.

Dermis

The deep, inner layer of skin that contains connective tissue, nerves, hair follicles, glands, immune cells, and blood vessels.

Subcutaneous tissue

Tissue that anchors the skin layers to the underlying tissues, primarily composed of adipose tissue.

Functions of the Skin

The skin serves various functions including protection, sensory perception, regulation of body temperature, synthesis of vitamin D, psychosocial effects, immunologic defense, absorption, and elimination.

Wound Classification

The categorization of wounds based on their characteristics such as intentional vs. unintentional, open vs. closed, acute vs. chronic, and thickness.

Haemostasis

The process to stop bleeding, which can be achieved spontaneously or through first-aid measures.

Primary intention

Wound healing where there is minimal tissue loss and wound edges are well approximated, resulting in minimal scarring.

Secondary intention

Wound healing where edges are not well approximated, leading to delayed healing through granulation and tissue contraction.

Tertiary intention

Wound healing that involves infection or foreign bodies, requiring cleaning prior to closure, usually done 3-5 days later.

Partial thickness

A type of wound characterized by a shallow depth, involving loss of the epidermis and part of the dermis.

Full thickness

A type of wound where the loss of tissue extends through the dermis into the subcutaneous fat.

Red, Yellow, Black Color Code

A wound classification system where red indicates healthy granulation tissue to protect, yellow indicates nonviable slough to cleanse, and black indicates necrotic tissue that needs debridement.

Local factors affecting wound healing

Factors such as pressure, dehydration, trauma, and infection that can impact the healing process of a wound.

Stage 1 Pressure Injury

An injury defined by intact skin with nonblanchable redness, potentially differing color in darkly pigmented skin.

Stage 2 Pressure Injury

Partial thickness skin loss involving the epidermis, dermis, or both; may present as an open ulcer or fluid-filled blister.

Stage 3 Pressure Injury

Full thickness tissue loss where fat may be visible and necrotic tissue may be present.

Stage 4 Pressure Injury

Full thickness tissue loss with exposed bone, muscle, or tendon; may include necrotic tissue and often involves tunneling.

Braden Scale

A tool used to assess the risk of pressure injuries with a scoring system that evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Negative-pressure wound therapy (NPWT)

A therapeutic technique that applies negative pressure to a wound to accelerate healing and optimize blood flow.