Comprehensive Study Guide for Tissue Integrity and Wound Care and Integumentary Health

Course Information and Primary Resources

• Topic: Tissue Integrity

• Domain: Nursing Concepts

• Associated Concepts: Evidence-Based Practice ($EBP$); Healthcare Delivery; Safety; Clinical Decision Making; Patient-Centered Care.

• Lead Professor: Dr. January

• Revision Date: June $2026$ / $CJ$

• Required Textbooks:

  • Burton, M & Smith, D ($2023$). Davis Advantage for Fundamentals of Nursing Care, $4\text{th}$ Edition, F.A. Davis.

    • Chapter $18$: Applying heat and cold therapy (Entire chapter, pp. $343$-$354$).

    • Chapter $26$: Wound care (Entire chapter, pp. $523$-$556$).

    • Chapter $30$: Bowel elimination and care (Focus on colostomy care only).

    • Chapter $38$: Intravenous Therapy (Complications of peripheral intravenous therapy, pp. $856$-$859$, terminating at severed cannula).

  • Williams, L.S. & Hopper, P.D. ($2023$). Davis Advantage for Understanding Medical-Surgical Nursing, $7\text{th}$ Edition, F.A. Davis.

    • Chapter $53$: Understanding the Integumentary System (Sections: Anatomy and Physiology, Data Collection, Physical Examination; stop at diagnostic tests).

    • Chapter $54$: Understanding the Integumentary System (Stop at inflammatory skin disorders).

• Web Resources:

  • National Pressure Ulcer Advisory Panel Guidelines - Pressure Injury Advisory Panel Guidelines.

Terminology of Skin and Tissue Integrity

• Abrasions: Scrapes or wearing away of the skin surface.

• Erythema: Redness of the skin, often a sign of inflammation or infection.

• Ischemia: Deficiency of blood supply to a tissue, often resulting in tissue damage.

• Necrotic: Refers to dead tissue that can no longer be salvaged.

• Eschar: Thick, leathery, necrotic, devitalized tissue (can be black, brown, or tan).

• Emaciation: The state of being abnormally thin or weak.

• Jaundice: A yellowing of the skin and eyes caused by excess bilirubin.

• Maceration: Softening and breaking down of skin resulting from prolonged exposure to moisture.

• Keloids: Overgrowth of scar tissue that extends beyond the original wound.

• Alopecia: Hair loss or thinning.

• Pallor: Unnatural paleness of the skin.

• Petechia: Tiny, circular, non-raised patches on the skin resulting from bleeding.

• Turgor: The elasticity of the skin; an indicator of hydration status.

• Ecchymosis: A bruise or discoloration of the skin resulting from bleeding underneath.

• Cellulitis: A common, potentially serious bacterial skin infection.

• Debridement: The medical removal of dead, damaged, or infected tissue.

• Vesicant: An agent that causes blistering of the skin or mucous membranes.

• Purulent: Containing, consisting of, or forming pus.

• Cellular Function: The biological processes occurring within a cell to maintain life.

• Hemostasis: The process of stopping bleeding or blood flow.

• Interstitial Space: The space between cells in a tissue.

• Vasoconstriction: The narrowing of blood vessels to decrease blood flow.

• Vasodilation: The widening of blood vessels to increase blood flow.

• Phagocytosis: The process by which cells (phagocytes) ingest and destroy foreign particles or bacteria.

Fluids and Drainage Characteristics

• Sanguineous: Bloody drainage, typically seen in fresh wounds.

• Serosanguineous: A thin, watery drainage that is blood-tinged (mixture of serum and blood).

• Serous: Clear, watery plasma drainage.

• Purulent: Thick drainage that may be yellow, green, tan, or brown, indicating infection.

Anatomy and Physiology of the Integumentary System

• Epidermis: The outermost layer of the skin providing a waterproof barrier and creating skin tone.

• Dermis: Found beneath the epidermis, containing tough connective tissue, hair follicles, and sweat glands.

• Hypodermis (Subcutaneous Tissue): The deeper subcutaneous tissue made of fat and connective tissue, providing insulation and cushioning.

Data Collection and Physical Assessment

• Objective Data: Observations made by the nurse (e.g., skin color, temperature, moisture, texture, and lesions).

• Subjective Data: Information provided by the patient during the physical examination (e.g., reports of itching, pain, or history of skin conditions).

• Gerontological Issues: Specific considerations for the aging population, including thinning skin, decreased elasticity, and increased risk for injury (Ref: Medical-Surgical Textbook, p. $1099$).

Classification and Contamination of Wounds

• Types of Wounds:

  • Contusions: Closed wounds caused by blunt trauma (bruises).

  • Abrasions: Superficial scrapes.

  • Puncture Wounds: Wounds caused by sharp objects (e.g., nails).

  • Penetrating Wounds: Wounds where an object enters the body and remains or passes through.

  • Lacerations: Deep cuts or tears in skin or flesh.

  • Pressure Injuries: Localized damage to the skin and/or underlying soft tissue, usually over a bony prominence.

• Wound Contamination Levels:

  • Clean: Uninfected; minimal inflammation; respiratory, alimentary, and genitourinary tracts are not entered.

  • Clean-Contaminated: Surgical wounds where the respiratory, alimentary, or genitourinary tracts have been entered under controlled conditions.

  • Contaminated: Open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique.

  • Infected: Wounds containing clinical signs of infection (purulent drainage, high bacterial count).

  • Colonized: Wounds that contain microorganisms but show no signs of infection.

The Physiology of Wound Healing

• Phases of Wound Healing:

  • Inflammatory Phase: Initial response to injury featuring hemostasis and phagocytosis.

  • Reconstruction Phase: Also known as the proliferative phase; characterized by the formation of granulation tissue.

  • Maturation Phase: The final stage where the scar tissue is remodeled and gains strength.

• Types of Wound Closures:

  • Primary Intention (and Approximation): Occurs when wound edges are close together (well-approximated) and heal with minimal scarring (e.g., surgical incisions).

  • Secondary Intention: Occurs when there is significant tissue loss; the wound is left open to heal from the bottom up, resulting in a larger scar.

  • Tertiary Intention: Delayed primary closure; occurs when a wound is left open initially (due to infection or edema) and then closed surgically later.

Complications and Nursing Care in Wound Management

• Factors Negatively Affecting Healing: Factors such as poor nutrition, impaired circulation, smoking, chronic illnesses (e.g., diabetes), and advanced age.

• Common Wound Infections:

  • MRSA: Methicillin-resistant Staphylococcus aureus.

  • E Coli: Escherichia coli.

  • Clostridia: Spore-forming anaerobic bacteria.

  • Candida Auris: A multidrug-resistant fungal infection.

• Surgical Incision Problems:

  • Dehiscence: The partial or total separation of wound layers.

  • Evisceration: Protrusion of visceral organs through a wound opening (a medical emergency).

  • Hemorrhage: Excessive or profuse bleeding.

Wound Treatments and Specialty Devices

• Wound Closure Materials:

  • Sutures and Staples.

  • Skin adhesive.

  • Steri-strips.

• Wound Drains and Drainage Devices:

  • Hemovac: A circular suction device for large amounts of drainage.

  • Jackson-Pratt (J-P): A bulb-shaped suction device for smaller amounts of drainage.

  • Penrose: A flat, open drainage tube that drains via gravity onto a dressing.

  • Wound Vac: Vacuum-assisted closure using negative pressure to promote healing.

Nursing Skills for Wound Care

• Cleaning/Irrigation (Skill $26.3$): The process of washing or flushing out a wound with sterile saline.

• Obtaining a Culture (Skill $26.4$): Collecting a sample from the wound to identify infecting organisms.

• Wet-to-Damp Dressing (Skill $26.5$): Used to mechanically debride a wound.

• Transparent and Hydrocolloid Dressings (Skill $26.6$): Specialty dressings used to protect wounds and maintain a moist environment.

• Nursing Responsibility: Maintaining sterile technique and assessing for progress or infection.

Thermal Therapies: Heat and Cold

• Purpose of Heat Application: Increases blood flow (vasodilation), relieves muscle tension, and promotes relaxation.

• Purpose of Cold Therapies: Decreases blood flow (vasoconstriction), reduces swelling/edema, and numbs pain.

• Safety Concerns: Risks of thermal injury (burns or frostbite). Close monitoring of skin integrity and temperature is required.

• Nursing Assessments: Must evaluate medical history, skin condition, current temperature, and signs of discomfort before, during, and after therapy.

Wound Documentation and Registry

• Photography Guidelines:

  • Obtain patient consent.

  • Maintain HIPAA compliance.

  • Ensure patient privacy.

  • Protect identifying features to keep the patient anonymous.

• Documentation Elements:

  • Location and Size (Length, Width, Depth).

  • Type and Appearance (Color, Granulation).

  • Odor and Pain level.

  • Evidence of Infection.

  • Treatment applied and Progress toward healing.

Pressure Injury Risk and Prevention

• Risk Factors: Immobility, medical device-related pressure, shearing force, pressure over bony prominences, aging, incontinence, and impaired circulation.

• The Braden Scale: A standardized tool used to predict pressure sore risk by assessing sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

• Nursing Interventions:

  • Frequent repositioning.

  • Use of pressure-redistributing surfaces.

  • Keeping skin clean and dry (moisture management).

  • Optimizing nutrition and hydration.

Pressure Injury Staging

• Stage $1$: Non-blanchable erythema (redness) of intact skin.

• Stage $2$: Partial-thickness skin loss with exposed dermis (often looks like a blister).

• Stage $3$: Full-thickness skin loss; adipose (fat) is visible in the ulcer.

• Stage $4$: Full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, or bone.

• Unstageable: Full-thickness skin and tissue loss in which the extent of damage cannot be confirmed because it is obscured by slough or eschar.

• Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration.

• Other Wound Types:

  • Statis Ulcers: Caused by venous insufficiency.

  • Sinus Tract: A narrow tunnel or passage that extends in any direction from the wound through soft tissue.

Intravenous (IV) Therapy Complications

• Infiltration: Leaking of a non-vesicant IV solution into the extravascular tissue.

• Extravasation: Leaking of a vesicant IV solution (medicine that causes blisters/necrosis) into the tissue.

• Phlebitis: Inflammation of the vein.

• Thrombophlebitis: Inflammation of a vein associated with a blood clot.

Specialized Care: Ostomy and Bowel Care

• Assessment of the Stoma:

  • Evaluate color (should be pink/red and moist).

  • Monitor peristomal skin for irritation.

  • Skills $30.6$ & $30.7$ detail procedural care.

• Enema Administration (Skills $30.1$, $30.2$): Safe introduction of fluid into the rectum for bowel cleansing.

• Rectal Suppository (Skill $36.7$): Safe administration of medication via the rectal route.

Student Learning Outcomes

• Outcome $1$: Safety/Quality Improvement: Describe basic healthcare principles and quality improvement practices.

• Outcome $2$: Patient-Centered Care: Provide care that respects patient preferences and encourages participation.

• Outcome $3$: Professionalism: Adhere to legal and ethical nursing standards.

• Outcome $4$: Teamwork/Collaboration: Recognize multidisciplinary team roles.

• Outcome $5$: Evidence-Based Practice/Clinical Reasoning: Incorporate research and evidence into care.

• Outcome $6$: Informatics: Utilize technology for documentation and safety management.