Exam 3 · LVN Study Guide
Tissue Integrity
Skin anatomy, wound types, pressure injuries, wound care, healing phases, and complications
📍 The Big Picture Flow
🔬 Skin Anatomy
3 Layers
→
⚠️ Risk Factors
MOIST Groups
→
🔍 Assessment
Braden + Skin
→
🩹 Wound Types
Acute + Chronic
→
🛑 Pressure Injuries
Stages 1–4 + More
→
💊 Wound Care
Dressings + Drains
→
🔄 Healing
3 Phases
🔬 Skin Anatomy — 3 Layers (EDS)
🧬
EPIDERMIS — Outermost
- Keratinocytes — protect from water loss, pathogens, injury; migrate basal→superficial→shed
- Melanocytes — produce melanin; skin/hair/eye color; absorbs UV rays
- Merkel cells — detect light touch (palms + soles)
- Langerhans cells — ingest antigens → lymphocytes → immune response
🏗️
DERMIS — Thickest Middle
- Connective tissue + capillaries + blood/lymph vessels
- Papillary region: fibroblasts → hyaluronic acid + fibronectin → wound healing
- Collagen and elastin fibers → strength + elasticity
- ↓ collagen with aging = ↑ tissue integrity risk
🛡️
SUBCUTANEOUS — Deepest
- Mostly adipose tissue
- Insulates body, absorbs shock, pads organs
- Blood vessels + nerves → thermoregulation + sensation
Barrier to injury/infection/UV
Touch/pain/pressure
Eliminates waste
Synthesizes Vitamin D
⚠️ Risk Factors + MOIST Mnemonic
Risk Groups by Client
- Neonates/Children — immature skin → diaper rash, maceration, skin tears
- Older Adults — ↓ collagen, ↓ elasticity, ↓ blood supply → skin tears, PIs, cellulitis
- ↓ Mobility (SCI, spina bifida, cerebral palsy) — ↓ circulation, incontinence, muscle atrophy → PIs
- Obese — maceration, ↑ skin temp, ↓ blood/lymph flow → PIs, skin-fold rashes
- Cancer/Radiation — radiation-induced dermatitis, ↓ blood supply → delayed healing
- Chronic illness — hepatic, kidney, cardiovascular diseases → skin tears, PIs
🧠 MOIST Mnemonic
Risk Factor Groups
MMobility ↓ (immobility = #1 risk)
OOld age / Obesity
IIncontinence (moisture damage)
SSensory loss (can't feel pressure)
TThin/malnourished (↓ albumin)
📝Key terms: Maceration = moisture→epidermis. Dermatitis = feces/urine/stoma. Skin frailty = at-risk vulnerable skin. Cellulitis = superficial skin infection.
🔍 Skin Assessment + Braden Scale
Assessment Rules
- Within 24 hr of admission, then daily/per shift
- Two RNs assess on admission for confirmation
- Head-to-toe; focus bony prominences
- Check under ALL medical devices
- Check obese clients' skin folds
- Pain at pressure point = RED FLAG ⚠️
- LPN gathers data → reports to RN
💡Blanchable = turns white → returns red (early warning). Non-blanchable = doesn't change = structural damage = Stage 1 PI!
Braden Scale (Score 6–23)
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
⚠️Lower score = Higher risk. Does NOT include hair braids — look beyond scale!
📋Mrs. Rogers case study (68yo COPD, high-Fowler's, perspiring, poor appetite): Braden score total is 12 = HIGH RISK. Subscores: Moisture 1, Activity 2, Mobility 2, Nutrition 1, Friction/Shear 2, Sensory 4.
Dark Skin Tone Findings
- Pallor — ashen-gray in mucous membranes; use halogen lighting
- Cyanosis — check palms, soles, conjunctiva, nail beds; grayish-white tongue/lips
- Jaundice — check hard palate, mucous membranes, sclera, palms, soles
- Erythema — difficult to detect; palpate for warmth
- Ecchymoses — darker area vs adjacent skin; tenderness when palpated
- Inflammation — compare to non-affected area; check warmth, tautness, swelling
🔑Dark skin PI: temperature + moisture = FIRST indicators. Skin appears taut, shiny, indurated.
🩹 Wound Types + Surgical Timeline
Acute Wounds
- Lacerations — blunt/sharp objects; irregular/jagged; simple or complicated
- Skin tears — mechanical forces (tape removal); depth = severity; upper/lower extremities
- Surgical wounds — intentional, sterile; closed with staples/sutures/adhesive
- Classification: Clean/Clean-contaminated (close at end) vs Contaminated/Dirty (leave open)
Wound Color Timeline
Days 1–4: Red
Days 5–14: Bright pink
Day 15–1yr: Pale pink
Day 4: Epithelial closure
Day 5: Edema + exudate resolve
Days 10–12: Staples removed
🎨Scar: light skin = white/silver. Dark skin = pale pink → darker than usual.
Chronic Wounds
- Venous ulcers — chronic venous insufficiency
- Arterial ulcers — peripheral artery disease
- Neuropathic ulcers — diabetes/nerve damage
Also at risk: smokers, undernourished, immunosuppressed, immobilized
💧MASD (Moisture-Associated Skin Damage): from feces, urine, stoma effluent, wound exudate, sweating. Symptoms: pain, burning, itching. MASD → predisposes to PI!
Exudate / Drainage Types
- Serous — clear/watery ✅ normal
- Serosanguineous — pink/watery ✅ normal
- Sanguineous — bloody ✅ normal early
- Purulent — infected ⚠️ REPORT TO PROVIDER
Wound Measurement: Tracing (see-through film) OR ruler (length × width). Use same method consistently! Tunneling/depth = sterile cotton tip applicator → mark → ruler.
🛑 Pressure Injuries — Complete Staging
🔑Mnemonic: 1 Red · 2 Wet · 3 Fat · 4 Bone | Shearing = forces parallel to skin surface (high risk: high-Fowler's). Friction = not direct cause but ↑ risk. ~60,000 US deaths/year from PI. Hypoperfusion + prolonged pressure = tissue breakdown in less than 2 hours.
| Type | Skin Intact? | What You See | Depth Reached |
|---|
| Stage 1 | ✅ Yes | Non-blanchable erythema; temp/consistency changes may precede color; difficult in dark skin | Epidermis only |
| Stage 2 | ⚠️ Partial | Partial-thickness loss; pink/red moist wound bed OR ruptured serum-filled blister | Epidermis + top dermis |
| Stage 3 | ❌ No | Full-thickness; visible ADIPOSE; granulation tissue; rolled edges; tunneling/undermining possible; NO bone/tendon visible | Dermis + subcutaneous fat |
| Stage 4 | ❌ No | Full-thickness; fascia/muscle/tendons/ligaments/cartilage/BONE VISIBLE; rolled edges; tunneling/undermining | Down to bone |
| Unstageable | — | Covered by SLOUGH (yellow, stringy) or ESCHAR (hard, black/brown); reveals Stage 3 or 4 when removed | Unknown |
| DTPI | Intact/broken | Non-blanchable deep red, maroon, or purple; intense + persistent pressure + shear | Deep tissues |
| MDRPI | Varies | From O2 mask, urinary cath, cervical collar, compression stockings; assumes shape of device | Varies |
| Mucosal Membrane | Mucosal | From ETT, O2 tubing, feeding tubes, urinary catheters; CANNOT BE STAGED (mucosa ≠ skin layers) | Mucosal |
| HAPI | Varies | Hospital-acquired PI; ICU/DM/kidney disease ↑ risk; Stage 3+4 NOT reimbursed by CMS | Varies |
PI Locations (Bony Prominences)
HeelsToesSacrumHipsElbowsShouldersOcciput (back of head)
PI Documentation Includes
Location, stage, sizeTissue descriptionWound bed colorWound edgesUndermining + tunnelingFoul odorDrainagePain reports
PI Prevention
Reposition q2h (20°–30° side-lying)HOB <30°Pressure-relieving mattressEmollientspH-balanced cleansersBraden scale on admissionRemove tight braids on admission
💊 Wound Care — Dressings, Debridement + Drains
Debridement Types
- Surgical — scalpel/scissors; removes dead tissue + biofilm; fastest; infected tissue → culture + sensitivity; chronic wounds may need multiple sessions
- Irrigation — 0.9% NaCl; bedside or surgical suite
- Enzymatic — collagenase (targets ONLY necrotic tissue; proven ✅); papain (papaya); bromelain (pineapple); collagenase = best for non-surgical candidates
- Larvae therapy — green bottle fly + Australian sheep blowfly; liquifies necrotic; healthy tissue untouched; antimicrobial; dispel patient fears
📝Clean vs Sterile: Sterile dressings for 24–48 hrs post-surgery. After 48hrs → clean technique. Home care = clean technique. Wound bed must be moist (not wet)!
Dressing Types (Match to Wound)
- Wet-to-dry (Open) — 0.9% NaCl gauze; debrides; RARELY used today (removes healthy tissue)
- Semi-open — 3 layers; poor drainage control
- Films — superficial/minimal exudate; O2 enters; visualize without removing
- Hydrocolloid — abrasions/burns/PIs; yellow gel = NORMAL (not infection!); can cause contact dermatitis
- Alginate — moderate–high exudate; needs secondary dressing
- Hydrofiber — moderate–high; less maceration than alginate
- Foam — mild–moderate; silicone foam to sacrum within 24hr → ↓ HAPIs
- Polymeric — mild exudate; doesn't stick to wound bed
- Hydrogel — dry wounds/necrosis/eschar; adds OR removes moisture
- Antimicrobials — Iodine (check iodine allergy) | Honey (check bee sting allergy) | Silver (infected/moist wounds)
Wound Closures + Drains
- Sutures — synthetic (nylon/polyester) or natural (silk/linen); absorbable or nonabsorbable; synthetic = less tissue reaction
- Staples — faster; 7–14 days; NOT on face or neck; removal: prongs under → depress → bend outward
- Skin adhesive — small straight wounds; NOT over joints; 3–4 layers; peels 5–10 days
- NPWT — large wounds; ↓ edema; ↑ granulation; constant or intermittent
Drain Types
- Penrose — flat, pliable, passive, gravity; 4×4 gauze around it
- Jackson-Pratt (JP) — active, closed; empty every 8hr or >half full; compress bulb → close port
- Large Bottle — high pressure; change when half-full; measure at eye level
- Hemovac — circular, low vacuum; spring squeezed flat; open plug → cup → alcohol swab → squeeze flat
🔑Remove drain when 30–100 mL/day. After removal: gauze → 24hrs → open to air. Drainage: starts sanguineous → serosanguineous.
🔄 Wound Healing + Complications
Healing Phases (IPR)
Phase 1 — Hemostatic/Inflammatory
Day 0–6
Blood vessels constrict → clotting → bleeding stops. Histamine released → vasodilation → WBCs flood in. Neutrophils → cytokines → new vessels + fibroblasts + tissue maturation.
Phase 2 — Proliferative
Day 3–24
Granulation tissue (fibroblasts + collagen) forms. Collagen strengthens wound. Re-epithelialization: keratinocytes migrate toward center.
Phase 3 — Remodeling/Maturation
Day 21 → 1+ year
Collagen replaced with stronger collagen. Myofibroblasts → contractile force → pull wound edges together.
Healing Types (Intention)
1°Primary — clean/sutured; FASTEST
2°Secondary — left open; granulates bottom-up; HIGH infection risk
3°Tertiary — left open 5–10 days THEN sutured
8 Factors That DELAY Healing
- Diabetes mellitus — ↓ peripheral perfusion + impairs sensation
- Infection — breaks down collagen
- Foreign body — ↑ infection risk
- Steroids — prevent collagen + fibroblast formation
- Malnutrition — need protein, Vit A+C, zinc
- Tissue necrosis — ↓ blood supply
- Hypoxia — from vasoconstriction (blood loss, pain, low temp)
- Multiple wounds — compete for nutrients → all heal slower
🥗Nutrition for healing: Protein · Omega-3 · Omega-6 · Vitamin A · Vitamin C · Zinc. High-calorie high-protein supplements for at-risk clients. Dietitian consult if indicated.
Complications + SSI
- Dehiscence — suture line separation; ~16% mortality; occurs day 7–10; preceded by serosanguineous discharge; management: sterile saline dressing → notify provider → possible OR + abdominal binder/NPWT
- Evisceration 🚨 — organs protrude; EMERGENCY → sterile saline-soaked dressing → OR
- Hematoma — blood accumulation; anticoagulants + obesity = risk factors
- Seroma — serous fluid collection; small = monitor; large = drain + pack with gauze
Wound Culture — 8 Steps in Order
- Label culture tube
- Remove old dressing
- Rinse wound with 0.9% NaCl
- Remove swab from culture tube
- Place sterile swab into wound bed
- Rotate swab in area of drainage
- Activate the culture medium
- Note if client received recent antibacterial/antifungal therapy
🦠SSI: Superficial = within 30 days. Deep = 30–90 days. #1 cause: Staphylococcus aureus. Prevention: CHG wipes perioperatively.