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Skin Anatomy and Wound Classifications Study Guide

This guide provides a foundational understanding of skin anatomy and the various ways wounds are classified. It covers the three layers of the skin and details common wound types such as contusions, abrasions, puncture wounds, penetrating wounds, lacerations, stasis ulcers, sinus tracts, and surgical incisions. This information is essential for healthcare professionals in assessing and managing wound care.

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Pathophysiology and Nursing Care of Altered Tissue Integrity

Skin Anatomy, Physiology, and Wound Healing

This module explores the pathophysiology, risk factors, and clinical presentation of alterations in tissue integrity, including skin inflammatory conditions, infections, and burns.

Pathophysiology of tissue integrity
Skin anatomy and physiology
Epidermis
Dermis
Hypodermis
Skin barrier dysfunction
Wound healing stages
Hemostasis
Inflammation
Burn injury resuscitation volumes
Temperature regulation
Fluid and electrolyte balance

Alterations in Tissue Integrity and Wound Healing

This content examines the stages of wound healing, risk factors for skin injuries, and clinical management of acute and chronic wounds.

Stages of wound healing
Hemostasis
Inflammation
Proliferation
Tissue remodeling
Epidemiological and etiological risk factors
Friction and shearing
Incontinence-associated dermatitis (IAD)
Intertrigo
Skin tears
Nutritional requirements for healing
Chronic wounds
Arterial ulcers
Venous ulcers
Diabetic ulcers
Diagnostic studies for wound assessment
Nursing roles in wound management

Nursing Management of Tissue Integrity and Pressure Injuries

This content details the nursing process for assessing, planning, implementing, and evaluating care for clients with alterations in wound healing and pressure injuries.

Wound Assessment
Wound Healing Stages
Pressure Injury Risk Factors
Infection Prevention

Skin Anatomy and Wound Classification

Skin Anatomy and Wound Classifications

The skin is the largest organ system of the body consisting of three layers and various wound classifications.

Skin layers
Skin color assessment
Contusions
Abrasions
Puncture wounds
Penetrating wounds
Lacerations
Stasis ulcers
Sinus tracts
Surgical incisions

Principles and Guidelines of Sterile Technique

Principles of Surgical Asepsis and Sterile Technique

This unit covers principles of sterile technique, establishing a sterile field, and guidelines for using surgical asepsis.

Autoclaving
Chemical Disinfection
Contamination
Gaseous Disinfection
Principles of Sterile Technique
Establishing a Sterile Field
Opening Sterile Supplies
Restricted Areas
Circulating Nurse
Scrub Nurse

Perioperative Nursing Care and Risk Management

This lesson examines nursing responsibilities across the preoperative, intraoperative, and postoperative phases, including preoperative assessment, informed consent, client teaching, and management of surgical risk factors.

Perioperative nursing phases
Preoperative assessment
Informed consent
Preoperative client teaching
Surgical risk factors
Malignant hyperthermia
Postoperative delirium
Postoperative cognitive dysfunction
Multimodal pain therapy
Comprehensive surgical checklist

Pre-Operative and Intra-Operative Nursing Care

Nursing Care of the Surgical Client

Nursing care includes postoperative care in the PACU, assessment of complications, and surgical wound care.

Malignant hyperthermia
Postoperative care
Surgical wound care
Wound healing processes
Evisceration
Dehiscence
Hematoma
Risk for infection
Nursing interventions

Principles of Perioperative Nursing Care

Perioperative Nursing Care and Responsibilities

This module analyzes the principles of perioperative nursing, including the nurse's role and responsibilities during the preoperative, intraoperative, and postoperative phases of surgery.

Perioperative phases
Classifications of surgery
Informed consent
Surgical safety checklist
Preoperative physical preparation
NPO restrictions
Age-related physiological changes
Preoperative diagnostic screening
Intraoperative nursing interventions
Types of anesthesia
Postoperative client safety

Perioperative Nursing Safety and Education

Postoperative education and safety considerations focus on preventing complications through incentive spirometer use, surgical site verification, and infection prevention.

Surgical Site Infections (SSI) prevention
Skin antisepsis
Surgical site preparation

Lesson 35: Hygiene and Physical Barriers

Hygiene and Physical Barriers

Hygiene consists of actions and practices that decrease the spread or transmission of pathogens to lessen the occurrence of illness.

Hygiene definition
Physical barriers
Integumentary system
Skin layers (epidermis, dermis, hypodermis)
Mucous membranes
Langerhans cells
Handwashing and health care-associated infections
Health promotion
Bariatric client physiological changes
Dementia and personal hygiene
Perineal care
Complete and partial bed baths

Nutrition and the Digestive System

Fundamentals of Nutrition and Digestion

This lesson explores the significance of the balance between caloric intake and energy expenditure, the physiology of digestion, and nursing interventions to assist clients in meeting nutritional needs.

caloric intake and energy expenditure
nutritional status
therapeutic diets
nursing interventions
physiology of digestion
peristalsis
nutrient absorption
digestive organs

Client Personal Hygiene and Infection Prevention

This lesson reviews the role of the body's defenses against pathogens, the impact of hygiene on health, and procedures for providing hygiene-related care.

integumentary system
mucous membranes
skin layers
epidermis
dermis
hypodermis
pathogens
hand hygiene
infection prevention
health care–associated infections (HAIs)
skin integrity
nail care
oral care
health promotion
nursing process

Nursing Interventions for Client Hygiene

Nurses evaluate client-specific factors and provide assistance with activities of daily living to maintain privacy, dignity, and skin integrity.

social determinants of health
health inequities
client privacy and dignity
cultural and religious preferences
diaper dermatitis
noncomedogenic solutions
hemiplegia
aspiration pneumonia
adaptive bathroom equipment
spinal cord injury
pressure injuries
visual impairment
bariatric challenges
skin folds
dementia
activities of daily living
limb removal
complete bed bath
chlorhexidine gluconate (CHG) bathing
linen changes

Management of Inflammatory and Infectious Skin Conditions

Alterations in Tissue Integrity

This document discusses skin inflammation and infection, including risk factors, clinical presentations, and the wound infection continuum.

Infection continuum
Inflammatory skin conditions
Wound infection risk factors
Clinical presentation of skin infections
Skin inflammation etiology
Microbial colonization
Systemic infection
Biofilm development
Diagnostic studies for skin conditions

Nursing Management of Skin Inflammation and Infection

Nurses assess, prioritize, and implement care for clients experiencing inflammatory skin conditions or infections, including managing anaphylaxis and administering pharmacological treatments.

Assessment of skin inflammation and infection
Anaphylaxis recognition and treatment
Nursing process for skin conditions
Standard precautions and transmission prevention
Client education for skin management
Pharmacological management of inflammation
Antibiotic therapy for skin infections
Antifungal and antiviral medications
Treatment for scabies and lice
Nonpharmacological management methods

Wound Assessment and Pressure Ulcer Management

Tissue Integrity and Wound Assessment

This unit covers categories of wound contamination, pressure ulcer staging, wound assessment, and the wound healing process.

Categories of Wound Contamination
Laceration
Sinus tract
Pressure Ulcer Staging
Unstageable pressure injury
Wound Assessment
Braden score
Wound Healing Process

Maintaining and Assessing Tissue Integrity

Wound Drain Types and Management

This text discusses wound drains used to decrease accumulation of fluid and air, including passive and active systems.

Negative Pressure Wound Therapy
Passive drains
Active drains
Open drains
Closed drains
Penrose drain
Portable wound bulb suction device
Bottle drainage
Circular portable wound suction device
Hemovac drain
Drainage monitoring and care

Perioperative Complications and Nursing Care Responsibilities

Perioperative Nursing Care and Complications

This document details nursing responsibilities, anesthetic types, and potential postoperative complications including venous thromboembolism, fluid imbalances, and surgical wound issues.

Obesity risk factors
Venous thromboembolism
Deep vein thrombosis
Pulmonary embolism
Hypovolemia
Hypervolemia
Atelectasis
Surgical site infections
Wound dehiscence
Wound evisceration
Oliguria
Intraoperative nursing responsibilities
Universal Protocol
Circulating nurse role
Surgical technologist role
Aseptic and sterile technique
Local anesthesia
Regional anesthesia

Nursing Care of the Surgical Client

Peri-operative Nursing Care and Responsibilities

This content covers pre-operative nursing responsibilities, intra-operative care, and the roles of the circulating and scrub nurse during surgical procedures.

Pre-operative nursing responsibilities
Health history and physical status
Pre-op nurse teaching
Intra-operative care
Circulating nurse
Scrub nurse
Types of anesthesia
Client safety
Sterile team and clean team

TeamSTEPPS and Perioperative Communication Tools

Perioperative Communication and TeamSTEPPS Strategies

TeamSTEPPS framework
Perioperative care
SBAR communication tool
I PASS the BATON handoff tool
Continuity of care
Transitions of care
Client safety
Interprofessional client-focused team

Nutrition, Eating Patterns, and Digestive Health

Fundamentals of Nutrition and Dietary Patterns

This content covers the physiology of digestion, nutrient requirements, and the impact of eating patterns on health and weight management.

digestive system
macronutrients
micronutrients
protein
carbohydrates
glycemic index
fats
vitamins
water-soluble vitamins
fat-soluble vitamins
minerals
macrominerals
trace minerals
water
calorie density
nutritional labels
serving size
percent daily value
body mass index
antioxidants

Burn Injury Pathophysiology and Management

Management of Alterations in Tissue Integrity: Burns

This content discusses the pathophysiology, clinical presentation, and nursing management of burn injuries, including fluid resuscitation, nutritional support, and wound care.

Burn pathophysiology
Coagulation, zone of stasis, and zone of hyperemia
Burn depth classifications
Superficial, partial thickness, and full thickness burns
Rule of Nines
Lund and Browder chart
Fluid resuscitation and Parkland formula
Compartment syndrome
Escharotomy
Inhalation injury
Hypermetabolic state
Autograft, allograft, and xenograft
Skin substitutes
Primary and secondary survey
Laboratory monitoring for electrolytes and renal function

Wound Healing, Dressings, and Complications

Wound Healing and Tissue Integrity

Information regarding types of wound closures, dressing selection, factors affecting wound healing, and complications of wound healing.

Types of wound dressings
Purposes of dressing
Factors affecting wound healing
Protein and wound healing
Signs of wound infection
Nursing response to wound infection
Hemorrhage
Dehiscence
Evisceration
Phases of wound healing

Postoperative Nursing Care and Complications

Postoperative Nursing Care and Safety

Nursing care for the surgical client includes managing pain, wound care, monitoring gastrointestinal and renal systems, and addressing safety considerations like fall risk and aspiration.

Nonpharmacological pain management
Surgical wound care
Integumentary system assessment
Gastrointestinal system monitoring
Renal system monitoring
Hydration assessment
Fall risk prevention
Aspiration prevention
Postoperative delirium
Perioperative phases
Nursing roles in perioperative care

Perioperative Nursing Process and Transplant Care

Perioperative Nursing and Transplant Care

Perioperative nursing care includes caring for a surgical client during the preoperative, intraoperative, and postoperative phases of surgery using the nursing process to ensure safe and successful client outcomes.

Nursing process
Perioperative phases
Preoperative assessment
Postoperative complications
Pain management
Opioid stewardship
Malignant hyperthermia
Aldrete scoring system
Venous thromboembolism prophylaxis
Wound dehiscence and evisceration
Transplant nursing
Acute graft rejection
Immunosuppressive medications

Nutritional Support and Glucose Management

Nutrition Management and Aspiration Precautions

This content covers aspiration prevention, glucose monitoring, insulin administration, and the delivery of enteral and parenteral nutrition.

aspiration
dysphagia
overt aspiration
silent aspiration
thickened liquids
swallowing techniques
chin-tuck position
blood glucose monitoring
hypoglycemia
insulin administration
gastrostomy tube
nasogastric tube
nasojejunal tube
enteral nutrition
parenteral nutrition
total parenteral nutrition
partial parenteral nutrition

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