NUFT - 204: (EXAM 2) SKIN INTEGRITY & WOUND CARE | LATEST UPDATED 2026/2027 (GRADED A+)
epidermis ✔️top layer of skin
dermis ✔️inner layer of skin + collagen
dermal-epidermal junction ✔️separates dermis and epidermis
names for pressure ulcers ✔️pressure sore, decubitus ulcer, or bed sore
tissue ischemia ✔️death of skin bc lack of blood flow
blanching ✔️skin goes pale when pressed then goes back to pink when released (think nails)
risk factors for pressure ulcer development ✔️Impaired sensory perception
Impaired mobility
Alteration in LOC
Shear
Friction
Moisture
friction ✔️*superficial / visible injury*
= the mechanical force exerted when skin is dragged across a coarse surface (such as bed linens)
shear ✔️*internal injury*
= affected by the amount of pressure exerted, the coefficient of friction between the materials contacting each other, and the extent to which
the body makes contact with the support surface
classification of pressure ulcers ✔️Stage I
Stage II
Stage III
StageIV
Unstageable
stage I pressure ulcer ✔️intact skin with nonblanchable redness
stage II pressure ulcer ✔️*partial thickness skin loss* involving epidermis, dermis, or both (can be a scab, bloody, or blister)
stage III pressure ulcer ✔️full thickness tissue loss with *visible fat*
stage IV pressure ulcer ✔️full-thickness tissue loss with *exposed bone, tendon, or muscle*
necrosis ✔️tissue death
slough ✔️to shed dead tissue
eschar ✔️scab or crust from trauma
dehiscence ✔️the splitting or bursting open of a wound.
ischemia ✔️lack of blood flow
tunneling or sinus tract ✔️*a narrow opening or passageway underneath the skin* that can extend in any direction through soft tissue and
results in dead space with potential for abscess formation
serous drainage ✔️clear fluid
epidermis ✔️top layer of skin
dermis ✔️inner layer of skin + collagen
dermal-epidermal junction ✔️separates dermis and epidermis
names for pressure ulcers ✔️pressure sore, decubitus ulcer, or bed sore
tissue ischemia ✔️death of skin bc lack of blood flow
blanching ✔️skin goes pale when pressed then goes back to pink when released (think nails)
risk factors for pressure ulcer development ✔️Impaired sensory perception
Impaired mobility
Alteration in LOC
Shear
Friction
Moisture
friction ✔️*superficial / visible injury*
= the mechanical force exerted when skin is dragged across a coarse surface (such as bed linens)
shear ✔️*internal injury*
= affected by the amount of pressure exerted, the coefficient of friction between the materials contacting each other, and the extent to which
the body makes contact with the support surface
classification of pressure ulcers ✔️Stage I
Stage II
Stage III
StageIV
Unstageable
stage I pressure ulcer ✔️intact skin with nonblanchable redness
stage II pressure ulcer ✔️*partial thickness skin loss* involving epidermis, dermis, or both (can be a scab, bloody, or blister)
stage III pressure ulcer ✔️full thickness tissue loss with *visible fat*
stage IV pressure ulcer ✔️full-thickness tissue loss with *exposed bone, tendon, or muscle*
necrosis ✔️tissue death
slough ✔️to shed dead tissue
eschar ✔️scab or crust from trauma
dehiscence ✔️the splitting or bursting open of a wound.
ischemia ✔️lack of blood flow
tunneling or sinus tract ✔️*a narrow opening or passageway underneath the skin* that can extend in any direction through soft tissue and
results in dead space with potential for abscess formation
serous drainage ✔️clear fluid
