Fundamentals of Nursing Practice · Skin and Wound Care
Skin Integrity, Wound Healing, and Wound Complications
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Skin integrity Skin intact and acting as a barrier Full entry → means the skin is intact and functioning as a barrier. A Wound A break in skin or tissue Full entry → is any break in that barrier, and healing proceeds through four overlapping phases: Hemostasis Stopping bleeding via clotting Full entry →, inflammatory, proliferative, and maturation. Wounds close by primary, secondary, or tertiary intention depending on how their edges are managed. Complications such as Hemorrhage Excessive bleeding Full entry →, Infection Microbial invasion of the wound Full entry →, Dehiscence Partial or full separation of wound edges Full entry →, Evisceration Organs protruding through an open wound Full entry →, and Fistula Abnormal passage between organs or to skin Full entry → can interrupt healing, especially when Perfusion Blood flow delivering oxygen and nutrients Full entry →, Nutrition Adequate protein, calories, vitamins, minerals Full entry →, or blood-sugar control is poor.
Why this matters
Recognizing normal versus abnormal healing drives safe, person-centered care. The nurse documents wound findings objectively so the health record reflects actual status, and communicates concerning changes promptly — early recognition of infection, dehiscence, or evisceration prevents serious harm. Wound-care techniques and clean-versus-sterile decisions vary by institution and jurisdiction; learners should rely on skills-lab checklists, faculty guidance, and supervised training rather than notes alone. Teaching nutrition, blood-sugar management, and wound protection is a key independent nursing role.
The college version
1. Skin integrity and how wounds are classified
Intact skin blocks microbes, protects deeper tissue, and prevents fluid loss. A wound is a disruption of that surface. Wounds are described as intentional (surgical) or unintentional (traumatic); open (surface broken) or closed (surface intact but deeper tissue bruised, as in a contusion); and acute (recent, healing on schedule) or chronic (stalled, failing to progress through normal healing).
2. The phases of wound healing
Healing is one continuous process in four overlapping phases. Hemostasis: vessels constrict and platelets clot, stopping bleeding and forming a scaffold. Inflammatory phase White blood cells cleaning the wound Full entry →: white blood cells clear bacteria and debris; warmth, redness, and swelling are the normal early cleanup. Proliferative phase Building of new tissue and vessels Full entry →: granulation tissue (new pink, vascular tissue) fills the wound from the base, epithelialization (new skin cells) resurfaces it from the edges, and new collagen adds strength. Maturation (remodeling) phase: over weeks to months, collagen remodeling reorganizes and strengthens the tissue, and the scar matures — regaining only part of the original skin's strength.
3. Intention types, influences, and complications
Primary intention approximates edges for fast healing with a thin scar. Secondary intention leaves the wound open to fill with granulation tissue — slower, with a larger scar. Tertiary (delayed primary) intention leaves a contaminated wound open a while, then closes it later. Healing is shaped by perfusion (blood flow delivering oxygen and nutrients), nutrition (protein, calories, vitamins, minerals), and diabetes (elevated glucose impairs immune function and repair). Complications include hemorrhage (excessive bleeding), infection (increasing redness, warmth, pain, or purulent drainage), dehiscence (wound edges separating), evisceration (internal organs protruding through a dehisced wound — a surgical emergency), and fistula (an abnormal passage between organs or to the skin).
How it works
- Injury disrupts skin; vessels constrict and clot (hemostasis).
- Inflammatory cells clear microbes and debris over the first days.
- New vessels grow and fibroblasts deposit collagen, forming granulation tissue from the base.
- Epithelial cells migrate from the edges to close the surface.
- Collagen is remodeled over weeks to months, strengthening the scar.
- If any step is disrupted — poor perfusion, nutrition, infection, or glucose — the wound stalls or a complication develops.
Common confusions
| Do not confuse | With | Difference |
|---|---|---|
| Granulation tissue | Scar | Granulation tissue is early, vascular repair tissue; scar is later, mature, stronger collagen |
| Dehiscence | Evisceration | Dehiscence is edges separating; evisceration is organs protruding — an emergency |
| Inflammatory phase | Infection | Early warmth and redness are normal healing; infection shows worsening signs plus fever or purulent drainage |
| Fistula | A normally draining wound | A fistula is an abnormal passage; a draining wound has no such tract |
Memory aids
Remember the phases as "Stop, Sweep, Build, Strengthen" — Stop bleeding (hemostasis), Sweep out germs (inflammatory), Build tissue (proliferative), Strengthen/remodel (maturation). For intentions: "P = Pushed together, S = Stay open, T = Third (delayed)."
Quick review
Topic Recap
- Skin integrity is the intact skin barrier; a wound is any disruption of it.
- Wounds are classified by intent, open versus closed, and acute versus chronic.
- Healing runs through hemostasis, inflammatory, proliferative, and maturation phases — with granulation tissue, epithelialization, and collagen remodeling as the key events.
- Primary, secondary, and tertiary intention describe different closure strategies and healing timelines.
- Hemorrhage, infection, dehiscence, evisceration, and fistula are the main complications; perfusion, nutrition, and diabetes are the main influences.
Knowledge Check
- What are the four phases of wound healing, in order?
- What is granulation tissue, and why is it a good sign?
- How does primary intention differ from secondary intention?
- A postoperative wound's edges separate and bowel is visible. What is this, and what is the nurse's priority?
- Name three factors that can delay wound healing.
Answers and Rationales
- Answer: Hemostasis, inflammatory, proliferative, maturation. Why: This is the standard sequence from stopping bleeding through cleaning and building to strengthening.
- Answer: New pink, vascular tissue filling the wound from the base; it signals healthy repair. Why: Its color reflects new vessels delivering oxygen and nutrients.
- Answer: Primary intention approximates edges for fast healing with a thin scar; secondary intention leaves the wound open to fill with granulation tissue, healing more slowly with a larger scar. Why: Edge approximation determines how much new tissue must be built.
- Answer: Evisceration, a surgical emergency; the nurse stays with the person, calls for qualified help, and follows emergency-response and escalation policy. Why: Protruding organs need prompt, appropriate team management.
- Answer: Any three of poor perfusion, poor nutrition, infection, diabetes, or advanced age. Why: Each interferes with oxygen, nutrients, or cellular function needed for repair.
Eli explains
The same idea, in plain words
Explain it like I’m 10
Think of skin as the wall around a house; intact, it keeps weather and pests out. A wound is a hole in that wall, and healing is a repair crew working in shifts: the first crew boards up the hole to stop the rain (hemostasis, stopping bleeding), the second hauls away broken bricks and sweeps (the inflammatory phase clearing germs), the third pours new concrete and bricks (the proliferative phase building granulation tissue and new skin), and a final crew returns for weeks to smooth and reinforce the patch (maturation, remodeling collagen).
The comparison stops being exact because a wall is repaired with inert materials, while living skin must grow its own blood supply and cells — and that growth stalls if blood flow is poor, infection gets in, or the body lacks protein and oxygen. That is why some wounds heal quickly and others stall or fall apart.
Simple Example
A clean surgical incision closed with sutures heals quickly with a thin scar (primary intention), while a large open scrape heals slowly by filling in from the bottom (secondary intention).
Worked example
- Assess: Inspect and palpate (clean technique) the wound and surrounding skin — size, depth, edges, drainage, odor — separating objective findings from interpretation and adding the person's report of pain.
- Diagnose: Cluster cues into nursing diagnoses such as Risk for Impaired Skin Integrity or Risk for Infection.
- Plan: Set measurable outcomes (wound decreases in size without signs of infection) and confirm the ordered wound-care plan.
- Implement: Support healing within scope — positioning to protect the wound, supporting nutrition and glucose control, and following ordered wound care per policy.
- Evaluate, document, communicate, escalate: Reassess and document factually; communicate changes to the team; escalate increasing redness, purulent drainage, fever, separating edges, or visible organs (possible evisceration) for immediate qualified clinical intervention.
Key takeaways
- High yield: Healing follows four overlapping phases: hemostasis, inflammatory, proliferative, maturation.
- High yield: Granulation tissue is new pink, vascular tissue — a key sign of healthy repair.
- High yield: Epithelialization closes from the edges; granulation tissue fills from the base.
- High yield: Primary intention (approximated edges) heals fastest with least scar; secondary intention (open wound) is slower with more scarring.
- High yield: Dehiscence is edges separating; evisceration is organs protruding — an emergency needing immediate response.
- High yield: Perfusion, nutrition, and blood-glucose control most affect healing.
- A fistula is an abnormal tract, not a normal part of healing.
- Scars rarely regain full original strength.
Study tools & related lessonsYou’ll learn to · Key vocabulary · Related
You’ll learn to
- Define skin integrity and classify wounds by intent, degree of opening, and time course.
- Describe the phases of wound healing and the roles of granulation tissue, epithelialization, and collagen remodeling.
- Compare healing by primary, secondary, and tertiary intention.
- Recognize major wound complications and the factors that influence healing.
Key vocabulary
- Skin integrity
- Skin intact and acting as a barrier
- Wound
- A break in skin or tissue
- Intentional / unintentional
- From a planned procedure vs. trauma
- Open / closed
- Surface broken vs. intact with deeper injury
- Acute / chronic
- Recent and healing on schedule vs. stalled
- Hemostasis
- Stopping bleeding via clotting
- Inflammatory phase
- White blood cells cleaning the wound
- Proliferative phase
- Building of new tissue and vessels
- Maturation phase
- Remodeling and strengthening over weeks
- Granulation tissue
- New pink, vascular tissue filling the wound
- Epithelialization
- New skin cells migrating across the wound
- Collagen remodeling
- Reorganization of collagen for strength
- Primary / secondary / tertiary intention
- Closed edges vs. open filling vs. delayed closure
- Hemorrhage
- Excessive bleeding
- Infection
- Microbial invasion of the wound
- Dehiscence
- Partial or full separation of wound edges
- Evisceration
- Organs protruding through an open wound
- Fistula
- Abnormal passage between organs or to skin
- Perfusion
- Blood flow delivering oxygen and nutrients
- Nutrition
- Adequate protein, calories, vitamins, minerals
- Diabetes
- Chronic condition of elevated blood glucose
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