Definition of terms:
Abscess: A collection of localized pus.
Anasarca: Generalized infiltration of fluid into subcutaneous tissue.
Angiogenesis: The process of new blood vessel formation.
Autolysis: The breakdown of devitalized tissue by endogenous enzymes.
Callus: Localized hyperplasia of the horny layer of the epidermis caused by friction or pressure. Not callous though it can be nasty.
Cellular senescence: Loss of a cell's power of division and growth, deterioration with age.
Cellulitis: Inflammation of the subcutaneous tissues, characterized by edema, redness, pain, loss of function, and fever.
Chronic wound: A wound which has shown no progress toward healing within 30 days.
Colonization: Micro-organisms are in the wound but with no evidence of infection.
Contraction: This is a major reason for the decrease in the size of a wound and also interference with subsequent function. Myofibroblasts are present in a wound by the fifth day post injury.
Cross hatch: This deep scratching of eschar allows gels and enzymatic debriders to penetrate more quickly.
CWOCN: Certified wound, ostomy, and continence nurse. All cert WOC nurses have a nursing degree and specialist nurse education; many have advanced degrees. They are clinical nurse specialists and nurse practitioners. Their clinical expertise is very patient focused and recognized by the American Nurses Association.
Dead space: Tissue destruction producing a cavity which may underlie intact surface tissue.
Debridement: The removal of foreign matter or devitalized, injured, infected tissue from a wound until the surrounding healthy tissue is exposed. Types are surgical, sharp, autolytic, enzymatic, and mechanical.
Deep tissue injury: A pressure ulcer that has intact skin and a dusky red (non-blanching) color, but it may also look more bruised and there will be induration or a boggy feel to it.
Dehiscence: Separation of a surgical wound, internal structures may be visible and protrude. Sometimes associated with infection.
Demarcation: Visible defined line of separation between two areas, such as viable and non-viable tissue or the leading edge of cellulitis.
Denuded: Loss of the epidermis. This is often what people mean when they say excoriated.
Epibole: Where the wound edge is rounded and there is no epithelial ridge. If you can’t remember how to say it, revert to rounded edge.
Epithelialization: Regeneration of the epidermis across the wound surface.
Epithelial ridge: Regenerative skin/wound edge. It is a raised, silvery-pink line (even on black skin).
Erythema: Redness of the skin produced by vasodilation, may indicate heat, heat damage, allergy, infection, or pressure.
Eschar: Thick, fibrin-containing necrotic tissue. Devitalized tissue which adheres to wound bed. It makes the depth of the wound non-observable and staging is not possible.
Excoriation: Linear scratches on the skin, not merely epidermal loss.
Extra-cellular matrix: The ground substance formed by the fibroblasts from proteins and sugars (proteoglycans), fibronectin, and collagen. It supports collagen deposition and angiogenesis.
Bloody: bright red, blood-like.
Serosanguinous: thin, watery but pink or pale red.
Serous: thin, watery, straw-colored fluid.
Purulent: thin or thick, opaque tan/yellow.
Foul purulent: thick, opaque yellow/green, offensive odor.
Exudate (amount of):
None: wound dry.
Scant: wound moist but no measurable exudate.
Small: moist wound, exudate well controlled by dressing.
Moderate: wet wound, dressing just containing exudate.
Large: wet wound, dressing unable to control exudate.
Factitious wound: A self-inflicted wound.
Fibroblast: A cell capable of producing collagen and proteoglycans, which form essential components of new connective tissue.
Fluctuant: When palpated, the area moves under the fingers, it is able to be compressed, changes shape as pressed.
Granulation tissue: Beefy red, moist connective tissue (extracellular matrix), containing new collagen, proteoglycans, blood vessels, fibroblast, and inflammatory cells.
H202: Hydrogen peroxide.
Hemosiderosis: The brown discoloration of the skin caused by breakdown of hemoglobin and poor venous return. Occurs in the gater area of people with venous disease.
Hydrophilic: Attracting water.
Hydrophobic: Repelling water.
Hyperkeratosis: Keratinous hyperplasia similar to callus but not necessarily associated with friction or pressure. Occurs at the wound edge and on the legs of obese patients or people with lymphedema.
Incontinence: Involuntary loss of urine. The person may or may not be aware of the urine loss, which may be a small amount or the full contents of the bladder.
Incontinence Associated Dermatitis: A moisture lesion also called diaper rash associated with the use of incontinence and plastic product use wear. The skin dehydrates and no longer is able to act as a barrier, the chemicals in the urine and feces penetrate and the area becomes inflamed, red, painful. There may be superficial fluid-filled blister & multiple eroded patches of denuded skin. It is an irregular lesion and though it may involve a bony prominence, it is not a pressure ulcer. A pressure ulcer would have a round or oval appearance with a better defined edge. Pressure ulcers can occur within a moisture lesion, as can secondary infection with yeast or bacteria.
Induration: The sensation of localized hardening of normally soft area when palpated.
Infection: Invasion of micro-organisms which elicits an the immune response, giving the patient redness, swelling, pain, and temperature. The wound becomes friable, bleeding easily.
Intertrigo: A moisture lesion within a skin fold. The skin is moist and rubs against the opposing surface, it becomes red, sore, and sometimes denuded. Secondary infection with yeast or bacteria is common.
Keloid: A large, bulging, hypertrophic scar caused by abnormal amounts of collagen in the connective tissue.
Keratinocyte: The productive cells of the basal cell layer that produce keratin.
LEAD, LEVD, LEND: Lower extremity Arterial Disease.
Lipodermatosclerosis: The leathery type skin that occurs in the legs of obese patients and those with chronic lymphedema. It is also associated with hyperkeratosis, making the skin look scaly (alligator skin).
Maceration: Disintegration of skin from prolonged exposure to excessive moisture. The peri-wound area is soft and white/pink.
Macrophage: Derived from monocytes that are activated by vessel damage/inflammation, these phagocytic cells play a major role in the orchestration of wound healing. They release numerous biological regulators (growth factors, cytokines, MMP’s and TIMP’s).
MASD: Moisture Associated Skin Damage that may be associated with incontinence, moist skin surfaces, poor exudate management.
Melanin: A natural pigment produced by some cells throughout the body. Within the skin, melanocytes in the basal layer of the epidermis produce this pigment. Epithelialization in naturally dark-skinned people lacks melanin initially and coverage is bright pink.
MMP’s: Matrix metalloproteinases are enzymes that break down proteins.
Moisturizer: Emollients are lipid based and smooth out the skin (silicone, cocoa butter). Humectants attract water and hold onto it (glycerol, hyaluronic acid, and aloe vera.) Occlusives are barriers and seal in the moisture (petrolatum, lanolin, beeswax, and shea butter).
Neoangiogenesis: Formation of new blood vessels in wound healing.
Non-blanchable erythema: A red (erythematous) area that when pressed does not whiten, and on release capillary refill can’t be seen. If the erythematous area does blanch, it is termed blanchable. Non-blanchable erythema indicates damage to the microvascular circulation and is the definition of a stage I pressure injury. This cannot be seen on black skin.
Offloading: Offloading redistributes the weight from one area over a wider area below or beside the sore spot.
Ostomy: Ostomy is an opening from a portion of intestine to the outside. It is usually created surgically by bringing up a piece of bowel, cuffing it back, and stitching it to the skin. Once healed, it should be over 1/2 inch above the skin level, round, a healthy bright red, with no dips or creases if at all possible.
pH: pH is an acidity and alkalinity scale ranging from 0-14, no units are required. The lower case p is the mathematical constant and the H international formulary for hydrogen. A low pH is such as the stomach contents acid around 3, neutral is 7, and saliva is up to 7.6. The pH of skin is around 5.5.
Phases of wound healing:
Inflammatory Phase: Initial response to injury, lasting several days and consisting of brief vasoconstriction phase and subsequent vasodilation. There is edema, swelling, and redness with associated white cell migration.
Proliferative Phase: The second stage of wound healing, lasting 4–20 days. Angiogenesis, granulation, and epithelialization occur in this phase.
Maturation Phase: The third phase of wound healing that may last for several years & remodeling phase occurs. Scar tissue is strengthened to 80% of original strength.
Planimetry: A form of circumferential measurement that gives an accurate area of an irregular two-dimensional plane.
Prurigo nodularis: Thick, hard nodules present on the extensor surfaces of the forearms and legs from neurotic chronic picking.
Pus: Thick fluid indicative of infection. Contains leukocytes, bacteria, and cellular debris.
TIMP’s: Tissue inhibitors of matrix metalloproteinases. Biological regulators.
Urethra: The passage through which urine flows to exit from the bladder.
Urticaria: Raised, itchy rash/hives.