Definitions
Wounds as a result of shearing, friction, or trauma to the skin causing a separation of skin layers.
What is a skin tear?
A skin injury caused by a combination of pressure and shearing, although there are many confounding factors.
What is a pressure ulcer?
New skin that is light pink and shiny.
What is epithelial tissue?
Serous and blood tinged drainage.
Boney, beak-like shaped structure at the distal end of the sacrum.
What is the coccyx?
An open wound that develops on the skin as a result of injury, circulation issues, or pressure.
What is an ulcer?
Ulcers caused by peripheral venous disease, typically in the lower leg. The ulcer may have a moist, granulating wound bed, may be superficial, and may have minimal to copious amounts of serious drainage (unless infected).
What is a venous ulcer?
Pink or red tissue with cobblestone/bumpy appearance, moist, bleeds easily when injured.
What is granulation tissue?
Made up of inflammatory cells and tissue debris, often green, brown, or yellow.
What is purulent drainage?
Exudate (drainage) that covers more than 67% of the dressing surface; dressing is often saturated.
What is a large amount of exudate?
Skin damage caused by moisture rather than pressure; sustained moisture (i.e. incontinence).
What is moisture associated skin damage (MASD)?
Ulcers caused by neuropathic and small blood vessel complications, typically occurring over the plantar (bottom) surface of the foot; ulcers are typically deep with necrotic tissue, moderate amounts of exudate, and callused wound edges.
What is a diabetic ulcer?
Non-viable yellow, tan, grey, green, or brown tissue; often moist, stringy, and mucinous in texture. May be adhered to the wound base or present in clumps.
What is slough?
Sides or walls are present; floor or base of wound is deeper than the edge.
What is not attached?
Redness that does not fade when pressure is applied.
What is non-blanching erythema?
Localized injury to the skin and/or underlying tissue, typically over a bony prominence.
What is a pressure ulcer?
What are the different types of ulcers?
Unavoidable pressure, Avoidable pressure, Diabetic, Arterial, Venous
Dead or devitalized tissue that is hard or soft in texture, usually black, brown, or tan in color; may appear scab like.
What is eschar?
A passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound.
What is tunneling?
Tissue loss with exposed bone, tendon, or muscle.
What is a stage IV pressure injury?
What is the difference between trauma (abrasion) and a cut (laceration)?
An abrasion is caused friction against a rough surface (i.e. road rash) whereas a laceration is a torn or jagged wound (tear) caused by blunt trauma (fall) and/or a sharp/dull object.
What are the different stages of a pressure ulcer?
Stave I, II, III, IV
Bonus points: unstageable (covered by slough, etc.) and true depth is unknown.
White/yellow/pale stringy tissue that forms as a wound is healing; part of the inflammatory/healing process.
What is fibrinous tissue?
The destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is large at the base than at the skin surface.
What is undermining?
Purple or maroon localized area of discolored skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be mushy, boggy, firm, warmer, or cooler compared to other tissue. HOWEVER, extent of injury is typically unkown.
What is a deep tissue injury (DTI)?