Skin Integrity and Wound Care

Stage 1 Pressure Injury

Intact skin with a localized area of nonblanchable erythema (redness) that does not turn white when pressure is applied.

Stage 2 Pressure Injury

Partial-thickness skin loss with exposed dermis; the wound bed is viable, pink or red, and moist, and may also appear as an intact or ruptured serum-filled blister.

Stage 3 Pressure Injury

Full-thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges (epibole) are often present.

Stage 4 Pressure Injury

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.

Unstageable Pressure Injury

Full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because it is obscured by slough or eschar.

Deep-Tissue Pressure Injury

Intact or nonintact skin with a localized area of persistent nonblanchable deep red, maroon, or purple discoloration, or a blood-filled blister.

Hemostasis

The initial phase of healing where injured blood vessels constrict and platelets gather to stop bleeding and form a fibrin matrix for cellular repair.

Inflammatory Stage

A phase lasting 3 to 6 days focused on controlling bleeding and cleaning the wound bed as macrophages and neutrophils move into the damaged tissue.

Proliferative Stage

A phase lasting from 3 to 24 days where the wound is filled with granulation tissue, wound contraction occurs, and the surface is repaired through epithelialization.

Maturation (Remodeling) Stage

The final phase of healing, which can last for more than a year, where the collagen scar reorganizes and continues to gain strength.

Abrasion

A superficial wound with little bleeding, considered a partial-thickness injury that often appears "weepy".

Approximated

Wound edges that are closed or pulled together, as seen in a clean surgical incision.

Blanchable Hyperemia

Redness that turns lighter in color when pressure is applied, indicating a transient attempt to overcome an ischemic episode.

Debridement

The removal of nonviable, necrotic tissue to provide a clean base for wound healing and eliminate sources of infection.

Dehiscence

The partial or total separation of wound layers, commonly occurring before collagen formation.

Epithelialization

The process where new epithelial cells migrate across a moist wound bed to resurface the injury.

Eschar

Black, brown, tan, or necrotic tissue that must be removed before a wound can heal.

Evisceration

A medical emergency involving the total separation of wound layers and the protrusion of visceral organs through the opening.

Exudate

Fluid, such as wound drainage, that accumulates during the inflammatory and proliferative phases of healing.

Friction

The mechanical force exerted when skin is dragged across a surface, affecting the epidermis and often appearing as a "sheet burn".

Granulation Tissue

Red, moist tissue composed of new blood vessels, indicating that a wound is progressing toward healing.

Hemostasis

A series of physiological events, including blood vessel constriction and platelet gathering, designed to stop bleeding and seal an injury.

Induration

Hardening of the tissue around a wound, often accompanied by edema and indicating potential wound deterioration.

Laceration

A torn, jagged wound caused by trauma, which may bleed profusely depending on its depth and location.

Primary Intention

A healing process for wounds with little tissue loss where edges are approximated; it heals quickly with minimal scarring.

Purulent

Thick, yellow, green, tan, or brown drainage that is a sign of infection. Puss

Sanguineous

Bright red drainage that indicates active bleeding.

Secondary Intention

A healing process for wounds involving tissue loss where edges are left open; it heals by granulation and carries a higher risk of infection.

Serosanguineous

Pale, pink, watery drainage consisting of a mixture of clear and red fluid.

Serous

Clear, watery plasma drainage.

Shear

The sliding movement of skin and subcutaneous tissue while the underlying muscle and bone remain stationary, causing deep tissue damage.

Slough

Soft yellow or white stringy substance attached to the wound bed that must be removed for the wound to heal.

Tissue Ischemia

A decrease or absence of blood flow to tissues, which can lead to tissue death if pressure is prolonged.

MDRPI

pressure injury from a medical device