Skin Integrity and Wounds

Abnormal reactive hyperemia

An increase in blood flow to an area following a period of ischemia.

Acute wound

A wound that progresses through the normal phases of healing in a timely manner.

Approximated

Edges of a wound that are brought together to promote healing.

Bioburden

The number of bacteria living on a surface that has not been sterilized.

Capillary closing pressure

The pressure at which blood flow to the capillaries is occluded.

Chronic wound

A wound that does not heal in an orderly set of stages.

Clean contaminated wound

A wound that is surgically created under sterile conditions but involves a system that is not sterile.

Clean wound

A wound that is not infected and is created in a sterile environment.

Closed wound

An injury in which the skin is intact.

Colonized wound

A wound with bacteria that are present but not causing an infection.

Contaminated wound

A wound that contains bacteria but has no signs of infection.

Critical closing pressure

The specific pressure that when applied, can lead to tissue necrosis.

Debridement

The removal of dead, damaged, or infected tissue to promote healing.

Dehiscence

The separation of the layers of a surgical wound.

Dermis

The inner layer of skin beneath the epidermis.

Epidermis

The outermost layer of skin.

Eschar

A scab or dry, necrotic tissue that can cover a wound.

Evisceration

The protrusion of internal organs through a wound.

Fistula

An abnormal connection between two body parts.

Friction

The resistance that one surface or object encounters when moving over another.

Full-thickness wound

A wound that extends through the dermis and tissues underneath.

Granulation tissue

New connective tissue and microscopic blood vessels that form on the surface of a wound.

Healing ridge

A sign that indicates normal healing around the edges of a wound.

Hemovac drain

A type of closed drainage system that uses negative pressure to remove fluids.

Incontinence-associated dermatitis (IAD)

Skin damage caused by prolonged exposure to moisture and urine or feces.

Infected wound

A wound that contains a significant number of bacteria and shows signs of infection.

Infection

The invasion of the body by pathogenic organisms.

Inflammatory phase

The initial phase of wound healing characterized by redness, swelling, and heat.

Jackson-Pratt (JP) drain

A closed suction device used to remove fluids from a surgical site.

Maceration

Skin breakdown due to prolonged exposure to moisture.

Maturation phase

The final phase of wound healing where tissue strengthens and matures.

Medical adhesive–related skin injury (MARSI)

Skin damage caused by adhesives used in medical settings.

Medical device–related pressure injury

Skin injury that occurs due to a medical device.

Moisture-associated skin damage (MASD)

Skin damage related to prolonged exposure to moisture.

Open wound

A wound in which the skin is not intact.

Papillary dermis

The uppermost layer of the dermis that contains finger-like projections.

Partial-thickness wound

A wound that extends partially through the dermis.

Penrose drain

A flexible drain used to prevent fluid accumulation.

Pressure injury

Localized damage to the skin or underlying tissue from prolonged pressure.

Primary intention

Wound healing that occurs when the edges of the wound are approximated.

Proliferative phase

The phase of wound healing characterized by tissue formation.

Rete ridges

Projection of the dermis into the epidermis that helps anchor the two layers together.

Sanguineous

Pertaining to blood or having a bloody appearance.

Scar tissue

Fibrous tissue that replaces normal tissue after injury.

Secondary intention

Wound healing that occurs when the edges are not approximated.

Serosanguineous

A type of wound drainage that is pale red and contains blood and serum.

Serous

A clear fluid that resembles serum.

Shear

A force that moves across the parallel plane of an object.

Sinus tract

A channel or tunnel that develops from a wound.

Stage 1 pressure injury

Non-blanchable erythema of intact skin.

Stage 2 pressure injury

Partial-thickness skin loss with exposed dermis.

Stage 3 pressure injury

Full-thickness skin loss that may involve damage to subcutaneous tissue.

Stage 4 pressure injury

Full-thickness skin and tissue loss with exposed bone, tendon, or muscle.

Stratum corneum

The outermost layer of the epidermis.

Stratum germinativum

The deepest layer of the epidermis where new cells are generated.

Subcutaneous layer

The layer of fat and connective tissue beneath the skin.

Superficial wound

A wound that affects only the epidermis.

Suspected deep tissue injury

A localized area of discolored intact skin or blood-filled blister.

Sutures

Stitches used to close a wound.

Tertiary intention

Wound healing that occurs when the wound is intentionally left open.

Tunnel

A channel that forms under the skin at the wound site.

Undermining

Tissue destruction underlying intact skin along the wound margins.

Unstageable pressure injury

A pressure injury where the full extent cannot be confirmed.