cna wounds

Wound

a break in the skin or mucous membrane

Mucous membrane

the moist inner lining of some organs and body cavities

Partial-thickness

the dermis and epidermis are broken

Full-thickness

the dermis, epidermis, and subcutaneous tissues are broken

Contusion

a closed wound injury that occurs when blood vessels are damaged. Causes localized bleeding under the skin. Commonly called a bruise. Caused by a blow to the body

Abrasion

A partial-thickness wound caused by the scraping away or rubbing of the skin

Excoriation

loss of epidermis caused by scratching or when skin rubs against skin, clothing, etc

Incision

A cut produced surgically by a sharp instrument. Creates and opening into an organ or body space

Laceration

An open wound with torn tissues and jagged edges

Ulcer

A shallow or deep crater-like sore of the skin or mucous membrane

Skin tear

A break or rip in the outer layers of the skin. The epidermis separates from the underlying tissue. When the skin is peeled back or completely gone

Epidermis

The top layer of the skin

Falls or bumping

Common causes of skin tear

Circulatory ulcers (vascular ulcers)

Open sores on the lower legs or feet caused by decreased blood flow through arteries and veins

Gangrene

A condition in which there is death of tissue

Hemorrhage

Excessive loss of blood in a short time

Dehiscence

The separation of the wound layers

Evisceration

The separation of the wound along with the protrusion of abdominal organs. Surgical emergency

Serous drainage

Clear, watery fluid

Sanguineous drainage

Bloody drainage

Serosanguineous drainage

Thin, watery drainage that is blood-tinged

Purulent drainage

Thick green, yellow, brown drainage

Penrose

Rubber tube that opens and drains into a dressing. Open drain; microbes can enter

Hemovac

Tube that removes blood and fluid from a wound after surgery. Inserted under the skin and connected to a collection container with suction. Closed; microbes can’t enter

Jackson-Pratt (JP)

Flexible tube with a bulb that gently removes fluid from a wound after surgery

Bony prominence (pressure point)

An area where the bone sticks out or projects from the flat surface of the body

Intact skin

Normal skin and skin layers without damage or breaks

Ulcer

Shallow or deep crater-like sore of the skin or mucous membrane

Bedfast

Confined to a bed

Chairfast

Confined to a chair

Edema

Swelling of body tissues with water

Pressure Injury Stage 1

Non-blanchable erythema of intact skin

Erythema

Redness of this skin or mucous membrane

Blanch

To become white when pressure is applied to skin; blood is pressed away

Pressure Injury Stage 2

Partial-thickness skin loss with exposed dermis. Wound is pink or red and moist. May be broken or intact blister

Pressure Injury Stage 3

Full-thickness skin loss. Skin is gone, fat can be seen in the ulcer, slough & eschar may be present

Slough

Dead tissue that is shed from the skin. Light colored, soft, moist.

Eschar

Thick, leathery dead tissue that may be loose or adhered to skin

Pressure Injury Stage 4

Full-thickness skin and tissue loss, skin is gone, muscle, tendon, ligament, cartilage, or bone os exposed

Unstageable

Obscure full-thickness skin and tissue loss, the extent of damage can’t be seen because of slough & eschar

Deep tissue pressure injury (DTPI)

Persistent, non-blanchable deep red, maroon, or purple discoloration

Kennedy Terminal ulcer

Occurs over a bony prominence 2-3 days before death, rapidly progresses

Elbow and heel protectors

Made of foam padding, pressure relieving gel, sheepskin. Promotes comfort and reduces friction & shearing

Alternating pressure mattress

Bed rotates side to side to prevent skin breakdown & pressure injuries

Sepsis

Severe and often fatal reaction to an infection in the body

Osteomyelitis

Inflammation of the bone and bone marrow