Wounds and Edema Management – Part 1

These flashcards cover key vocabulary related to Wound and Edema Management to aid in understanding concepts critical for the upcoming exam.

Chronic Wound

Wounds that fail to progress through the normal healing process in a timely manner.

Acute Wound

A disruption of skin integrity that heals through phases in an uncomplicated manner.

Pressure Injury

Localized damage to the skin and/or underlying tissue usually over a bony prominence due to pressure, shear, or friction.

Braden Scale

A tool used to assess a patient’s risk for developing pressure injuries.

Wound Bed Preparation

The process of treating the immediate environment of a wound to promote healing.

Slough

Yellow, green, or brown devitalized tissue, bacteria that accumulates in wound bed.

Hyper-Granulation

Overly active granulated tissue that appears pink/red and protrudes beyond the wound margins.

Eschar

Necrotic tissue that appears black and leathery in a wound (firm)

Tunneling

A wound characteristic where there is a channel or tunnel under the surface of the skin.

Undermining

Similar to tunneling. Tissue destruction underlying intact skin along the wound margins, confined to under wound edges.

Erythema

Redness of the skin around wound, typically associated with inflammation.

Chronic Wound

Wounds that fail to progress through the normal healing process in a timely manner. ~6 weeks

Serosanguineous

Drainage that is a mixture of serum and blood.

Wound Assessment

The evaluation process that includes subjective history, wound characteristics, and surrounding tissue evaluation.

Wound Characteristics

Features of the wound that inform treatment, including size, depth, drainage, and tissue type present.

Support Surfaces

Devices or materials used for pressure redistribution to prevent pressure injuries.

Moisture Balance

The management of moisture in wound care to promote healing and prevent tissue damage.

Debridement

The removal of dead or non-viable tissue from a wound to promote healing.

Comorbidities

Pre-existing conditions that can affect a patient's ability to heal wounds.

Wound Staging

A system for classifying the severity of pressure injuries based on depth and tissue involvement.

Acute vs. Chronic

Refers to the classification of wounds based on healing timeline and progression.

Risk Factors for Pressure Injuries

Factors like inadequate nutrition, incontinence/moisture, pressure, friction, shear, medications.

Medical co-morbidities that cause immobility, diminished sensation, impaired blood flow, poor venous return etc…

• diabetes

• obesity

• neuromuscular impairment

• COPD

• GI issues

• arthritis

• depression

Granulation Tissue

Healthy red or pink tissue that fills an open wound during the healing process.

Biofilm

A community of bacteria encased in a protective layer that adheres to a wound and resists treatment.

Maceration

The softening and breaking down of skin resulting from prolonged exposure to moisture (tissue sensitive to damage)

Induration

Abnormal firmness or hardness of the skin and tissue surrounding a wound.

Primary Intention

Wound closure where the edges are brought together, such as with sutures or staples.

Secondary Intention

Healing that occurs when a wound is left open to heal by the formation of granulation tissue.

Autolytic Debridement

A process where the body's own enzymes and moisture liquefy non-viable tissue.

Mechanical Debridement

The use of external force, such as irrigation or wet-to-dry dressings, to remove debris.

Enzymatic Debridement

The application of chemical enzymes to digest necrotic tissue from a wound.

Sharp Debridement

The use of surgical instruments like scalpels or scissors to remove dead tissue.

Colonization

The presence of bacteria on a wound surface without signs of infection or host immune response.

Infection

The invasion of microorganisms into viable tissue, causing inflammation and clinical symptoms.

Shear

Sliding force - Internal tissue damage caused by gravity pushing the body down while the skin remains stationary.

Friction

Rubbing force - The mechanical force of skin rubbing against a surface, causing superficial damage.

Pressure injury stage 1

non blanchable erythema of intact skin

Pressure injury stage 2

partial thickness skin loss with exposed dermis

pressure injury stage 3

full thickness skin loss

pressure injury stage 4

full thickness skin and tissue loss

pressure injury - unstageable

obscured full-thickness skin and tissue loss. extent of damage cannot be confirmed because it it obscured by slough or eschar

pressure injury - deep tissue pressure injury

persistent non-blanchable deep red, maroon, or purple

Prevention of friction and shear

use proper transfer techniques and equipment

• transfer boards

• slider boards

• move the sheet not the skin

• awareness/protection of high risk areas

• sheepskin to reduce shear

phases of wound healing: hemostasis (1)

• immediate response to stop blood loss (seconds)

  • clot formation follow day fibrinolysis (clot breakdown)

phases of wound healing: inflammation (2)

• 2-6 days post injury

• may observe warmth, erythema, edema, pain

• swelling = fluid with healing

phases of wound healing: proliferation (3)

• wound starts to heal - accumulation of new tissue synthesis

• wound contraction

  • day 6 up to couple of weeks

phases of wound healing: maturation or remodelling (4)

can take up to 2 years - will never achieve greater than 80% tensile strength

callus

A thickened area of skin that forms at the site of repeated friction or pressure, commonly associated with wound healing and protection of underlying tissues.

• can act as foreign object if big enough

excoriation

superficial redness/open area (road rash)

rolled edges

• edges should be attached and blend with wound, but are rolled

• impede wound healing

wound assessment

length and width measurements should be taken at right angles