Wounds

Crust

Dry, raised area cover with a crust or scab

Cyst

Encapsulated sac that forms beneath the skin, typically filled with fluid

Macule

Flat, smooth spot on the skin that differs in color from the surrounding area

Freckles, flat moles

Papules

Small, raised bumps on the skin

Similar to a mosquito bite

Can be firm and a variety of colors

Pustule

Bumps on the skin filled with fluid or pus

In acne

Can be red at the base

Ulcer

Break in the skin or open sore

Often involve deep layers of skin

Vesicle

Small, fluid-filled lesions

Blisters like in herpes

Wheal

Swollen, inflamed areas of skin that often itch or burn

Usually from an allergic reaction

Assessing moles for melanoma

A- asymmetry: even or irregular

B- borders: smooth and even or irregular, ragged or blurred

C- color: single shade of brown or black or multicolored (brown, black, red, white, or blue)

D- diameter: Small or larger then 6 mm

E- evolving: stays the same or changing in size, shape or color

Keloids

Overgrown raised scars that develop after a wound has healed

Stage 1

Intact skin with non-blanchable redness over a bony prominence

Stage 2

Partial-thickness loss of skin

Can appear as an open ulcer or fluid-filled blister

Wound bed may appear red or pink

Stage 3

Full-thickness tissue loss, where subcutaneous fat can be seen

Undermining and tunneling may occur

May be slough or eschar

Stage 4

Full-thickness loss with exposed bone, muscle, or tendon

Undermining and tunneling may occur

May be slough or eschar

Unstageable

When slough or eschar is covering the wound so it is undetermined if it is stage 3 or 4

Deep tissue injury

Super deep purple bruise

Plantar wound

Can develop due to neuropathy

Serous drainage

Clear or light yellow

Thin, watery plasma

Sanguineous drainage

Fresh, bright red bleeding

Serosanguineous drainage

Mix of blood and serous fluid

Typically pink color

Purulent drainage

Thick, opaque, yellow/green/tan color

NEVER NORMAL

No excudate

No drainage on bandage and wound base is dry

Scant excudate

Moist wound base, no measurable amount on bandage

Minimal excudate

Less than 25% of the bandage is covered

Moderate excudate

25-75% of the bandage is covered

Large or copious excudate

More than 75% of the bandage is covered

Hemostasis

Occurs immediately after an injury

Blood vessels constrict and platelets gather at the wound site to form a clot

Inflammatory

Occurs immediately after an injury

Blood vessels constrict and platelets gather at the wound site to form a clotOccurs immediately after an injury

Blood vessels constrict and platelets gather at the wound site to form a clot

Proliferative

Body begins to rebuild tissue

Including these processes:

-Epithelialization: regrowth of skin

-Angiogenesis: formation of new blood vessels

-Collagen formation: which provides stregth

-Contraction

Maturation

Where the newly formed tissue gains strength and flexibility

Primary intention

A healing process where wound edges are brought together, allowing for minimal scarring and faster healing

Secondary intention

A healing process where wounds are left open to heal from the inside out, typically resulting in more scarring and a longer healing time.

Tertiary intention

A healing process used for wounds that are intentionally left open for some time to prevent infection, then closed surgically for improved healing and reduced scarring.