Chapter 26: Wound Care Study Guide

Vocabulary flashcards covering wound classification, pressure injury staging, healing phases, surgical complications, drainage types, and wound dressing selections from Chapter 26.

Closed / contusion

A wound where the skin remains intact, caused by blunt trauma; blood leaks into the tissue, producing discoloration.

Abrasion

A superficial open scrape, scratch, or friction injury.

Puncture

A wound where a sharp object pierces the skin, producing a small opening that may extend deeply into tissue.

Penetrating wound

A wound in which an object enters the tissue and remains embedded.

Laceration

Torn or cut tissue characterized by irregular, jagged edges.

Pressure injury

Damage to the skin or underlying tissue caused by pressure and/or shear, most commonly occurring over bony prominences.

Clean wound

A wound category characterized by the absence of infection.

Clean-contaminated wound

A surgical wound resulting from entry into the respiratory, urinary, or gastrointestinal tract without unusual contamination.

Contaminated wound

A traumatic or surgically contaminated wound resulting from a break in asepsis.

Infected wound

A wound with an established infection, potentially exhibiting purulent drainage or tissue necrosis.

Colonized wound

A wound in which microorganisms are present without exhibiting signs of infection; culture results alone do not establish infection.

Stage 1 pressure injury

Intact skin with nonblanchable erythema, which may appear purple, maroon, or differing in color in darker skin tones; must not be massaged.

Stage 2 pressure injury

Partial-thickness skin loss with exposed dermis presenting as a shallow, moist pink/red wound or a serum-filled blister; subcutaneous fat is not visible.

Stage 3 pressure injury

Full-thickness skin loss where subcutaneous fat may be visible, but muscle, tendon, and bone are not exposed; may present with undermining or tunneling.

Stage 4 pressure injury

Full-thickness skin and tissue loss with exposed or directly palpable deep structures including fascia, muscle, tendon, or bone; carries a risk of osteomyelitis.

Unstageable pressure injury

Full-thickness tissue loss obscured by slough or eschar such that wound depth cannot be determined until the base is visible.

Deep tissue pressure injury (DTPI)

Persistent nonblanchable deep red, maroon, or purple discoloration of intact or broken skin, sometimes presenting as a blood-filled blister.

Mucosal membrane pressure injury

Pressure injuries occurring on mucous membranes that are not assigned a numerical stage.

Inflammatory phase

The immediate phase of wound healing characterized by hemostasis to halt bleeding and phagocytosis to clear bacteria and debris; warmth, erythema, swelling, and pain are normal early findings.

Reconstruction / proliferation phase

The healing phase lasting approximately $21\,\text{days}$ where fibroblasts synthesize collagen, capillaries develop, and fragile red/pink granulation tissue fills the wound bed.

Maturation / remodeling phase

The phase of healing continuing for $1\text{--}2\,\text{years}$ in which scar tissue contracts and strengthens as collagen reorganizes; excess collagen deposition can lead to keloid formation.

Granulation tissue

Moist, beefy red or pink, fragile vascular tissue that fills a healing wound from the base upward during the reconstruction phase.

Primary intention

Wound closure involving a clean incision with minimal tissue loss whose edges are approximated using sutures, staples, or glue, typically producing a narrow scar.

Secondary intention

Healing of a wound with separated margins that cannot be approximated, requiring it to remain open to fill with granulation tissue from the base upward.

Tertiary intention (delayed primary closure)

A method of wound closure where the wound is initially left open and subsequently sutured closed after drainage or contamination resolves.

Healing ridge

A palpable ridge along a healing surgical incision expected around postoperative day $5$.

Gas gangrene

An urgent anaerobic infection caused by Clostridia marked by extensive tissue necrosis, foul-smelling exudate, and crepitus.

Dehiscence

The separation of surgical incision edges, sometimes preceded by a sudden increase in serosanguineous drainage.

Evisceration

A surgical emergency where internal abdominal organs protrude through an opened surgical incision.

Hemorrhage

Excessive bright-red external bleeding or internal blood loss causing clinical signs of tachycardia, weak thready pulse, hypotension, and pale, cool, clammy skin.

Sanguineous drainage

Wound exudate that appears bright red and bloody.

Serous drainage

Watery, clear to pale yellow wound exudate.

Serosanguineous drainage

Pink-tinged wound drainage composed of a mixture of serum and red blood cells.

Purulent drainage

Thick, opaque yellow, green, or tan exudate containing pus, indicative of infection.

Seropurulent drainage

Clear or pale serous fluid mixed with purulent pus.

Bilious drainage

Dark greenish exudate containing bile, commonly seen following gallbladder surgery.

Alginate dressing

A seaweed-derived dressing that absorbs moderate-to-heavy wound drainage and can be loosely placed into tunneling wounds.

Foam dressing

An absorbent dressing utilized for heavy exudate, commonly applied to Stage 2 or shallow Stage 3 pressure injuries.

Hydrocolloid dressing

An occlusive or semi-occlusive dressing that maintains a moist environment in clean, minimally draining wounds; generally contraindicated for infected wounds.

Hydrogel dressing

A moisture-donating dressing used on dry wound beds that facilitates autolytic debridement.

Transparent film dressing

A clear barrier dressing used on clean wounds with minimal to no drainage that allows direct visualization of the wound bed.

Negative pressure wound therapy (wound VAC)

A specialized therapy utilizing an airtight sealed dressing connected to controlled suction to evacuate exudate and stimulate granulation tissue formation.

Montgomery straps

Adhesive straps with laced or tied ends that facilitate frequent dressing changes without repeated tape application to fragile skin.