Unit 1

Stage 1 Wound

Localized, non-blanchable erythema indicating poor blood flow due to ischemia.

Stage 2 Wound

Partial thickness skin loss with a wound bed that appears intact, resembling a ruptured blister.

Stage 3 Wound

Full thickness skin loss with visible fat, possible undermining, erosion of wound edges, and tunneling.

Stage 4 Wound

Full thickness loss exposing cartilage, tendons, ligaments, muscle, or bones.

Unstageable Wound

Full thickness loss cannot be identified due to slough or eschar covering the wound.

Braden Scale

A risk assessment tool for pressure injuries assessing sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Hemostasis Phase

Initial phase of wound healing where blood vessels constrict and clotting factors activate.

Inflammation Phase

Phase characterized by vasodilation and the arrival of white blood cells to clean the wound.

Proliferation Phase

Phase where new epidermis and granulation tissue form; healthy tissue appears pink or red.

Maturation Phase

Phase of remodeling skin tissue and collagen production to strengthen the wound.

Dehiscence

Reopening of a previously closed wound.

Evisceration

Dehiscence with protrusion of organs; requires saline-moistened gauze over the open area.

Sanguineous Drainage

Fresh bloody drainage from a wound.

Serous Drainage

Clear, thin, watery plasma drainage.

Purulent Drainage

Thick, opaque, yellow/green drainage, never considered normal.

Signs of Infection

Indicators such as fever, redness, inflammation, pain, swelling, and high white blood cell count.

Chain of Infection

The cycle consisting of infectious agents, reservoirs, portals of exit, modes of transmission, portals of entry, and susceptible hosts.

Aseptic Technique

Practices to prevent contamination and infection during procedures.

SMART Goals

A framework for creating objectives that are Specific, Measurable, Achievable, Relevant, and Timely.

Pressure Injury Risk Factors

Contributors to pressure injuries including immobility, age, incontinence, poor nutrition, and smoking.

Primary Intention Healing

Wound healing where edges are sutured or stapled together, healing beneath the closure.

Secondary Intention Healing

Wound healing process occurs when edges cannot be approximated, healing from the inside out.

Tertiary Intention Healing

Wound left open or reopened due to severe swelling or infection.