Pressure Injury, Wounds and Management

Flashcards covering vocabulary related to pressure injuries, wound classification, stages of healing, and clinical management strategies including the Braden Scale and VAC therapy.

Pressure Injury

A specific type of tissue injury from unrelieved pressure, usually over bony prominences, that results in ischemia and damage to the underlying tissue.

Ischemia

A restriction in blood supply to tissues, causing a shortage of oxygen that is needed for cellular metabolism to keep tissue alive.

Moisture-Associated Skin Damage (MASD)

Also called perineal dermatitis, diaper rash, or incontinence-associated dermatitis; it is an inflammation of the skin in the perineal area, buttocks, skin folds, and inner thighs caused by chronic moisture exposure.

Maceration

A whitening of the skin that occurs when skin has been exposed to moisture for too long, often observed in moisture-associated skin damage.

Braden Scale

A tool for predicting pressure sore risk consisting of six categories: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction & Shear.

Epidermis

The relatively waterproof outer layer of skin that prevents most bacteria and viruses from entering the body and produces the pigment melanin.

Dermis

The middle layer of skin containing nerve endings for pain and temperature, sweat glands, sebaceous glands that secrete sebum, and hair follicles.

Fat Layer

The innermost layer of skin that helps insulate the body from heat and cold, provides protective padding, and serves as an energy storage area.

Deep Tissue Pressure Injury (DTI)

Purple, deep red, or maroon non-blanchable discoloration of the skin resulting from intense or prolonged pressure.

Stage 1 Pressure Injury

An area of intact skin with non-blanchable redness, usually over a bony prominence.

Stage 2 Pressure Injury

Partial thickness skin loss with exposed dermis, appearing as a superficial break in skin integrity or an intact/ruptured blister.

Stage 3 Pressure Injury

Full-thickness skin and tissue loss where fat may be visible, but bone, tendon, or muscle are NOT exposed; may include undermining or tunneling.

Stage 4 Pressure Injury

Full-thickness skin and tissue loss with cartilage, bone, fascia, muscle, ligaments, or tendon exposed in the wound or easily palpable.

Unstageable Pressure Injury

A pressure injury where the wound bed is covered with eschar or slough, making it impossible to visualize the extent of tissue loss and determine the stage.

Eschar

Necrotic tissue that appears black, tan, or brown in a wound bed.

Slough

Necrotic tissue that is typically yellow, tan, gray, green, or brown in appearance.

Undermining

A wide area of tissue damage extending under the wound edges, generally measured in $cm$ by clock position.

Tunneling

A narrow tract or passage extending in one or multiple directions from a wound, measured in $cm$ by clock position.

Primary Intention Healing

Wound healing where edges are brought together (approximated) with sutures, staples, or adhesive; characterized by minimal tissue loss and low infection risk.

Secondary Intention Healing

Healing that occurs when a wound is left open to fill in naturally with granulation tissue; common for pressure ulcers and burns.

Tertiary Intention Healing (Delayed Primary Closure)

A process where a wound is left open initially to allow drainage or reduce infection risk, and then closed later.

Hemostasis

The first stage of wound healing occurring within minutes of injury, involving vasoconstriction and platelet plug formation to stop bleeding.

Inflammatory Stage

The second stage of wound healing lasting $0$ to $3$ days, focused on controlling bleeding and removing debris.

Proliferative Stage

The third stage of wound healing lasting from day $3$ to day $24$, where lost tissue is replaced with connective or granulation tissue and collagen.

Maturation (Remodeling) Stage

The final stage of wound healing beginning around day $21$ and potentially lasting over $1$ year, involving the strengthening of the collagen scar.

Serous Drainage

Wound exudate that is watery, clear, and slightly yellow.

Sanguineous Drainage

Thick, reddish wound drainage indicating active bleeding (if bright) or older bleeding (if dark).

Serosanguineous Drainage

Pale and pink wound drainage that is a mixture of blood and clear fluid.

Purulent Drainage

Thick drainage resulting from infection that has a foul odor and may be yellow, tan, green, or brown.

Vacuum-Assisted Closure (VAC)

Also known as negative pressure wound therapy, it is a method of decreasing air pressure around a wound to pull edges together and stimulate new tissue growth.

Hydrocolloid Dressings

Specialized wound care products used for Stage $2$ injuries to create a moist healing environment.

Proteolytic Enzymes

Chemical agents used in the treatment of Stage $3$ or Stage $4$ pressure ulcers to assist in wound debridement.