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Red

pink granulation tissue; protect wound; maintain moist environment

Yellow

moist yellow slough; remove exudate & debris; absorb drainage

Black

black, thick eschar firmly adhered; debride necrotic tissue

Selective Debridement

involves removing only nonviable tissues from a wound; is most often performed by a sharp debridement, enzymatic debridement, & autolytic debridement

Sharp Debridement

requires the use of scalpel, scissors, &/or forceps to selectively remove devitalized tissues, foreign materials or debris from a wound; is most often used for wounds w/large amounts of thick, adherent, necrotic tissue, or in the presence of cellulitis or sepsis; the most expedient form of removing necrotic tissue

Enzymatic Debridement

refers to the topical application of enzymes to the surface of necrotic tissue; can be used on infected & non-infected wounds w/necrotic tissue; this type of debridement may be used in wounds that have not responded to autolytic debridement or in conjunction w/other debridement techniques; process can be slow to establish a clean wound bed & should be discontinued after removal of devitalized tissues in order to avoid damage

Autolytic Debridement

refers to using the body's own mechanisms to remove non-viable tissue; common methods include transparent films, hydrocolloids, hydrogels, & alginates; results in a moist wound environment that permits rehydration of the necrotic tissue & eschar & allows enzymes to digest the non-viable tissue; can be used w/any amount of necrotic tissue & is non-invasive & pain free; requires a longer period of time for overall wound healing to occur; should not be performed on infected wounds

Non-selective Debridement

involves removing both viable & non-viable tissues from a wound; often termed "mechanical" & is most commonly performed by wet-to-dry dressings, wound irrigation, & hydrotherapy (whirlpool)

Wet-to-dry Dressings

refer to the application of a moistened gauze dressing placed in an area of necrotic tissue; the dressing is then allowed to dry completely & is later removed along w/the necrotic tissue that has adhered to the gauze; most often used to debride wounds w/moderate amounts of exudate & necrotic tissue; thist type of debridement should be used sparingly on wounds w/necrotic tissue & viable tissue since granulation tissue will be traumatized in the process; removal of dressing from granulation tissue may cause bleeding & be extremely painful

Wound Irrigation

removes necrotic tissue from the wound bed using pressurized fluid; pulsatile lavage is an example that uses a pressured stream of irrigation solution; most desirable for wounds that are infected or have loose debris; most devices permit varying pressure settings & provide suction for removal of the exudate & debris

Hydrotherapy

most commonly employed using a whirlpool tank w/agitation directed toward a wound that requires debridement; this process results in the softening & loosening of adherent necrotic tissue; side effects include dependent positioning of the LEs, systemic effects such as drop in BP, & maceration of surrounding skin

Abrasion

a wound that occurs from the scraping away of the surface layers of the skin, often as a result of trauma

Contusion

an injury in which the skin is not broken; the injury is characterized by pain, swelling, & discoloration

Hematoma

a swelling or mass of blood localized in an organ, space or tissue, usually caused by a break in a blood vessel

Laceration

a wound or irregular tear of tissues that is often associated w/trauma

Penetrating Wound

a wound that enters into the interior of an organ or cavity

Puncture

a wound that is made by a sharp pointed instrument or object by penetrating through the skin into underlying tissues

Ulcer

a lesion on the surface of the skin or the surface of a mucous membrane, produced by the sloughing of inflammatory, necrotic tissue

Factors Influencing Wound Healing

Age, Illness, Infection, Lifestyle, and Medication

Factors Influencing Wound Healing: Age

a decreased metabolism in older adults tends to decrease the overall rate of wound healing

Factors Influencing Wound Healing: Illness

compromised medical status such as CV disease may significantly delay healing; thsi often results secondary to diminished oxygen & nutrients at the cellular level

Factors Influencing Wound Healing: Infection

an infected wound will impact essential acitvity associated w/wound healing including fibroblast activity, collagen synthesis, & phagocytosis

Factors Influencing Wound Healing: Lifestyle

regular physical activity results in increased circulation that enhances wound healing; choices such as smoking negatively impacts wound healing by limiting the blood's oxygen carrying capacity

Factors Influencing Wound Healing: Medication

there are a variety of pharmacological agents that can negatively impact wound healing; types include steriods, anti-inflammatory drugs, heparin, antineoplastic agents, & oral contraceptives; undesirable physiologic effects include delayed collagen synthesis, reduced blood supply, & decreased tensile strength of connective tissues

Scar Management

immediately after an injury, homeostasis attempts to occur & the acute inflammatory response is triggered; scars can form in an organized manner termed normotrophic scarring or in a disorganized manner such as seen w/hypertrophic or keloid scars

Proliferative/Fibroplastic Phase

includes granulation tissue formation & reepithelialization

Maturation/Remodeling Phase

includes the remodeling of the tissue & scar formation

Serous Exudate

presents as clear, light color w/a thin, watery consistency; considered to be normal in a healthy healing wound

Sanguineous Exudate

presents as red w/a thin, watery consistency; appears to be red due to the presence of blood or may be brown if allowed to dehydrate; this type of exudate may be indicative of new blood vessel growth or the disruption of blood vessels

Serosanguineous Exudate

presents as light red or pink color w/a thin, watery consistency; can be normal in a healthy healing wound

Seropurulent Exudate

presents as opaque, yellow or tan color w/a thin, watery consistency; may be an early warning sign of an impending infection

Purulent Exudate

presents as yellow or green color w/a thick, viscous consistency; generally an indicator of wound infection

Stage I Pressure Ulcer

an observable pressure related alteration of intact skin whose indicators as compared to an adjacent or opposite area on the body may include changes in skin color, skin temp, skin stiffness or sensation

Stage II Pressure Ulcer

a partial-thickness loss that involves the epidermis &/or dermis; the ulcer is superficial & presents clinically as an abrasion, a blister or a shallow crater

Stage III Pressure Ulcer

a full-thickness loss that involves damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; the ulcer presents clinically as a deep crater w/or w/o undermining adjacent tissue

Stage IV Pressure Ulcer

a full-thickness loss w/extensive destruction, tisue necrosis or damge to muscle, bone or supporting structures (e.g., tendon, joint capsule)

Wagner Ulcer Grade 0

no open lesion but may possess pre-ulcerative lesions; healed ulcers; presence of body deformity

Wagner Ulcer Grade 1

superficial ulcer not involving subcutaneous tissue

Wagner Ulcer Grade 2

deep ulcer w/penetration through the subcutaneous tissue; potentially exposing bone, tendon, ligament or joint capsule

Wagner Ulcer Grade 3

deep ulcer w/osteitis, abscess or osteomyelitis

Wagner Ulcer Grade 4

gangrene of digit

Wagner Ulcer Grade 5

gangrene of foot requiring disarticulation

Bony Prominences Associated w/Pressure Injuries: Supine

occiput, spine of scapula, inferior angle of scapula, vertebral spinous processes, medial epicondyle of humerus, posterior iliac crest, sacrum, coccyx, heel

Bony Prominences Associated w/Pressure Injuries: Prone

forehead, anterior portion of acromion process, anterior head of humerus, sternum, ASIS, patella, dorsum of foot

Bony Prominences Associated w/Pressure Injuries: Sidelying

ears, lateral portion of acromion process, lateral head of humerus, lateral epicondyle of humerus, greater trochanter, head of fibula, lateral malleolus, medial malleolus

Bony Prominences Associated w/Pressure Injuries: Sitting (chair)

spine of scapula, vertebral spinous processes, ischial tuberosities

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