Glossary of Common Wound Care Terms & Definitions
Glossary of Common Wound Care Terms and Definitions
Abrasion An injury caused by rubbing or scraping that results in the loss of the superficial layer of skin or epidermis and or dermis and may involve the mucous membrane
Acid Mantle Body’s natural protection of the outer layer of skin having a pH between 4.0 and 5.5. Made from sebum and sweat. Inhibits the growth of harmful micro-organisms and pollutants
Angiogenesis The process of forming new blood vessels. Occurs in the granulation phase of healing in wound repair
Arterial Blood Flow
Autolysis The process where devitalized or dead tissue is self digested through the action of enzymes
Bacterial Burden or Load The number and virulence of bacteria in a wound
Blanching When pressure is applied to a reddened area ( inflammation) the area under the pressure becomes white
Cellulitis Inflammation or infection of the cells in tissues characterized by redness, pain, heat and edema. Firmess of the tissue may also occur
Champagne Leg (inverted) shape of a leg that looks like an inverted champagne bottle on some legs that have venous disease. The ankle and lower leg are narrow and the upper calf is much wider
Charcot ( Char Coe) Foot a progressive condition affecting the musculoskeletal system of the foot in persons with diabetes. Fractures of the bones in the foot joint dislocation and deformities can occur. The bottom of the foot has the appearance of the hull of a boat due to the arch of the foot collapsing
Collagen A protein that is the principle component of skin, bone, tendon cartilage and other connective tissue. Collagen is needed in wound repair to provide the scaffolding in which the wound fills in when healing with secondary intention.
Contraction Shrinking is size. In wound healing, contraction occurs around the edges of the wound causing the wound size to become smaller. It is important to measure wounds to identify change over time; healing or deterioration.
Debridement The removal of devitalized or dead tissue and foreign material from the wound bed. A wound should be clear of dead or devitalized tissue to support healing and reduce the risk of infection There are many ways to debride. See appendix on Debridement Types.
Dependent opposite of elevated
Dependent Rubor A redness or purple color of a leg when it is in the dependent or lowered position. If the leg blanches on elevation it may be a sign of lower leg ischemia
Dermis the second layer of the skin, under the epidermis. This layer provides blood supply to the nonvascular epidermis, contains the sweat and sebaceous glands, hair follicles, lymph and blood vessels nerves and pigment cells.
Enzymes a protein secreted by cells that acts as a catalyst to induce chemical changes capable of breaking down necrotic tissue
Epidermis Outermost layer of the skin
Epithelialization the process of epithelial cell formation and migration from the wound edges ( including hair follicles) that close over the wound
Erythema redness of the skin. Caused by vasodilatation related to inflammation, infection or injury
Eschar necrotic tissue that forms a black thickened covering over wounds ***
Extravasation leakage of fluid from a blood or lymph vessel into surrounding tissue
Extremities Refers to the arms and legs
Exudate Fluid that comes from wounds. Can be clear ( serous), sanguineous (bloody) or purulent (pus)
Fibrin a protein involved in the blood clotting process. Can also be involved in the granulation phase of healing
Fascia a band or sheet of connective tissue found throughout the body
Fibroblast an important cell in wound healing. ****
Friable Tissue Tissue that bleeds easily. Then this occurs in a chronic wound, infection should be suspected (see infection in a chronic wound appendix)
Granulation Tissue tissue that forms in the wound base which fills in wounds with scar tissue as healing with secondary intention. The tissue is red or pink and has a lumpy appearance like small grapes. This tissue is necessary to fill in wounds so that they can heal
Granulation Phase of Healing
Growth Factors. Specialized proteins that cause cells to migrate to an area as well as make other proteins needed in healing.
Hematoma a localized collection of blood
Hemosiderin Staining amdiscoloration of the lower leg often present in venous disease. It is caused by the release of iron containing pigment as red blood cells disintegrate. Staining can been seen above the ankle and can be an indicator of venous disease
Hollistic An approach to care that supports many relationships and disciplines to support a comprehensive treatment plan
Homeostasis the ability of a system such as the human body, to maintain equibrium when changes occur
Hyperkeratosis The thickening of the skin such as callus formation
Hypodermis. A layer of cells below the dermis that store fat and anchor the skin to the underlying structures
Induration A process where the skin becomes firm, often surrounds a wound as a healing ridge or can be a sign of building bioburden
Inflammatory phase of healing The body’s initial response to injury and lasts between two to 4 days. During this phase the body attempts to close off broken blood vessels and clean up the wound
Intermittent Claudication often identified as a pain in the lower limbs related to poor or com-promised blood supply. The pain usually occurs when wlaking and relieved with rest.
Ischemia a deficiency of blood supply to an area
Laceration a wound that is produced by the tearing or slashing of the skin or injury by an object that causes a tear in the skin
Lipodermatosclerosis A thickening in the tissues of the lower legs which feels hard and woody
Loss of Protective Sensation (LOPS) occurs in persons with diabetes where feeling in the feet is diminished or absent. This places the area at risk for developing wounds
Maceration A softening and whitish look to the intact skin around wounds caused by excessive moisture. Often occurs when exudate is not well managed by dressings
Macrophage A white blood cell that cleans up the wound, ingesting dead cells, micro-organisms, foreign material and other debris.
Malleolus The ankle bone.
Matrix Metalloprotease (MMP’s) An enzyme that breaks wound proteins during wound healing. When found in large numbers in chronic wounds these enzymes can interfere with healing as they will break down good proteins as well as proteins that can negatively impact healing
Maturation Phase of Healing The final phase of wound healing that begins at about day 21 of the healing process and can last up to 2 years. During this phase collagen is restructured and the scar tissue softens and changes colour. The closed wound is only about 80% as strong as the tissue was before injury.
Moist wound healing
Moisture Vapour Permeability (MVP)
Necrotic Tissue dead tissue that usually presents as black or brown and is hard or leathery in texture
Neuropathy Any abnormal degenerative or inflammatory state of the peripheral nervous system. Symptoms include, numbness, tingling or pain in the extremities
Occlusive when referring to a dressing, it closes the wound from the external environment
Offload to reduce or eliminate pressure from an area
Orthotic an orthopaedic applicance such as a form placed in a shoe to support the foot or redistribute pressure areas
Osteomyelitis Inflammation/infection of a bone
Oxygenation providing oxygen to an area or system
Paresthesia A non-painful abnormal sensation such as numbness tingling, burning for a feeling of skin stiffness
Pathogen An organism that can cause disease such as a virus, bacteria or othermicro-organism
Pathology A condition in the body produced by disease
Perfusion The pumping of a liquid into tissues or an organ****** Delayed wound healing can result is there is inadequate oxygen perfusion to the wounded area
Peri-ulcer ( peri-wound) the tissue the surrounds the wound
Phagocytosis The process where cells surround and digest cells debris, micro-organisms necrotic tissue and foreign bodies.
Plantar relating to the sole of the foot
Pressure reduction a device or surface designed to reduce pressure over an area
Pressure Relief A device or surface designed to provide pressure relief over an area
Proliferative Phase of Healing the second phase of healing lasting 3 to 21 days. During this phase the wound fills in with granulation tissue, contraction of the wound occurs, and epithelialization takes place. This phase reduces the area and depth of the wound
Purulent Containing or forming pus
Qualitative Wound Culture A collection of wound fluid to gather a specimen from a single point in a wound to be assessed for type and amount of bacteria in the wound. A culture should be taken before antibiotics are prescribed.
RNAO Best Practice Guidelines. BP guidelines developed by an interprofessional team to support the awareness and deliver of best practice wound care. Guidelines can be located at www.RNAO.org
Rubor Red or purple color often accompanied by swelling, heat and pain
Semi-permeable when pertaining to wound care dressings, it is a property where certain type of molecules are allowed to pass through a membrane while other types of molecules are not. For example oxygen molecules may be allowed to pass but bacteria are not. See Moisture Vapour Permeability (MVP)
Sinus Tract A tunnel extending from a wound creating
Skin Stripping Loss of the epidermis from removal adhesives in dressings or tapes
Slough Dead tissue usually yellow in color and can be stringy in appearance. Can be a source for bacteria and should be removed. Autolytic debridement is often the chosen approach to remove the necrotic tissue. Should not be mistaken for fibrin
Strike-through refers to wound drainage that becomes visible on the outside of dressings
Subkeraotoic Hematoma An area filled with blood under a callus. Often caused by repeated trauma, over a bone, in a person with LOPS
Swab Culture a specimen collection of fluid ( wound ) to determine number and type of bacteria present. A wound should be cleansed prior to a swab being taken and granulation tissue should be swabbed if possible
Systemic Relating to an entire system vs individual parts of the system
Tensile Strength the strength of a closed or healed wound in terms of the greatest stress the tissues can bear without tearing. Tissues over a healed wound are approximately 80% as strong pre-injury
Total Contact Cast a fibreglass device/cast often used to support the healing of diabetic foot ulcers ( neuropathetic ulcers) by redistributing the weight along the entire surface of the foot
Ulcer *** a break in the skin or mucous membrance with the loss of the surface tissue
Validated Tool A that accurately measure what it is intended to measure
Vasoconstriction Constriction or narrowing of the blood vessels
Vasodilation Dilation or widening of blood vessels