Wearing away of the skin through some mechanical process (friction or trauma).
Accumulation of pus formed in tissue as a result of infection.
A highly absorptive dressing derived from brown seaweed.
Inflammation of the tissues indicating a local infection; characterized by redness, edema and tenderness.
Main supportive protein of the skin and connective tissue.
Removal of foreign material and devitalized or contaminated tissue from a wound.
Separation of wound edges.
Removal or loss of superficial skin layers.
Outermost layer of the skin.
Diffuse redness of the skin.
Thick, leathery black crust; it is nonviable tissue and is colonized with bacteria.
Linear scratches on the skin.
Wound fluid or drainage.
Rubbing that causes mechanical trauma to the skin.
Tissue destruction extending through the dermis to involve subcutaneous level and possibly muscle, fascia or bone.
Formation of connective tissue and many new capillaries in a full-thickness wound; typically appears as red and cobblestoned.
A category of wound dressings composed of materials, such as gelatin, pectin and carboxymethylcellulose, that provide a moist healing environment and adhere to the skin around the wound.
Water- or glycerin- Based gels, impregnated gauzes or sheet dressings. Hydrogels maintain a moist healing environment and absorb a minimal amount of wound exudate.
Overgrowth of microorganisms in sufficient quantities to overwhelm the body’s defenses.
Softening of tissue by soaking in fluids.
Devitalized tissue; may appear yellow and moist, gray, or dark and leathery.
Wounds that extend through the epidermis and may involve the dermis; these wounds heal by re-epithelialization.
The area immediately around the wound.
Stage 1: An observable pressure-related alteration of intact skin with indicators, as compared to an adjacent or opposite area on the body which may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching).
The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. (NPUAP, 2003)
Stage 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. (NPUAP, 2003)
Stage 3: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. (NPUAP, 2003)
Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint, capsule). Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers. (NPUAP, 2003)
Thick fluid composed of leukocytes, bacteria, and cellular debris.
Sliding of skin over subcutaneous tissues and bones obstructing cutaneous capillaries, which may lead to ischemia.
A course or pathway which can extend in any direction from the wound base; results in dead space with potential for abscess formation.
The epidermis, which is the outermost layer of the skin, is characterized as follows: avascular, varies in thickness (depending on body location), a dry structure which sheds cells and replaces itself every 4 to 6 weeks; approximately the thickness of a piece of plastic wrap.
The dermis is located directly beneath the epidermis and is characterized as follows: provides strength and structural support through a vascular network of connective tissue blood vessels, nerves, hair and nails. Sebaceous glands and sweat glands originate from this layer which is thicker than the epidermis.
Below the dermis is the subcutaneous tissue which is composed of major vessels, lymphatics, fat and connective tissue. This area provides insulation and nutritional support for the skin. Located below the subcutaneous tissue are fascia, muscles, tendons and bone. The thickness of the dermis and subcutaneous layers vary from person to person and on different parts of the body.
Stringy, necrotic tissue; usually yellow.
Removal of epidermis by mechanical means, usually tape.
Patented TRIACT Technology combines:
- diffuse hydrocolloid particles in a cohesive matrix, that help create a moist environment for wound healing;
- petrolatum molecules dispersed throughout the matrix that help prevent adherence to the wound or surrounding skin and reduce pain when wound dressings are changed (to facilitate ease of use, the dressing does not adhere to itself); and
- a specially designed lock net polyethylene mesh formed from continuous filaments that is flexible and conforms to various wounds. The pores within the mesh are engineered to remain open, thus maintaining the diffusion of fluids and gas, and reducing maceration and odor.
Loss of epidermis/dermis or mucous membrane with definite margins.
Types of Ulcers
Pressure Ulcers: Any lesion of the skin caused by unrelieved pressure resulting in damage to underlying tissue. Pressure ulcers usually occur over bony prominences such as the heel, coccyx or trochanter which are in contact with a surface, such as a bed, wheelchair, shoe or cast. When pressure is not relieved, tissue ischemia develops and a pressure ulcer results. Most pressure ulcers are preventable. Therefore, early risk assessment, skin care, attention to patient support surfaces and education are essential.
Venous Ulcers: These are the most common type of lower-leg ulcers in ambulatory people. The underlying cause involves vein damage or an incompetent calf muscle pump action which leads to venous hypertension. As a result, the blood pools in the lower extremities causing edema and leakage of fibrinogen and other blood products into the tissues. Trauma to the area or increased pressure within the tissues results in ulceration.
Arterial Ulcers: Arterial ulcers result from chronic or acute arterial insufficiency to the skin and subcutaneous tissue of the lower extremities. The most common cause is a progressive disease: atherosclerosis. The precipitating event leading to ulceration is usually trauma, such as a bumped toe or tight shoes. Arterial ulcers may occur alone or in combination with diabetes, venous stasis and numerous other conditions. Multidisciplinary management of these patients with early intervention and close monitoring is key to prevention of more serious complications.
Neuropathic Ulcers: Neuropathic ulcers may occur in individuals with diabetes, spinal cord injury, Hansen’s Disease, or other conditions that result in loss of sensation in the legs and feet. Diabetic foot ulcers are most commonly caused by peripheral neuropathy and peripheral vascular disease. Multidisciplinary management of these patients with early intervention and close monitoring is key to prevention of more serious complications.
Skin edges of a wound that have lost supporting tissue under intact skin.
Unstageable Pressure Ulcer
Covered with eschar or slough which prohibits complete assessment of the wound.
A break in the integrity of the skin; an injury to the body which causes a disruption of the normal continuity of the body structures.
Rim or border of a wound.