CWCA (ABWM) key terms

A structured evaluation of a wound's location, size, depth, tissue types, drainage, edges, surrounding skin, odor, and pain, repeated over time so that healing progress or deterioration is recognized early.

The underlying cause of a wound, such as pressure, venous insufficiency, arterial disease, diabetes, or trauma; identifying it determines which treatments can work and which will fail.

Recording wound size as length from head to toe, width side to side, and depth in centimeters, using the same method each time so that serial measurements reflect real change.

A narrow channel extending from the wound into surrounding tissue beneath intact skin; it is gently probed with a sterile cotton-tipped applicator and recorded by depth and clock-face direction.

Tissue destruction beneath intact wound edges that creates a lip of skin over a cavity; it is documented by clock-face location and the distance tissue extends under the edge.

The tissue immediately surrounding a wound, inspected for redness, maceration, dryness, scaling, callus, or induration because these findings signal moisture damage, pressure, or spreading infection.

Fluid that leaks from a wound, described by amount, color, consistency, and odor; heavy or purulent drainage can signal infection or poor management and guides dressing choice.

The ratio of ankle to brachial systolic blood pressure measured with a Doppler; a value of 0.90 or below suggests arterial disease and warns against strong compression.

A classification from stage 1 through stage 4 plus unstageable and deep tissue injury that describes the depth of pressure damage; it is never applied to other wound types.

An organized approach to wound bed preparation addressing nonviable Tissue, Infection or inflammation, Moisture imbalance, and nonadvancing Edges, which guides debridement, antimicrobial use, dressing selection, and edge treatment.

Removal of dead tissue, debris, and bacteria from a wound by sharp, enzymatic, autolytic, mechanical, or biologic methods so healing can proceed and underlying tissue can be assessed.

The principle that a wound kept clean, warm, and moist heals faster with less pain and scarring than one allowed to dry out and form a hard scab.

Irritation and breakdown of intact skin from prolonged contact with urine, stool, wound drainage, or sweat, appearing as redness or maceration; care focuses on cleansing, barrier protection, and containing the source.

A sealed system that applies controlled suction through a foam or gauze dressing to remove drainage and promote granulation; it suits selected deep or complex wounds with adequate blood flow.

Bacteria attached to a surface and embedded in a self-made protective matrix that resists antibiotics and immune defenses; it is suspected when a wound stalls despite appropriate care.

A middle state in which bacteria multiply enough to delay healing, causing more drainage, odor, or pain without the classic signs of surrounding infection.

Wound findings such as increasing pain, purulent drainage, foul odor, spreading redness, warmth, swelling, and stalled healing that suggest bacteria have overcome local defenses.

A sample taken to identify bacteria in a wound; tissue from the wound bed is preferred over a surface swab, and culture is indicated when infection is suspected, not routinely.

Infection of bone beneath a wound, suggested by exposed bone, probe-to-bone, or infection that persists despite treatment; it requires medical evaluation, imaging, and prolonged antibiotics.

Using antibiotics and antiseptics only when indicated, with the right agent, dose, and duration, to limit resistance and side effects; routine use on clean healing wounds is discouraged.

A brief validated check of weight change, food intake, and body condition that identifies patients needing a full nutrition assessment and dietitian referral because poor intake impairs healing.

A blood protein often followed as a marker of nutritional status; low levels are linked with poor healing and fluid shifts, but they also reflect inflammation and illness.

Keeping blood glucose within target through medication, food choices, and monitoring; high glucose impairs immune function, collagen formation, and circulation, slowing healing and raising infection risk.

Narrowing of the leg arteries that reduces blood flow, causing claudication, cool shiny skin, hair loss, and poor wound healing; it must be identified before compression or aggressive debridement.

A teaching method in which the learner restates or demonstrates information in their own words, allowing the clinician to confirm understanding and correct gaps before the person goes home.

A person's ability to find, understand, and act on health information; low literacy calls for plain language, pictures, and checking understanding instead of relying on written instructions alone.

The extent to which a person carries out an agreed plan such as offloading, compression, or dressing changes; it improves with shared goals, simple routines, and removal of practical barriers.

Graduated external pressure applied to the leg to counter venous hypertension, improve blood return, and heal venous ulcers; it is essential for venous disease but requires vascular assessment first.

Reducing or removing pressure and shear from a vulnerable area using support surfaces, repositioning, footwear, or casts so tissue can recover and pressure injuries or foot ulcers can heal.

A validated tool scoring sensory perception, moisture, activity, mobility, nutrition, and friction or shear; lower totals mean higher risk and the score drives the prevention plan.

Regularly changing a person's body position, commonly at least every two hours or on an individualized schedule, to relieve pressure over bony prominences; a 30-degree tilt avoids direct pressure on the hip.

A force that pulls and stretches tissue layers in opposite directions, injuring deep tissue and small vessels; it occurs when a person slides down in bed or chair.

A shallow, irregular wound on the lower leg caused by sustained high venous pressure, usually near the inner ankle with swelling and skin staining; compression is central to healing.

A wound caused by insufficient arterial blood flow, often on the toes, foot, or outer ankle, with a pale base, punched-out edges, and severe pain; compression is unsafe until perfusion is checked.

A molded, well-padded cast that spreads weight over the whole foot to offload a plantar diabetic foot ulcer; it is the preferred method when infection and poor blood flow are controlled.

A structured handoff format-Situation, Background, Assessment, Recommendation-used to report a patient's condition briefly and clearly to another clinician or at a care transition.

The activities a clinician may legally and professionally perform based on licensure, education, and workplace policy; anything outside it must be referred or delegated appropriately.

Deliberately organizing assessments, treatments, and follow-up among providers, settings, and family so care is not duplicated or missed, especially when a patient moves between hospital and home.