CWLS key terms

A disruption of the normal structure and function of skin and underlying tissue, caused by trauma, pressure, shear, friction, moisture, vascular insufficiency, or surgery. It may be acute or chronic depending on healing trajectory.

The coordinated biological process of restoring tissue integrity, classically described in phases: hemostasis, inflammation, proliferation, and remodeling or maturation. Chronic wounds stall, usually in the inflammatory phase, and fail to follow this orderly sequence.

Localized damage to skin and/or underlying soft tissue, usually over a bony prominence or related to a medical device, resulting from sustained pressure or pressure combined with shear. Staged from 1 through 4, plus unstageable and deep tissue injury.

A mechanical force that pulls and stretches tissue in parallel, typically when the skin stays fixed while deeper structures slide. Shear compounds pressure damage and is implicated in deep tissue injury and undermining.

Surface resistance between the skin and a contacting surface, such as dragging a patient across sheets. It abrades the epidermis and, combined with moisture, increases susceptibility to pressure and shear injury.

A validated risk assessment tool scoring six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Lower total scores indicate higher pressure injury risk and guide prevention planning.

Devitalized, thick, leathery black or brown necrotic tissue that adheres to the wound bed or edges. Eschar can obscure underlying structures and must be assessed before staging or debridement decisions.

Soft, moist, yellow, tan, or gray devitalized tissue that loosely adheres to the wound bed. Its presence suggests stalled healing and increased bacterial burden; it is distinct from purulent exudate.

Red or pink, moist, pebbly tissue formed by new capillaries and fibroblasts that fills a healing wound defect. Healthy granulation bleeds readily; pale, friable, or exuberant tissue may signal poor perfusion or other problems.

Migration and proliferation of epidermal cells across a wound surface to restore the barrier, often appearing as a thin pale rim advancing from wound edges or islands. It requires a moist, clean bed to progress.

Removal of devitalized tissue, foreign material, and bioburden from a wound to promote healing. Methods include sharp or surgical, conservative sharp, mechanical, enzymatic, autolytic, and biologic (larval) techniques, selected by tissue type and patient status.

Selective removal of necrotic tissue by the body's own enzymes and macrophages under a moisture-retentive dressing. It is slow, painless, and appropriate for noninfected wounds with adequate perfusion.

The principle that a balanced moist wound environment accelerates epithelialization, reduces pain, and supports autolytic debridement compared with a dry wound bed. It is achieved with appropriate dressings while avoiding maceration of surrounding skin.

Fluid released from a wound composed of serum, fibrin, white cells, and debris. It is described by amount (none, minimal, moderate, heavy) and character (serous, sanguineous, serosanguineous, purulent), guiding dressing selection.

Softening and breakdown of skin or wound edges caused by prolonged moisture exposure. It appears pale, wrinkled, and boggy, and is prevented by moisture barriers, proper dressing fit, and exudate management.

Superficial skin injury from prolonged exposure to moisture such as urine, stool, perspiration, or wound drainage, sometimes with friction. It is not a pressure injury, though the two frequently coexist.

Inflammation of the skin from prolonged contact with urine and/or stool, worsened by occlusive containment products and alkaline stool enzymes. It presents with erythema and erosion in perineal and buttock areas and raises pressure injury risk.

A chronic wound of the lower leg caused by sustained venous hypertension and insufficiency, typically in the gaiter area with edema, hemosiderin staining, and lipodermatosclerosis. Compression therapy is the cornerstone of management when arterial flow is adequate.

A wound caused by inadequate arterial perfusion, often on distal lower extremities, toes, or pressure points, with punched-out margins, pale base, and minimal exudate. It is associated with pain and must not receive compression without adequate perfusion assessment.

Ankle-Brachial Pressure Index: the ratio of ankle systolic pressure to brachial systolic pressure, used to screen for peripheral arterial disease before compression. Values are interpreted with caution in diabetes and renal disease because arteries may be calcified.

Graded external pressure applied to the lower leg to counteract venous hypertension, reduce edema, and promote venous ulcer healing. It requires confirmed adequate arterial perfusion and correct measurement and application technique.

A wound of the foot in a person with diabetes, usually from neuropathy, ischemia, or pressure at high-load sites. It requires offloading, infection control, perfusion assessment, and glycemic management to prevent recurrence and amputation.

Reducing mechanical load on a wound through devices such as total contact casts, removable cast walkers, or felted foam, and through activity modification. It is essential for healing plantar neuropathic and pressure-related foot ulcers.

Impaired nerve function, commonly sensory, motor, and autonomic in diabetes, causing loss of protective sensation, foot deformity, and dry skin. Loss of protective sensation is assessed with a 10 g monofilament and drives ulcer risk.

Blood flow delivery to tissue, determined by arterial supply, capillary function, and venous return. Adequate perfusion is a prerequisite for wound healing and is assessed through pulses, skin signs, and vascular testing.

The number and virulence of microorganisms in a wound, ranging from contamination to colonization, local infection, and spreading infection. Rising burden may present as delayed healing, increased exudate, odor, or friable tissue without classic signs.

A structured community of microorganisms encased in a self-produced matrix that adheres to wound surfaces and resists antibiotics and host defenses. It is suggested by stalled healing and is managed by repeated debridement plus appropriate antimicrobial strategies.

A state of increased bacterial burden that delays healing without the classic signs of infection. It is sometimes called local infection and typically responds to topical antimicrobials and debridement rather than systemic antibiotics.

A dressing containing agents such as silver, iodine, honey, or polyhexamethylene biguanide that reduces wound bioburden. It is indicated for infected or critically colonized wounds and should be used for limited periods with reassessment.

A systematic evaluation of wound location, size, depth, tissue type, exudate, edges, surrounding skin, pain, and signs of infection, repeated over time. Consistent measurement and documentation allow detection of healing or deterioration.

Quantifying wound dimensions using methods such as maximum length by width, planimetry, or digital imaging. Consistency in technique, patient position, and units is essential for meaningful comparison over time.

A wound edge that is detached from the wound base, creating a lip of tissue over a cavity, commonly from shear or infection. It is measured by probing the extent in clock-face positions and documented for tracking.

A narrow channel extending from the wound into adjacent tissue, sometimes called a sinus tract. It is assessed by gentle probing and described by depth and direction, and it influences packing and dressing choices.

A structured process of identifying patient and wound factors that predict delayed healing or new injury, such as immobility, nutrition, perfusion, and incontinence. It drives individualized prevention and treatment planning.

Intake of energy, protein, fluids, and micronutrients needed for tissue repair. Malnutrition, unintentional weight loss, and low albumin or prealbumin are associated with impaired healing and higher pressure injury risk.

Abnormal accumulation of interstitial fluid causing swelling, which increases tissue pressure, impairs perfusion, and stresses wound edges. It is managed by elevation, compression when appropriate, and treatment of the underlying cause.

Systematic evaluation of wound-related pain using self-report scales, timing, quality, and triggers, especially during dressing changes. Unrelieved pain impairs healing and function and should guide analgesia and dressing selection.

Choosing a dressing based on wound tissue, exudate amount, infection status, depth, surrounding skin, pain, and patient goals. Categories include films, hydrocolloids, hydrogels, foams, alginates, and antimicrobial dressings.