CWCA (Other exams) key terms

The body's first response to injury, in which blood vessels narrow and platelets form a clot to stop bleeding. The clot creates a scaffold that later healing stages build on.

The healing stage lasting roughly one to four days after injury, when blood vessels widen and white blood cells clear bacteria and debris. Redness, warmth, swelling, and pain are expected findings.

The healing stage, usually lasting several weeks, in which new tissue fills the wound. Fibroblasts build collagen, new capillaries form, and epithelial cells migrate to resurface the wound.

The final healing stage, lasting months to years, when collagen is reorganized and reabsorbed. The scar gains strength but stays less elastic, reaching only about 80 percent of original tissue strength.

New healthy tissue that fills an open wound, appearing red or pink, moist, and pebbled. It contains new capillaries, fibroblasts, and collagen, and its presence signals healing progress.

The process in which epithelial cells migrate from wound edges and intact hair follicles across the wound surface, forming a thin new skin layer that seals the wound.

Healing of a clean wound whose edges are closely brought together, such as a surgical incision. Tissue loss is minimal, so the wound closes directly with limited scarring.

Healing of a wound with significant tissue loss whose edges cannot be brought together. The wound fills with granulation tissue from the base upward and contracts, leaving a larger scar.

Fluid that leaks from a wound, made up of serum, white blood cells, and proteins. Its amount, color, odor, and consistency are assessed to judge healing and possible infection.

Soft, moist, yellow, tan, or gray dead tissue that is loosely attached to the wound bed. It can look like cottage cheese and may hide healthy tissue beneath it.

Dry, dark brown or black dead tissue that is firmly attached to the wound. It is not always removed, such as on a stable heel pressure injury when blood flow is adequate.

Tissue damage that extends beneath intact skin at the wound edges, creating a lip or pocket. It is probed with a cotton-tipped applicator and recorded by clock position and depth.

A narrow channel that extends from the wound into surrounding tissue. Its depth and direction are measured with a sterile probe and documented so packing reaches the entire tract.

Systematic recording of wound length, width, and depth, usually in centimeters, using the same method and body orientation each time so that healing trends can be compared.

A validated tool that scores six risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction or shear. Lower total scores indicate higher risk of developing a pressure injury.

The ratio of ankle systolic blood pressure to brachial systolic blood pressure, measured with a Doppler. It screens for peripheral arterial disease and helps determine whether compression therapy is safe.

The skin immediately surrounding a wound. It is checked for redness, maceration, swelling, hardness, and breakdown, which can point to infection, moisture damage, or pressure.

Localized damage to skin and underlying tissue caused by sustained pressure, often with shear, over bony areas. Staging describes depth, from non-blanchable redness to full-thickness tissue loss.

Skin irritation and breakdown caused by prolonged contact with urine, stool, perspiration, or wound drainage. It is not a pressure injury and is managed by controlling moisture and protecting skin.

A thin, sticky community of bacteria attached to a wound surface and protected by a matrix. It resists antibiotics and body defenses and often requires repeated cleansing and debridement.

A state in which bacteria multiply in a wound without classic infection signs but delay healing. Clues include increased exudate, stalled healing, and new pain or discoloration.

The series of steps needed for infection to spread: infectious agent, reservoir, exit route, mode of transmission, entry route, and susceptible host. Breaking any one link prevents transmission.

Infection control practices used for every patient regardless of diagnosis. They include hand hygiene, gloves, gowns, masks, eye protection as needed, and safe handling of sharps and soiled items.

Cleaning hands with soap and water or an alcohol-based rub at key moments, such as before and after patient contact and after glove removal, to prevent passing organisms between people.

A laboratory test of wound fluid or tissue that identifies organisms and guides antibiotic choice. Tissue biopsy or fluid aspiration is more reliable than a superficial swab.

Removal of dead tissue, debris, and foreign material from a wound to support healing and lower infection risk. Methods include sharp, surgical, enzymatic, autolytic, and mechanical techniques.

Using the body's own enzymes and moisture to soften and separate dead tissue, usually by covering the wound with a moisture-retentive dressing. It is slow and selective but generally painless.

The principle that a wound kept moist under an appropriate dressing heals faster, with less pain and scarring, than a wound allowed to dry out and form a hard scab.

Reducing or removing pressure and shear from a wound or high-risk area using devices such as special footwear, cushions, or scheduled repositioning, so tissue can heal and new damage is avoided.

Controlled external pressure applied to the leg with bandages or stockings to improve venous return and reduce swelling in venous leg ulcers. Arterial blood flow must be checked first.

A sealed dressing attached to a pump that applies controlled suction to a wound, removing exudate and drawing wound edges together while encouraging granulation. Adequate blood flow and infection control are required.

A structured approach to preparing a wound bed: Tissue management, Infection or inflammation control, Moisture balance, and Edge advancement. It guides assessment and selection of wound care interventions.

Regularly changing a person's body position on a planned schedule to relieve pressure over bony prominences and help prevent pressure injuries. Frequency is based on tissue tolerance and the support surface.

A person's ability to find, understand, and use basic health information to make care decisions. Low health literacy calls for plain language, pictures, and checking understanding.

A teaching method in which the patient or caregiver explains or shows the skill back to the clinician. It confirms real understanding instead of relying on a yes answer.

The extent to which a patient follows the agreed care plan, such as offloading, compression, or dressing changes. It improves when regimens are simple and barriers and beliefs are addressed.

A complete, accurate, and timely record of assessment findings, interventions, and patient responses in the medical record. It supports communication, continuity of care, and legal defense.

A patient's voluntary agreement to a procedure after receiving an explanation of its purpose, risks, benefits, and alternatives. A qualified clinician obtains it according to policy and law.

The duties and activities a clinician is legally allowed to perform based on licensure, education, and employer policy. Practitioners must recognize when to refer or escalate care.

Assigning another qualified person to perform a task while the delegating clinician keeps accountability for the decision and outcome. It requires matching the task to the person's training and legal limits.