CWCN key terms

A scored risk assessment tool that rates six factors-sensory perception, moisture, activity, mobility, nutrition, and friction/shear-to estimate a patient's likelihood of developing a pressure injury.

A classification system (stages 1 through 4, plus unstageable and deep tissue injury) describing how much tissue destruction exists beneath intact or broken skin at a pressure site.

Thick, leathery dead tissue that may be black, brown, or tan and clings to the wound bed or edges; unless a heel lesion is stable and dry, it usually needs removal before healing can be assessed.

Soft, moist, stringy dead tissue that is yellow, tan, gray, or green and loosely attached to the wound surface; it can hide infection and must be distinguished from purulent drainage.

New, healthy tissue that fills a healing wound, appearing red or pink, moist, and pebbly, with a rich blood supply; its presence signals progress and it bleeds easily when disturbed.

Wound edges that have rolled inward and thickened, forming a lip that blocks new skin cells from migrating across the wound bed; often a sign of stalled healing from pressure or moisture problems.

A pocket of tissue destruction that extends under intact skin at the wound margin, parallel to the surface; it is measured by probing with a cotton swab and described by depth and clock position.

A narrow channel of tissue loss that extends from the wound bed into surrounding tissue in any direction; it must be measured for depth and location so packing reaches the full tract.

Softening, whitening, and wrinkling of skin caused by prolonged moisture exposure, commonly overhydration from wound drainage, perspiration, or incontinence; it weakens skin and enlarges wound size.

Fluid that leaks from a wound, composed of serum, cells, and protein; amount, color, consistency, and odor are assessed because changes can signal infection or excessive moisture.

The Pressure Ulcer Scale for Healing, a validated three-item tool scoring wound surface area, exudate amount, and tissue type to track pressure injury healing over time with a numeric total.

A ratio comparing systolic ankle pressure with brachial artery pressure, measured with Doppler; values indicating poor arterial flow warn against compression therapy and prompt vascular referral.

A laboratory test of wound fluid or tissue to identify organisms and guide antibiotics; proper technique-cleansing first, then sampling viable tissue rather than surface pus-determines whether results are meaningful.

A community of microorganisms attached to a surface and encased in a self-made protective matrix; it resists antibiotics and immune attack, keeps wounds stalled, and requires repeated physical disruption and cleansing.

The presence of multiplying organisms that invade tissue and produce signs such as increasing pain, redness, warmth, swelling, foul odor, purulent drainage, fever, or delayed healing; it requires prompt escalation of care.

The principle that cells migrate and repair faster in a moist, warm, protected environment than in a dry one; it underlies modern dressing selection and reduces scarring and pain.

Removal of dead tissue, debris, and foreign material from a wound by sharp, enzymatic, autolytic, mechanical, or biologic methods so that healing can proceed and infection risk falls.

The body's own process in which moisture and enzymes soften and separate dead tissue under a moisture-retentive dressing; it is slow, selective, and often the safest option for fragile patients.

Removal of dead tissue with a scalpel, curette, or scissors at the bedside or in clinic; the nurse must work within state scope of practice and facility policy and know when to stop.

A wafer of gel-forming material that seals the wound, keeps it moist, and supports autolytic debridement; best for low-exudate partial-thickness wounds, and not for infected or heavily draining ones.

A water-based gel or sheet that donates moisture to a dry wound bed and helps soften slough and eschar; it needs a secondary dressing and is unsuitable for heavily draining wounds.

A dressing made from seaweed fibers that absorbs large amounts of drainage and forms a soft gel; it is used in moderately to heavily exudating wounds and needs a secondary cover.

A padded dressing that wicks and traps moisture away from the wound bed while cushioning it; available with or without adhesive, and useful for moderate exudate and fragile surrounding skin.

Managing wound fluid so the bed stays moist without soaking the surrounding skin; it is achieved by matching dressing absorption and frequency of change to the measured exudate level.

A closed system that applies controlled suction through a foam or gauze filler to remove drainage, reduce edema, and stimulate granulation; it requires adequate perfusion and careful monitoring for complications.

Graduated external pressure applied with wraps, stockings, or pumps to counteract venous hypertension in the legs; it is the cornerstone of venous ulcer treatment and is used only after arterial status is confirmed.

Relieving pressure and shear from a wound site by redistributing weight, using devices such as boots, cushions, or total contact casts so tissue can heal without repeated injury.

A planned timetable for turning and moving a patient, based on risk assessment and tolerance, that limits the duration of pressure on any one body area.

An antimicrobial dressing that releases silver ions into the wound to reduce bacterial burden; it is used short-term for infected or heavily colonized wounds and requires monitoring for staining and sensitivity.

Inflammation of skin exposed to urine or stool, appearing as diffuse redness and erosion in skin folds; it is not a pressure injury and is prevented with gentle cleansing, barrier products, and containment.

A method of checking understanding by asking the patient or caregiver to explain or demonstrate what they learned in their own words; it reveals gaps that a simple "Do you understand?" hides.

A person's ability to obtain, understand, and use health information to make decisions; low literacy calls for plain language, pictures, and limited amounts of information at each session.

The degree to which a patient follows an agreed care plan such as offloading, dressing changes, or diet; it is strengthened by shared goal-setting, simplicity, and addressing barriers rather than assigning blame.

A patient's physical, emotional, and cognitive capacity and motivation to learn at a given moment; pain, sedation, shock, or anxiety mean teaching should be postponed or shortened.

The activities a nurse is legally permitted to perform under state law, licensure, and employer policy; procedures such as sharp debridement or prescribing may require extra authorization or certification.

Infection control practices applied to every patient regardless of diagnosis, including hand hygiene, gloves, gowns, masks, and safe handling of sharps and body fluids.

Cleaning hands with soap and water or alcohol-based rub at specified moments, especially before and after patient or wound contact; it is the single most effective way to prevent transmission.

A complete, timely, and objective record of assessment findings, interventions, products used, patient response, and education given; it supports continuity of care, billing, and legal defense.

The group of professionals-nurses, providers, dietitians, therapists, and podiatrists among others-who coordinate care for a wound patient; clear communication among them improves outcomes and prevents conflicting treatment.