Patient Information | Wound Care
Glossary of Terms
Ankle brachial pressure index (ABPI)
A hand-held Doppler ultrasound test used to determine the
presence and degree of peripheral arterial disease in patients
with leg ulcers.
A dressing made from seaweed, which can be composed of galuronic
and mannuronic acid, with the proportions of these determining
the gel-forming properties of the final fiber. Best used
in moderate- to highly-exuding wounds. If the wound bed is
too dry, the alginate will not gel and will adhere to the
wound bed. Some alginates have haemostatic [what does this
Recommended product: Kaltostat (haemostasis only); Algisite
M (moderately heavy exudate)
This occurs during the proliferative phase of healing when
new blood vessels infiltrate the wound and capillaries are
formed by endothelial budding.
Recommended product: Silver sulfadiazine 1%.
Antiseptic impregnated fabric
Recommended product: Povadone iodine fabric dressing (low
exudate); Iodoflex/Iodosorb (heavy exudate).
The term used for the natural, spontaneous process of devitalized
tissue being separated from viable tissue. Together with
proteolytic enzymes, macrophage activity is thought to be
responsible for autolysis.
Collection of fluid under the epithelial layer, fluid may
be clear or pink/red in color.
Carbon dressing impregnated with silver. Activated charcoal
attracts and traps bacteria and odor. Silver kills bacteria.
Both components are effective in wet or dry wounds.
Recommended product: Actisorb silver (charcoal and silver);
Carboflex - odour (charcoal)
Inflammation of the tissues presenting as edema, redness,
pain and heat, often with hardness of the tissues and a
demarcation of the red area.
Involves using instruments/supplies that are not thoroughly
sterilized (completely free of potentially infectious agents).
Boxes of non-sterile gloves and gauze that comes many in
a package are examples of “clean” supplies. These “clean” supplies
are less expensive than “sterile” supplies. Appropriate
use of clean technique can save valuable resources while
not increasing the risk for infection.
A wound that is in the process of healing; usually it has
a bed of healthy granulation tissue (see below) without overlying
exudate or surrounding cellulitis.
Multiplication of micro-organisms without a corresponding
The process of removing dead/unhealthy tissue from a wound.
Delayed primary closure
Initially treating the wound with dressing changes, and then,
usually after 48 hours when the swelling has diminished and
there are no signs of infection, suturing the wound closed.
A wound covered with proteinaceous debris or eschar, but
without surrounding cellulitis.
Acute or chronic inflammation of the skin presenting as redness,
irritation, weeping, crusting, or scaly areas.
Abnormal collection of fluid in the tissue; skin is swollen,
shiny, and tense.
The final stage of wound healing where epidermal cells migrate
across the surface of the wound from the wound margins and
the remaining hair follicles. These cells are pink/white
in color at the wound edges or in islands over the granulation
A redness of the skin caused by congestion of capillaries
in lower layer of the skin, may be due to injury, infection,
inflammation, or hyperaemia.
The tan/grayish material that is found on the surface of
an open wound. It is proteinaceous material that comes from
the wound itself. It is not pus. Therefore, the presence
of exudate on a wound does not mean the wound is infected.
Used as primary of secondary dressing. Semi-permeable films
are made of clear polyurethane coated with an adhesive. They
are conformable and resistant to shear and tear. They prevent
bacterial colonization but do not absorb exudate.
Tissue (skin/subcutaneous tissue, muscle, fascia, bone, or
some combination) with a blood supply that can be moved to
cover a wound. Types of flaps:
Local flap - The tissue is adjacent to the open wound.
Distant flap - The tissue is not adjacent to the open
wound and must be moved to the defect.
c) Free flap - A distant flap
that is completely detached from the body and transferred
to the defect. The artery and vein that supply the flap
must be reconnected to vessels near the wound.
A dressing produced from polyurethane, a soft, open cell
sheet, and may be single-layer or multiple layers. These
are non-adherent, can absorb large amounts of exudates,
and can also be used as secondary dressings. They are also
available impregnated with charcoal and with a waterproof
Recommended product: Hydrocellular - Allevyn; Hydrofoam -
Lyofoam (tracheostomy only); Hydropolymer - Tielle and Tielle
Light: shallow wounds, Cutinova cavity: cavity
Unbroken skin that appears thin, delicate, and likely to
During the proliferative phase of healing, this is the bright
red tissue formed from new capillary loops or "buds" that
are red/deep pink and moist with a "bumpy" appearance.
Blood-stained fluid when serous fluid mixes with blood, red/pink
Purulent - frank pus coming from the wound
indicating infection, yellow/green in color, may be brown/red
if infection is causing wound to bleed.
Normal skin with no breaks and no problems.
A waterproof, occlusive dressing that consists of a mixture
of pectins, gelatins, sodium carboxymethylcellulose, and
elastomers. Hydrocolloids create an environment that encourages
autolysis to debride wounds that are sloughy or necrotic.
As the hydrocolloid mixes with exudate, it produces a yellow
gel with a characteristic odor, which the patient should
be told about.
Recommended product: Granuflex/Duoderm
A highly absorbent wound dressing made up of 100% hydrocolloid
(sodium carboxymethylcellulose). The hydrocolloid is spun
into fibers and needled to make a soft, non-woven fleece-like
dressing that comes as a sheet or ribbon. An alternative
to alginate dressing. The dressing retains a high quantity
of water without releasing it, thereby forming a thick, conformable
Recommended product: Aquacel
A dressing that comes as a sheet or gel. Sheets are used
for shallow or low-exuding wounds. The gels are suitable
for cavities and are effective for desloughing and debriding
wounds. Gels have a high water content, which aids the rehydration
of hard eschar and promotes autolysis in necrotic wounds.
Secondary dressing is required to keep the gel moist and
in situ. To prevent possible maceration a protective barrier
film may be applied on peri-wound areas.
Recommended product: Intrasite
Hydropolymer cavity dressing
Highly absorbent polyurethane dressing consisting of a vapor-permeable
The deposition and multiplication of organisms in tissue
with an associated host reaction.
Bacteria are killed, foreign matter and toxins are removed,
and damaged tissue is walled off. Symptoms are: erythema,
raised temperature, swelling, exudates, and pain.
No obvious breaks in the skin surface.
Larval therapy offers an effective approach to wound debridement
and removing bacteria. Specially bred, sterile maggots that
liquefy dead tissue using enzymes are now available to treat
a range of wounds. The treatment appears to have no adverse
Recommended product: Release
A softening or sogginess of the tissue owing to retention
of excessive moisture that presents as moist, red/white,
Recommended product: Calaband bandage, Icthopast bandage,
Zinc past bandage (Steripaste).
The local death of tissue. This tissue is often black/brown
in color and leathery in texture.
Granulation tissue that grows above the level of the surrounding
skin, preventing epithelial cells from growing across the
Recommended product: Jelonet, Vaseline
Suturing the edges of a wound together to close the wound.
New granulation tissue is formed to replace lost volume.
Epithelial cells grow around the wound, or in islets, to
form a new protective covering.
Provides a logical way to think about how to close an open
wound, regardless of the etiology of that wound. Whether
it is an acute traumatic wound or a wound that resulted from
excising a tumor, the same principles apply. This ladder
is set up so that if the first “rung” doesn’t
work, it will not prevent the next higher “rung” on
the ladder from being able to be attempted. The rungs on
the ladder are (in increasing order of complexity):
1. Secondary closure - Leave the wound open
2. Primary closure
3. Skin grafting
4. Local flaps
5. Distant flaps - Secondary closure - Allow the wound to
heal using dressing changes alone
A thin layer of skin used to cover an open wound. There are
a) Split thickness skin graft - All of the epidermis and
part of the dermis is included. The donor site (where the
skin graft was taken from) will heal by secondary intention.
b) Full-thickness skin graft - All of the epidermis and all
of the dermis is included. Subcutaneous tissue must be removed
from the undersurface of the dermis. The donor site must
be closed primarily or a large open wound will result.
Semi-permeable adhesive film
Recommended product: Tegaderm, Tegaderm IV
The term for the viscous yellow layer that often covers
the wound and is strongly adherent to it. Its presence can
be related to the end of the inflammatory stage of healing
when dead cells have accumulated in the exudate.
Uses instruments/supplies that have been specifically treated
so that there are NO bacterial/viral particles on their surfaces.
Examples of sterilized supplies include instruments that
have been autoclaved (subjected to high temperatures to kill
microorganisms) and gauze/gloves that have been specially
prepared at the factory and are individually packaged. Procedures
done in an operating room are usually done using sterile
Recommended product: Comfeel barrier cream, Orabase paste,
Orahesive powder, Stomahesive paste
The point at which a liquid pathway is formed between the
inner and outer surfaces of a dressing by the penetration
of blood, exudates, or tissue fluid.
The technique used to excise burned tissue, leaving the uninjured
deeper tissue intact. This is done in the operating room
under general anesthesia. A special knife is used to remove
the burned tissue in thin slices. When healthy tissue has
been reached, it bleeds. Dead, burned tissue does not bleed.
Vacuum-assisted closure (VAC)
Vacuum-assisted closure is a system that creates a hypoxic
environment within the wound bed in which aerobic bacteria
cannot survive. The environment forces the microcirculation
to regenerate rapidly and produce large amounts of capillaries.
The negative pressure also removes slough, loose necrotic
material and exudate from the wound bed.
A dressing technique used to treat a dirty wound or to prevent
build-up of exudate on a wound. Apply a saline moistened
(damp, not soaking wet) gauze pad to the wound and then
cover this with a dry gauze pad. The reason it is called
a “wet-to-dry dressing” is that the moist gauze
directly on the wound is allowed to dry out. When this
bottom layer of gauze is removed, it pulls off the exudate,
debris, and non-viable tissue that have become stuck to
the gauze. Studies have shown that wound healing is optimized
by being in a moist environment, so it is best to not let
the dressing completely dry out, making it more of a wet-to-damp
A dressing technique that will keep a clean wound clean,
and promote healing. Apply a saline- moistened (slightly
wetter than for a wet-to-dry dressing) gauze over an open
wound and cover it with a dry gauze pad. The dressing is
removed when it is still wet. If the bottom layer of gauze
dries out, pour saline over the gauze prior to removing it.