Skin Lesions and Wounds

Ulcer

Deep loss of skin surface that extends to dermis and frequently bleeds and scars; varies in size

Nodule

Elevated solid mass, deep and firm, 1-2cm

Macule

Flat, non palpable change in skin color, smaller than 1 cm

Evisceration

Protrusion of visceral organs through a wound opening

Tumor

Solid mass that extends deep through subcutaneous tissue; larger than 1-2 cm

Purulent

thick, yellow, green, tan, or brown

Atrophy

Thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent; varies in size

Serous

clear, watery plasma

Stage 2

Partial-thickness skin loss with exposed dermis

Sanguineous

Bright red; indicates active bleeding

Vesicle

Circumscribed elevation of skin filled with serous fluid, smaller than 1 cm

Pustule

Circumscribed elevation of skin similar to vesicle but filled with pus; varies in size

Stage 4

Full-thickness skin and tissue loss

Stage 3

Full-thickness skin loss

Wheal

Irregularly shaped, elevated area or superficial localized edema; varies in size

Stage 1

Nonblanchable erythema of intact skin

Unstageable

Obscured full-thickness skin and tissue loss

Serosanguineous

Pale, pink, watery; mixture of clear and red fluid

Papule

Palpable, circumscribed, solid elevation in skin, smaller than 1 cm

Deep-Tissue Pressure Injury

Persistent nonblanchable deep red, maroon, or purple discoloration

Dehiscence

The partial or total separation of wound layers

Slough or eschar is

Unstageable

Secondary Intention

Wound edges not approximated Surgical wounds that have tissue loss or granulation Wound heals by granulation tissue formation, wound contraction, and epithelialization

Chronic wound

Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity

Primary Intention

Wound that is closed Surgical incision, wound that is sutured or stapled Healing occurs by epithelialization; heals quickly with minimal scar formation.

Tertiary Intention

Wound that is left open for several days; then wound edges are approximated Wounds that are contaminated and require observation for signs of inflammation Closure of wound is delayed until risk of infection is resolved

Acute wound

Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity