Pressure Injury
Involve full-thickness tissue loss but are impossible to accurately stage because of the wound bed being obscured by eschar or excessive slough
Unstageable
What does purulent drainage indicate?
Infection
Contusion
Bruise
What are three things you should do if evisceration occurs?
- put patient in low Fowlers with knees flexed
- put normal saline soaked sterile gauze on exposed organ
- Call HCP
Full-thickness skin and tissue loss, only it involves deep tissue necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone
Stage 4
Pink
Serosanguinous
Scrapes / Scratches
Abrasion
Ways to prevent Wound Dehiscence?
- stool softener / nausea med
If wound dehiscence occurs put patient in supine position & call HCP
Erythema of intact skin that does not blanch
Stage 1
Red / Bloody
Sanguineous
Puncture
Open wound when small sharp item pierces skin
A surgical wound that bleeds profusely
Hemorrhage
Full-thickness loss involving damage to the epidermis, dermis, and subcutaneous tissue but not muscle or bone
Stage 3
Clear / Yellow
Serous
Laceration
Open wound from cutting or tearing
Dehiscence
Occurs when there is a partial or complete separation of the outer layers of a wound.
Partial thickness loss with an exposed dermis
Stage 2
Thick / Yellow / Green
Purulent
Penetrating
Wound from a sharp item that remains in tissue
Evisceration
An abdominal wound reopens & the abdominal contents protrude through the opening