Pressure Ulcers
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present.
What is a Stage IV
thin watery, pale pink/red
What is Serosanguinous
Red cobble stone appearance
What is granulation tissue
What is the STAR skin tear classification system
you do this on admission,at the first visit of the week and at discharge with all wound care patients and incisions
What is take a picture (and weekly measurements until wound is healed)
Full thickness tissue loss with slough present.
What is Stage III or unstageable (depending on amount of slough)
Pure red exudate.
What is Bloody
White/ grey tissue
What is non-viable tissue
A skin tear where the edges can be realigned in normal anatomical position (without undue stretching) and the skin or flap color is NOT pale, dusky or darkened
What is category 1A
What metal is in an antimicrobial dressing
What is silver.
Full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed.
What is Unstageable
thin or thick opaque, tan/yellow with or without odor
What is Purulent
adherent yellow, tan, brown tissue
What is slough
This category of skin tear would be categorized by edges that cannot be realigned and a skin flap that is NOT pale, dusky or darkened.
What is Category 2A
This would not be indicated in the treatment of a moist, exudative wound
What is a hydrogel
An intact or open/ruptured serum-filled blister.
What is Stage II
thin watery, clear
What is Serous
Adherent soft, black tissue
What is eschar
What we can use to protect our patients arms and legs and decrease the risk of skin tears
What are arm and leg protectors and moisturizing lotion daily
How often do we take wound pictures and wound measurements
What is weekly (at the first visit of the week) or with any observed decline of the wound.
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
What is Stage I
Dry
What is no exudate
Black, hard, firmly adhered
What is eschar
What is 24-48 hours
Wounds with this may present as shiny and stagnant
What is biofilm (AKA colonization)