Wounds 101
deep, painful, sores typically found on lower legs due to lack of blood flow
What is an arterial wound?
Longest measurement
What is always length of wound?
Visible wound bed
What is within scope for all nurses?
autolytic debrider used in slough/necrotic tissue/eschar
What is Iodosorb?
Intact skin w non-blanchable erythema with a change in temperature or firmness
What is a Stage 1 Pressure Injury?
bloody drainage
What is Sanguineous?
Red and pebbly
What is granulation Tissue?
NPWT
What is requiring Additional Education?
The product used for skin tears with a flap or with NPWT as a contact layer.
What is Mepitel or UrgoTul Silver?
Diabetes, smoking, substance use, drinking alcohol
What are risk factors for skin Breakdown?
superficial Loss of Tissue
What is Excoriated?
Once per week
What is taking measurements?
Packing
What requires Additional Education?
Products with Ag (silver) have this property.
What is Antimicrobial? This product also kill Staph and Strep A
erythema, pain, excess wound exudate
What are signs of infection?
Hard blackened area/scab
What is Eschar?
Large or copious
What is exudate?
Non-Visible Wound Bed
What requires Additional Education for LPN's?
The most absorbent silicone border dressing
What is Mepilex Border?
Micro-organisms that collect in sink drains etc after wound care, this is present in all chronic wounds and is not seen w the naked eye
What is Biofilm?
vacant space with no visible end
What is Undermining or tunneling?
Firmness around wound
What is induration?
Debride
What requires Additional Education for all staff?
Used to fill a space w s/s of infection
What is AMD packing Strips or PHMB Packing?
This refers to the separation of previously joined wound edges.
What is dehiscence?