Wound Basics
It is the largest organ of the body, protecting from infection, regulating temperature, and sensing pain and pressure.
What is the skin?
These two forces cause pressure injuries.
What are pressure and shear?
This is the first phase of wound healing, involving clotting and vasoconstriction.
What is hemostasis?
This is a scoring tool that evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear to predict risk for pressure injuries.
What is the Braden Scale?
This is the recommended interval for turning or repositioning a patient who cannot move independently.
What is every 2 hours?
It is a disruption in normal integrity and function of skin and underlying tissues.
What is a wound?
These anatomical sites most commonly affect pressure injuries.
What are bony prominences?
This is the phase during which macrophages and neutrophils remove debris and bacteria.
What is the inflammatory phase?
This term describes the skin immediately surrounding a wound, which must be assessed for redness, swelling, or breakdown.
What is periwound skin?
This item is used under bony prominences to reduce pressure and prevent tissue injury.
What is a pressure-relieving device (e.g., special mattress or cushion)?
It is a wound created intentionally under sterile conditions during surgery.
What is a surgical wound?
This describes a partial-thickness skin loss with exposed dermis, appearing as a blister or shallow open injury.
What is Stage 2 pressure injury?
This phase occurs when granulation tissue forms and the wound contracts.
What is the proliferative phase?
This describes drainage that is thin, clear, and watery.
What is serous drainage?
This is a type of dressing that keeps the wound moist and promotes autolytic debridement.
What is a hydrocolloid dressing?
These are three processes that stimulate wound healing, depending on tissue loss and closure.
What are primary intention, secondary intention, and tertiary intention?
This is a full-thickness skin and tissue loss with exposed bone, tendon, or muscle.
What is Stage 4 pressure injury?
This is one of the systemic factors that can delay wound healing.
What is poor nutrition, infection, advanced age, obesity, or chronic disease?
This describes thick, cloudy, yellow, green, or brown drainage that often signals infection.
What is purulent drainage?
This s a macronutrient essential for collagen formation and tissue repair.
What is protein?
This is an acronym used to assess wound healing and stands for Redness, Edema, Ecchymosis, Drainage, and Approximation.
What is REEDA?
This injury occurs when slough or eschar obscures the wound bed so depth cannot be determined.
What is an unstageable pressure injury?
This is the final phase of wound healing, in which collagen is remodeled and scar tissue strengthens.
What is the maturation or remodeling phase?
This is the systematic process nurses use to record a wound’s characteristics to guide care and track healing.
What is wound assessment?
This is a method of removing necrotic tissue using the body’s own enzymes and moisture.
What is autolytic debridement?