Skin Integrity
This is achieved when all layers of the skin are intact.
What is skin integrity?
A contusion or bruise is known as this type of wound.
What is a closed wound?
When the skin heals itself as the wound was only affecting the epidermis and dermis.
What is regenerative/epithelial healing?
Bloody drainage is known as this term.
What is Sanguineous?
These are two assessment tools for assessing risk of pressure injury.
What is/are the Braden scale and the Norton scale?
This age range of patients have drier skin due to diminished activity of the sebaceous and sweat glands. This can threaten skin integrity.
Who are older adults.
A localized collection of pus, will be opened and drained so healing can occur.
What is abscess?
This wound healing can happen when a wound is well approximated. Ex clean surgical incision.
What is primary intention healing?
Thick, often malodorous drainage that is associated with infected wounds.
What is purulent drainage/exudate?
Lengthxwidth, exudate amount, and tissue type are all data collected to complete this tool.
What is PUSH or pressure ulcer healing chart?
Limited activity or mobility can cause this of the skin.
What is injury?
What is an abrasion?
This wound healing is also known as delayed primary closure and happens when a wound is allowed to fill with granulation tissue and is then brought together.
Soft, stringy, pale yellow or gray tissue noted in a wound bed.
What is slough?
This pressure injury stage is known for a discoloration that remains >30 minutes after the nurse takes action to relieve the pressure.
What is stage 1?
Adequate this and this are key to maintaining healthy skin and when healing wounds.
What are nutrition and hydration?
This term can be used to describe a wound that is expected to have a short duration and anticipated spontaneous healing.
What is an acute wound?
This type of dressing is a mechanical debridement method characterized by a moistened gauze packed into a wound.
What is wet-to-damp dressing?
A pressure injury becomes unstageable when it is covered by what term.
What is eschar?
This stage of pressure injury is known for having full-thickness skin loss.
What is stage 4?
Maceration is a risk when this is noted during a skin assessment.
What is moisture?
This type of wound is caused by tissue ischemia and injury.
What is pressure injury?
This technique is commonly used by nurses to cleanse, hydrate and assist with visual inspection of a wound.
What is irrigation (lavage)?
Pebble-like red moist tissue in a wound bed is known by this term.
What is granulation tissue?
Name 3 risk factors for developing a pressure injury.
What are: decreased sensory perception, presence of moisture, immobility, poor nutrition, exposure to friction and shear?