Wound Bed Identification & Drainage type
Beefy/bumpy red or pink tissue, light pink drainage
What is granulation tissue with serosanguineous drainage
Partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present
What is a Stage 2
An irregular shaped wound that is typically found on the lateral leg, is moist, shallow, and tends to produce moderate to large amounts of drainage. Wound is often triggered by edema or trauma to the leg.
What is a venous stasis ulcer
This once popular wound dressing is no longer recommended for wound care as it can cause further trauma to the wound bed
What is a wet-to-dry dressing
Measurements are taken in this orientation
What is.....
Length is Head to toe & Width is shoulder to shoulder (L to R)
Depth is straight into the wound bed
Yellow, slimy tissue with creamy, odorous, yellow/tan drainage
What is slough with purulent drainage
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
What is a Stage 1
A wound that is caused by unrelieved pressure over a bony prominence.
What is a pressure injury
This dressing is derived from seaweed and helps maintain a moist environment and promotes granulation tissue
What is calcium alginate
When packing a wound, you should avoid doing this with the packing material
Hard black tissue
What is eschar
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur.
*BONUS: If the pressure injury type above has slough or eschar that obscures the extent of tissue loss it is classified as this.
What is a Stage 4
Bonus: What is an unstageable PI
A wound that is most commonly seen over the plantar aspect of the foot. Calluses / hyperkeratotic tissue are often observed on the periwound. The wound is a high risk for infection.
What is a Diabetic Foot Ulcer
This element found in some dressing materials provides an antimicrobial or antibacterial component
What is silver
The guidelines and frequency of measuring packing material include...
What is measuring what you take out and what you put in, include a tail at every visit
smooth, pink tissue with thin clear drainage
What is non-granulating tissue with serous drainage
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister.
What is a deep tissue pressure injury (DTPI)
This wound typically presents on the lower leg as small, dry, and round with regular borders. Often contains necrotic tissue. Patient may experience pain with leg elevation. The cause of these wounds is due to poor perfusion.
What is an arterial ulcer
This dressing material helps provide a non-stick layer for the dressing
What is a contact layer (adaptic, xeroform)
This step should be done prior to taking measurements of the wound
Clean the wound
Light pink, shiny pearl like appearance on closed wound
what is epithelialized tissue
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.
What is a stage 3
This wound type is often well-approximated and closed with sutures, staples, or glue. It can vary in size and be anywhere on the body.
BONUS: When the wound type above opens up unintentionally, this complication is called...
What is a surgical incision
BONUS: What is dehiscence
This dressing is made up of a protein naturally found in our skin and helps promote new skin growth with a micro scaffolding effect
What is collagen
A stall in wound progress may require a call to the following people
Who are the MD and wound nurse