Stage that Wound
An open area over a bony prominence in which muscle is visible?
What is a stage IV pressure ulcer?
The softening and breakdown of skin as a result of prolonged exposure to moisture = "diaper rash".
What is maceration?
Phases of wound healing process.
What are hemostatic, proliferative, remodeling?
Traumatic or surgical.
What are types of acute wound?
During dressing changes.
When does a wound assessment take place?
A partial thickness loss of dermis presenting as a shallow open ulcer.
What is a stage II pressure ulcer?
A risk assessment tool completed on admission and when any change in condition is noted.
What is the Braden Scale?
When stronger collagen replaces the soft gelatinous collagen, but not as strong as the original tissue and is susceptible to re-injury.
What is remodeling phase?
A form of dermatitis that develops when skin is exposed to irritants.
What is MASD (moisture-associated skin damage)?
Serous, serosanguineous, sanguineous, purulent.
How does the nurse describe wound exudate?
Actual depth of the ulcer is completely obscured by necrotic tissue or eschar.
What is an unstageable pressure ulcer?
Age, chronic diseases, mobility issues, malnutrition, sensory loss.
What are risk factors for impaired tissue integrity?
The damaged tissue releases cytokines which trigger this process.
What is hemostatic or inflammatory phase?
Develop as a result of injury.
What is an acute wound?
Purulent drainage.
What would indicate infection and should be reported to the provider?
Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear.
What is suspected deep tissue injury?
Bony prominences, such as heels, toes, sacrum, hips, elbows, shoulders and back of the head.
What are the most susceptible areas for pressure injury?
New collagen fibers form, a new wound bed is created, capillaries start growing and the wound edges begin to pull closer.
What is the proliferative phase.
What predisposes MASD?
Undermining.
What is an open area extending under intact skin along the edge of the wound?
An area on the abdomen which has dehisced and is draining.
What is NOT a pressure ulcer and therefore NOT staged.
DIDN'T HEAL
Plasm a can leak into surrounding tissue and causes swelling.
What is hemostatic or inflammatory phase?
Venous, arterial, neuropathic.
What are types of chronic wounds?
Tracing the wound and calculating surface area or using a ruler to measure length and width.
What are two methods for measuring wound size?