Cleaning
This solution found in the clean supply room can be used to cleanse almost any wound before dressing.
What is normal saline?
Take these 3 measurements when assessing a wound.
What is length x width x depth?
Purple or maroon area of intact skin or blood-filled blister that can be initially painful or boggy.
What is a deep tissue injury (DTI)?
For most wounds, avoid using this occlusive, impermeable protective dressing for covering lines and intact skin.
What is Tegaderm?
This barrier film can be applied to intact, periwound skin prior to application of a dressing.
What is 3M Cavilon barrier film?
This solution is used daily for bathing of all hospitalized patients with central lines.
What is Hibiclens?
This term describes a type of damage to the skin that can occur if the exudate is too high.
What is maceration?
A safety report should be filed upon discovery of a pressure injury with this stage or higher.
What is a stage 2 pressure injury?
This foam based dressing can be used on exudative wounds or to redistribute pressure over bony prominences.
What is Mepilex?
What is Cavilon Advanced?
A 30cc syringe + 18g blunt tip cannula can be used together to achieve the optimal psi for these two purposes.
What is irrigation and mechanical debridement?
This term describes an overgrowth of shiny, pink tissue that can be seen around a G-tube stoma with too much friction and moisture.
What is hypergranulation tissue?
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough.
What is a stage 2 pressure injury?
This topical agent comes in powder or ointment form to protect and heal skin with fungal irritation.
What is Nystatin?
These wipes contain 3% dimethicone and are great for incontinence moisture-associated skin damage.
What are Sage comfort shield wipes?
This solution, also known as sodium chloride-hypochlorous acid (HOCL), mimics one of the body's main ways of killing microorganisms.
What is Vashe?
This term describes the redness of the skin which blanches (turns white when pressed with a fingertip) then quickly returns to original redness once pressure is removed.
What is blanchable erythema?
Full thickness tissue loss with subcutaneous fat visible but no bone, tendon or muscle exposed.
What is a stage 3 pressure injury?
This occlusive and bacteriostatic non-adherent dressing is good for dry extremities, skin grafts, burns, and surgical incisions.
What is Xeroform?
Cut this from a roll to wick away moisture in intertriginous areas - but avoid using with any ointments!
What is Interdry?
This is the first step in assessing a wound bed.
What is cleaning the wound bed?
This type of exudate is thin, watery, and straw colored.
What is serous exudate?
Full thickness tissue loss in which base of ulcer is covered by slough and/or eschar.
What is an unstageable pressure ulcer?
This non-adherent silicone dressing can be used to wick exudate to a secondary dressing or to protect fragile blisters.
What is Adaptic?
This scale is used to measure a patient's risk for skin breakdown.
What is the Braden Scale?