Pressure Ulcers
Dressings
Documentation
Percentage of Necrotic Tissue
Name that wound
100
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present.
What is a Stage IV
100
thin watery, pale pink/red
What is Serosanguinous
100
Red cobble stone appearance
What is granulation tissue
100
Where do you document wound care if patient has a wound plan of care
What is the wound treatment sheet
100
you do this on admission and at discharge with all wound care patients and incisions
What is take a picture
200
Full thickness tissue loss with slough present.
What is Stage III
200
Pure red exudate.
What is Bloody
200
White/ grey tissue
What is non-viable tissue
200
What metal is in an antimicrobial dressing
What is silver.
300
Full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed.
What is Unstageable
300
thin or thick opaque, tan/yellow with or without odor
What is Purulent
300
adherent yellow, tan, brown tissue
What is slough
300
What do we use to secure stri-strips and a non adherent dressing over a skin tear?
What is transparent film(tegaderm)
300
What must you do to get the wound care team on a patient with a wound
What is write for a consult.
400
An intact or open/ruptured serum-filled blister.
What is Stage II
400
thin watery, clear
What is Serous
400
Adherent soft black tissue
What is eschar
400
What do we use to off load heels, placed under the calf with heels suspended?
What is pillows
400
How often does wound care team make their rounds?
What is weekly.
500
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
What is Stage I
500
Dry
What is no exudate
500
Black, hard, firmly adhered
What is eschar
500
Where do we position catheters when a patient is in bed to prevent a pressure ulcer.
What is over the leg.
500
What do you add to a dry wound to assist with healing
What is moisture
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