Wound Descriptions
Dead tissue
What is necrotic tissue?
Red, cobble stone appearance, looks like fresh hamburger meat.
What is normal, healthy granulation tissue?
If your patient is at risk for developing pressure injuries on their heels, what are 2 interventions you can use to help prevent this?
Skin prep, float heels, bunny boots
The minimum of number of times hands should be washed while performing a dressing change
What is 3 times (before, after removing the old dressing, and at completion of dressing change)?
Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present.
What is a Stage IV pressure ulcer?
The outermost layer of skin is called:
What is the epidermis?
White soft tissue surrounding a wound that may be raised
What is maceration?
Thin or thick opaque, tan/yellow drainage with or without an odor.
What is purulent drainage?
If you have a patient who is excoriated in their groin area, what is a common product you can use?
What is Interdry?
Full thickness tissue loss with slough present
What is a Stage III pressure ulcer?
What type of product uses negative pressure therapy to promote wound closure?
What is a wound-vac?
Black, hard, firmly adhered tissue
What is eschar?
Thin watery, clear drainage
What is serous fluid?
Where do we position the foley catheters when a patient is in bed to prevent a pressure ulcer.
What is over the leg using a stat lock?
Full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed.
What is an unstageable pressure ulcer?
A dry wound typically located on the plantar foot or toes that is surrounded by calloused tissue. The patient reports his blood sugar typically runs over 300 mg/dl and he feels pins and needles in his feet.
What is a neuropathic (diabetic) foot ulcer?
Adherent yellow, tan or brown tissue.
What is slough?
Pure red exudate
Where do you document wound care if patient has a wound plan of care.
What is in skin assessment?
An intact or open/ruptured serum filled blister.
What is a Stage II Pressure Ulcer?
An area over a surgical incision which has opened through the subcutaneous tissue, and is draining.
What is a dehisced surgical wound?
The single greatest risk factor for a diabetic foot ulcer is:
What is peripheral neuropathy?
Pink exudate
What is serosangeious?
If you see nectrotic tissue what does this mean for the skin underneath?
The tissue is dead
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
What is a Stage I pressure ulcer?