Stage That Wound
An open area over a bony prominence in which muscle is visible.
This is a stage IV pressure ulcer
This drainage is commonly called "pus" and often has a foul smell. What is this called?
Purulent
Wound care can be painful for patients, what should the nurse assess and treat prior to a dressing change?
The patients pain
A painful skin wound caused by electrical, chemical, or thermal energy. What is the name of this wound?
A burn
How many stages of healing are there and what are they?
There are 4 stages
- Hemostasis
- Inflammation
- Proliferation
- Remodeling
A shallow open area over a bony prominence involving the epidermis and dermis.
This is a stage II pressure ulcer
This fluid appears as a clear or pale yellow, thin, and water. What is this called?
Serous Fluid
what solution is used to clean the wound?
Normal Saline
A tear or cut in the skin. What is the name of this wound?
A laceration
The process of the wound being closed by clotting is what phase of healing?
Hemostasis Phase
An unopened, dry, nonblanchable area on a bony prominence
This is a stage I pressure sore
Tis fluid appears thin, watery, and pale red to pink in color. What is this fluid called?
Serosanguineous
The method that involves a solution and gravity. Solution is introduced in a top-to-bottom fashion.
Passive irrigation
Cuts in the skin to access the internal portion of the body during a surgical procedure. What is the name of this wound?
A surgical wound
Wound healing is complete, this process can take more than 1 year.
Maturation Phase (Remodeling Stage)
Wound is completely covered by a layer of slough and/or eschar.
This is an unstageable wound
This fluid is fresh bloody exude that appears when skin is breached. What is this fluid called?
Sanguineous
Involves the use of gauze and a cleansing solution to clean contaminated wound areas
Mechanical cleansing
Occurs from a scrape across a rough surface. What is the name of this wound?
An abrasion
This stage begins once the skin is injured and continues for about 24 hours. This phase includes skin color change, heat, swelling, pain, and loss of function.
Inflammatory Phase
Wound extended through the skin into deeper tissue and fat, but has not reached muscle, tendon, or bone.
This is a stage III pressure sore.
Fluid that appears cloudy, yellow, or tan. What is this fluid called?
Seropurulent
What position should the patient be in while the nurse is doing wound care?
Lateral position
The most serious level of abrasion that traumatizes all layers of the skin and exposes the underlying bone and muscles.
An avulsions
When the wound is rebuilt with new tissue made up of collagen and extracellular matrix. What phase is this?
This is the proliferative Phase