Wound Descriptions
White/grey tissue
What is non-viable tissue?
Red, cobble stone appearance, looks like fresh hamburger meat.
What is normal, healthy granulation tissue?
You do this upon admission and at discharge with all wound care patients and incisions.
What is take a picture?
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
What is maceration?
Thin or thick opaque, tan/yellow drainage with or without an odor.
What is purulent drainage?
A risk assessment completed on hospital admission, every 24 hours, and with each change in condition.
What is the Braden Scale?
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?
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 the lines, drains, and wounds section of the electronic medical record?
An intact or open/ruptured serum filled blister.
What is a Stage II Pressure Ulcer?
An area over a bony prominence which has dehisced, is open 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?
What do you add to a dry wound to assist with healing?
What is moisture?
If you see multiple colors in a wound bed, you should describe the wound according to the:
What is the percentage of tissue types?
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
What is a Stage I pressure ulcer?