Stage That Wound
Wounds
Other stuff
100
An open area over a bony prominence in which muscle is visible.
What is a Stage IV pressure ulcer
100

A partial or full thickness wound in which a flap may or may not be present

What is a skin tear

100

A risk assessment completed on hospital admission, every 12 hours, and with each change in condition

What is the Braden QD Scale

200
A shallow open area, over a bony prominence, involving the epidermis and dermis
What is a Stage II pressure ulcer
200

Erythema and inflammation of the buttocks which may or may not lead to open lesions

What is Incontinence Associated Dermatitis

200

How often a patient should be repositioned

Every 2 hours or touch time (NICU)

300
An unopened, dry, boggy, purple, nonblanchable area on a bony prominence
What is a Deep Tissue Injury
300
White soft tissue surrounding a wound
What is Maceration Tissue
300

This gel helps to promote a moist wound environment that aids and supports autolytic debridement. Treating local wound bed infection or reducing increased bacteria levels while educing odor caused by high bacteria levels and inflammation.

Medihoney

400

 Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Stage 3

400

This skin problem appears as superficial peeling of tissue as it resolves

What is Candidasis or Yeast

400

This along with friction and shear is a contributing factor to development of pressure injury

Microclimate

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