Stage That Wound
Dressings
Documentation
Odds 'N Ends
Name That Wound
100
An open area over a bony prominence in which muscle is visible.
What is a Stage 4 pressure injury
100
Vaseline Gauze or Adaptic, dry gauze, Kerlix, daily
What is the typical dressing for a Skin Tear
100
A risk assessment completed on hospital admission, every 24 hours, and with each change in condition
What is the Braden Scale
100
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)
100
A partial or full thickness wound in which a flap may or may not be present
What is a skin tear
200
A shallow open area, over a bony prominence, involving the epidermis and dermis
What is a Stage 2 pressure injury
200
Can be changed every 5-7 days, harsh on the skin, handles small to scant drainage, appropriate (but not the best choice) for Stage I and II pressure ulcers on the coccyx/sacrum
What is a Hydrocolloid
200
A scale used to classify Skin Tears
What is the Payne-Martin Scale
200
White soft tissue surrounding a wound
What is Maceration Tissue
200
Erythema and inflammation of the buttocks which may or may not lead to open lesions
What is Incontinence Associated Dermatitis
300
An unopened, dry, boggy, purple, nonblanchable area on a bony prominence
What is a Deep Tissue Pressure Injury
300
This dressing should never be placed on a Skin Tear
What is a Tegaderm
300
One of these two options must be choosen when entering a wound in the LDA - they directly impact incidence rates
What are "Nosocomial" and "Present On Admission"
300
This skin problem appears as superficial peeling of tissue as it resolves
What is Candidasis or Yeast
300
A wound located on the coccyx with < 50% yellow slough
What is a Stage III pressure ulcer
400
A round, dry, black area on the foot or toe which is not painful
What is an arterial ulcer?
400
An alternative to a dressing which can be placed over Stage I pressure ulcers, intact skin at risk for breakdown, and Deep Tissue Injuries which have not progressed to eschar
What is 3M No Sting Barrier Film wipe/spray
400
A scale used to describe depth of tissue damage from vascular, arterial, and diabetic ulcers
What is the Wagner Grade
400
The rate of hospital-acquired pressure ulcers measured at a specific point in time
What is prevalence
400
A dry wound typically located on the plantar foot or toes that is surrounded by hyperkeratotic tissue (callus)
What is a neuropathic (diabetic) foot ulcer
500
An area over a bony prominence which has dehisced, is open through the muscle tissue, and is draining
What is not a pressure ulcer and therefore not staged...a dehisced surgical wound
500
Can be changed every 5-7 days, gentle on the skin, handles moderate to large drainage, third-spaces drainage away from the skin and is the preferred dressing for Stage II pressure ulcers on the coccyx/sacrum
What is a Tegaderm Clear Absorbent
500
Charted as a full-thickness wound and is not staged
What is any wound which is not a pressure ulcer
500
The rate of hospital-acquired pressure ulcers measured over a period of time
What is incidence
500
A shallow wound, typically on the lower leg (gaiter area), which is irregular in shape and moist. These wounds are painful.
What is a venous insufficiency ulcer