Full thickness tissue loss where the base is covered by slough and/or eschar making it so the true depth is unknown
Unstageable
100
Skin Surface is broken
Open Wound
100
Lasts about 4-6 days, white blood cells move to the wound, characterized by pain, redness, heat, and swelling.
Inflammatory Phase
100
Partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.
Dehiscence
100
What solution is typically used to clean a wound
Normal Saline Solution (0.9% sodium chloride)
200
Intact nonblanchable redness of the skin
Stage I
200
Planned, Purposeful wound
Intentional Wound
200
Also known as the fibroblastic, regenerative, or connective tissue phase where new tissue is built to fill the wound space.
Proliferation Phase
200
Most serious complication of dehiscence where the wound completely separates with a protrusion of viscera through the incision
Evisceration
200
To prevent pressure ulcers, patients should be turned every _____ hours?
2
300
Full thickness tissue loss, bone/muscle not exposed
Stage III
300
Intact skin, soft tissue damage
Closed Wound
300
Occurs immediately after the initial injury, blood vessels constrict and blood clotting begins.
Hemostasis
300
may occur from a slipped suture, a dislodged clot at the wound site, infection, or the erosion of a blood vessel by a foreign body, such as a drain
hemorrhage
300
Drainage that consists of red blood cells
Sanguineous Drainage
400
Partial thickness loss of dermis
Stage II
400
Accidental, unexpected wound
Unintentional Wound
400
Final stage of healing, collagen in wound is remodeled and made stronger to match surrounding tissue
Maturation Phase
400
results when the patient’s immune system fails to control the growth of microorganisms
infection
400
Scale often used for predicting pressure sore risk
Braden Scale
500
Full thickness tissue loss with exposed bone or muscle
Stage IV
500
Heals within days to weeks
Acute Wound
500
Exudate accumulation causes swelling and pain and a hard scab is formed to protect the injury
Hemostasis
500
an abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another, often the result of an abscess from an infection