177 Exam #3 (Chap 18 & 26)

Pressure Injury

100

Involve full-thickness tissue loss but are impossible to accurately stage because of the wound bed being obscured by eschar or excessive slough

Unstageable 

200

Full-thickness skin and tissue loss, only it involves deep tissue necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone

Stage 4

300

Erythema of intact skin that does not blanch

Stage 1

400

Full-thickness loss involving damage to the epidermis, dermis, and subcutaneous tissue but not muscle or bone

Stage 3

500

Partial thickness loss with an exposed dermis

Stage 2

Wound Drainage

100

What does purulent drainage indicate? 

Infection  

200

Pink

Serosanguinous 

300

Red / Bloody

Sanguineous 

400

Clear / Yellow

Serous 

500

Thick / Yellow / Green

Purulent 

Wound Types

100

Contusion 

Bruise

200

Scrapes / Scratches 

Abrasion 

300

Puncture 

Open wound when small sharp item pierces skin

400

Laceration 

Open wound from cutting or tearing

500

Penetrating 

Wound from a sharp item that remains in tissue

Wound (random)

100

What are three things you should do if evisceration occurs? 

- put patient in low Fowlers with knees flexed 

- put normal saline soaked sterile gauze on exposed organ 

- Call HCP 

200

Ways to prevent Wound Dehiscence?

- splint when coughing or sneezing 

- stool softener / nausea med 

If wound dehiscence occurs put patient in supine position & call HCP 

300

A surgical wound that bleeds profusely

Hemorrhage  

400

Dehiscence   

Occurs when there is a partial or complete separation of the outer layers of a wound.

500

Evisceration 

An abdominal wound reopens & the abdominal contents protrude through the opening