Staging & Assessment
Intact skin with non-blanchable redness
What is Stage 1 Pressure Injury
Beefy red or pink moist tissue that indicates a healing wound bed
What is Granulation Tissue.
These ulcers are typically painless due to neuropathy and decreased sensation.
What is Diabetic foot ulcer
This clear, thin dressing is common for superficial wounds but should never be used on skin tear.
What is a Tegaderm/Film
The minimum recommended frequency for turning a bed-bound patient to prevent pressure injuries.
Every 2 hours
A fluid filled blister, whether intact or ruptured, is categorized as this stage.
What is Stage 2 Pressure Injury
Thick, dry, black necrotic tissue that can impair the ability to stage pressure ulcer.
What is Eschar
Cool skin, pale yellow nails, and loss of leg hair are classic signs of type of insufficiency.
What is Arterial insufficiency
This type of dressing contains 80-90% water and is best for adding moisture to dry wound beds.
What is Hydrogel
This validated scale is used to assess a patients risk for developing pressure injuries.
What is Braden Scale
Full thickness loss where adipose is visible, but bone/muscle is not.
What is Stage 3
Yellow, green, or grey stringy non-viable tissue that must be removed for healing to progress.
What is Slough
The gold standard treatment for venous insufficiency ulcers is this type of therapy.
What is Compression Therapy
These highly absorbent dressings are made from seaweed and are ideal for wounds with heavy exudate
What is Alginate
This Lab test is often considered the best clinical measure for protein deficiency in wound healing.
What is Prealbumin
An unstageable pressure injury is one where the wound bed is obscured by these two substances.
What is Slough/Eschar
The white, soft, appearance of skin caused by overexposure to moisture.
What is Maceration
This Ulcer type is often located on the lower leg and presents with hemosiderin staining (brownish staining)
What is Venous Ulcer
This silver-impregnated dressing is used specifically to manage and prevent infection.
What is Silver
This type of debridement uses the body's own enzymes and moisture-retentive dressings to liquefy necrotic tissue.
What is Autolytic debridement
A localized area of purple or maroon intact skin or a blood-filled blister due to pressure/ shear.
What is Deep Tissue Injury (DTI)
These cells are the primary "building blocks" of the dermis responsible for collagen production.
Fibroblasts
Name 2 or 3 Characteristics of Arterial Ulcer.
What is Yellow sores, Punched out look, Minimal drainage
This moisture-retentive dressing consists of pectin and gelatin and is often used on Stage 2 Ulcers.
What is Hydrocolloid
The number of times hand hygiene should be performed during a single dressing change.
What is 3 Times