Know Your Exudate
Yellow/clear with small amounts of blood.
What is serosanguineous?
Non-blanchable erythema on the coccyx.
What is stage 1?
This wound is located on the plantar surface of the foot, usually painless and difficult to heal.
What is a diabetic foot ulcer?
*often noted with calloused edges
Black, dry and firm tissue typically located on the heels.
What is eschar?
The number of clinicians required to stage a pressure injury.
What are 2 RNs?
Yellow or clear fluid leaking from a wound.
What is serous?
Black, dry and firm tissue usually located on the heels.
What is unstageable?
The patient's great toes have well defined edges and a necrotic base. The lower extremity is cool to touch with no visible hair present.
What is an arterial ulcer?
This tissue type is yellow/grey and stringy, usually hanging in a chronic wound.
What is slough?
The...Scale is the criteria used to determine when a patient is high risk for developing a pressure injury.
What is Braden?
What is sanguineous?
Full thickness wound on the trochanter, adipose tissue is visible.
What is stage 3?
What is a venous ulcer?
While providing wound care, you notice the tissue is red/pink, bumpy and moist.
What is granulation tissue?
This equipment is used to detect subepidermal moisture between the skin layers and is used to predict the occurrence of pressure injuries.
What is the Provizio scanner?
Thick yellow milky fluid from the wound bed.
What is purulent?
Closed blisters located on the elbow.
What is stage 2?
These wounds are found on bony prominences and caused by prolonged pressure and long periods of immobility.
What is a pressure injury?
Skin erosion and inflammation of the skin caused by feces and urine.
What is incontinent associated dermatitis (IAD/ MASD)?
The acronym SKINS used in pressure prevention protocol. The last "S" stands for?
What is surface?
Clear watery fluid, found in blisters.
What is serum?
Wounds in cavities, usually caused by medical devices.
What are mucosal membrane pressure injuries?
Saliva, sweat, urine, feces and other body fluids are the primary cause for these types of wounds.
What is moisture associated skin dermatitis (MASD)?
Located in the abdominal pannus and breast folds, this tissue type is usually red and painful.
What is intertriginous dermatitis (ITD)?
This nursing task is done on admission, per shift and upon transfer to a new unit.
What is the skin assessment?