Mending Magic
This is the first phase of wound healing beginning immediately after injury
inflammatory phase
pressure injuries most commonly occur over these bony areas
what are bony prominences
This scale assesses risk for pressure injuries using six categories
braden scale
the color of healthy granulation tissue
red
A patient that is chair bound and incontinent is at an increased risk for this type of injury
pressure injury
This phase involves rebuilding tissue with collagen and granualation
proliferative phase
this stage of pressure injury presents as non blanchable redness over intact skin
stage 1
turning and repositioning should occur at least this often for at risk patients
every two hours
yellow stringy tissue in a wound bed is called this
slough
a wound with partial thickness skin loss and a shallow open ulcer is classified as this stage
2
this final phase of healing can last months to years as collagen reorganizes
maturation
a wound with exposed bone tendon or muscle is classified as this stage
stage 4
excessive moisture from sweat urine and stool increases risk of this type of skin breakdown
moisture associated skin damage MASD
this term describes dead black brown tissue that may require debridement
eschar
a patient with poor mobility and a braden scale of 10 is considered at this level of risk
high or very high risk
adequate levels of this nutrient are essential for collagen synthesis
vitamin c
this term describes tissue that is soft boggy and may indicate deep tissue damage
DTPI deep tissue pressure injury
poor intake of this macronutrient slows wound healing and increases risk of breakdown
protein
the acronym REEDA is used to assess wounds what does the E stand for
edema
a purple intact area over the heel suggests this type f pressure injury
deep tissue injury
this type of wound healing occurs when the wound edges are not approximated and must fill in from the bottom up
healing by secondary intention
this type of pressure injury cannot be staged because slough or eschar covers the wound bed
unstageable pressure injury
this mechanical force occurs when the skin stays in place but deeper tissue slide often during repositioning
shear
this type of drainage is thick yellow or green and may indicate infection
purulent drainage
a wound with tunneling or undermining is at least this stage
3