Dressings
This is an Adhesive plastic, semipermeable, nonabsorbent dressing which allows an exchange of oxygen between the atmosphere and the wound bed.
What is Transparent Film?
This type of drainage is creamy, viscous, pale yellow thicker than serous
What is purulent drainage?
A wound that may present as an intact or open/ruptured serum-filled blister.
What is a stage II pressure ulcer?
This is a risk assessment for pressure ulcers completed on admission, every 24 hours, and with each change in condition
What is The Braden Scale?
These are 3 important numerical values related to the assessment of wounds
What are length X width X depth?
These are waterproof adhesive wafers, pastes, or powders. The inner adhesive layer has particles that absorb exudates and form a hydrated gel over the wound; the outer film provides an occlusive seal.
What are Hydrocolloids?
This drainage is thin, runny transparent liquid with some blood noted indicating damage to capillaries (common with surgical incisions)
What is serosanguinous drainage?
A wound with full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar.
What is an unstageable pressure ulcer?
An inexpensive, efficient technique used by nursing staff every 2 to 3 hours to reduce the incidence of pressure ulcers.
What is turning and repositioning?
This is often referred to in quantity and appearance when documenting a wound
What is drainage?
This dressing should never be placed on a Skin Tear
What is Tegaderm?
This is a dry, black area on a pressure ulcer that often impairs staging of pressure ulcers
What is eschar?
The category in which there is full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule
What is a Stage IV pressure ulcer?
By simply lowering the head of the bed (HOB) to 30 degrees or less this force can be significantly reduced
What is shearing force?
This can be unpleasant to describe but an important indicator of infection
What is an odor?
These are nonadherent dressings of powder, beads or granules, ropes, sheets, or paste that conform to a wound surface and absorb up to 20 times their weight in exudate; require a secondary dressing.
What are alginates?
This is white soft tissue surrounding a wound
What is Maceration Tissue?
Purple or maroon localized area or discolored intact skin or blood-filled blister due to damage to underlying soft tissue from pressure and/or shearing.
What is a suspected deep tissue injury?
Nurses should encourage patients to stop this activity to help improve the amount of functional hemoglobin/oxygen-carrying capacity of the blood to all areas of the body prone to breakdown
What is stop smoking?
The writing you should see on each wound dressing to communicate when the dressing was last changed.
What is the date, time and initials of the person changing the wound dressing?
This dressing is an appropriate treatment for a skin tear
What is vaseline gauze or Adaptic and kerlix?
This is is collagen-rich tissue which forms at the site of a healing pressure ulcer. It is usually moist and pink or red in color
What is granulation tissue?
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
What is a stage I pressure ulcer?
A treatment applied on intact skin to prevent skin breakdown from incontinence.
What is a protective barrier ointment?
This is an opening in a wound or pressure ulcer that must be documented by depth
What is tunneling?