Show:
Stage That Wound
Dressings
Documentation
Odds 'N Ends
Name That Wound
100
An open area over a bony prominence in which muscle is visible.
What is a Stage IV pressure ulcer
100
Vaseline Gauze or Adaptic, dry gauze, Kerlix, daily
What is the typical dressing for a Skin Tear
100
A risk assessment completed on hospital admission, every 24 hours, and with each change in condition
What is the Braden Scale
100

Place the used cannister in the biohazard. Place the used VAC Ulta in the dirty utility room. Call supply distribution (5-0603) for pick up. 

What do you do with a used VAC machine that is no longer needed?

100
A partial or full thickness wound in which a flap may or may not be present
What is a skin tear
200
A shallow open area, over a bony prominence, involving the epidermis and dermis
What is a Stage II pressure ulcer
200
Can be changed every 5-7 days, harsh on the skin, handles small to scant drainage, appropriate (but not the best choice) for Stage I and II pressure ulcers on the coccyx/sacrum
What is a Hydrocolloid
200

Cleanse, initiate treatment, document, place a MIDAS report, notify physician, and consult wound and ostomy team. 

What should be done when a new or degrading pressure injury is found?

200
White soft tissue surrounding a wound
What is Maceration Tissue
200
Erythema and inflammation of the buttocks which may or may not lead to open lesions
What is Incontinence Associated Dermatitis
300
An unopened, dry, boggy, purple, nonblanchable area on a bony prominence
What is a Deep Tissue Injury
300

Date, time, and initials. 

What should be noted on each dressing?

300
One of these two options must be choosen when entering a wound in the LDA - they directly impact incidence rates
What are "Nosocomial" and "Present On Admission"
300
This skin problem appears as superficial peeling of tissue as it resolves
What is Candidasis or Yeast
300

A wound located on the coccyx with < 50% yellow slough, without exposed bone, muscle, or tendon.

What is a Stage III pressure ulcer

400
A round, dry, black area on the foot or toe which is not painful
What is an arterial ulcer?
400
An alternative to a dressing which can be placed over Stage I pressure ulcers, intact skin at risk for breakdown, and Deep Tissue Injuries which have not progressed to eschar
What is 3M No Sting Barrier Film wipe/spray
400
A scale used to describe depth of tissue damage from vascular, arterial, and diabetic ulcers
What is the Wagner Grade
400
The rate of hospital-acquired pressure ulcers measured at a specific point in time
What is prevalence
400
A dry wound typically located on the plantar foot or toes that is surrounded by hyperkeratotic tissue (callus)
What is a neuropathic (diabetic) foot ulcer
500
An area over a bony prominence which has dehisced, is open through the subcutaneous tissue, and is draining
What is not a pressure ulcer and therefore not staged...a dehisced surgical wound
500
Can be changed every 5-7 days, gentle on the skin, handles moderate to large drainage, third-spaces drainage away from the skin and is the preferred dressing for Stage II pressure ulcers on the coccyx/sacrum
What is a Tegaderm Clear Absorbent
500
Charted as a full-thickness wound and is not staged
What is any wound which is not a pressure ulcer
500

If patient is going to another facility, remove and place a saline moistened gauze dressing for discharge. 

If the patient is going home with a compatible machine, the primary RN can switch the patient from the VAC Ulta to the ReadyVac for discharge. 

If the patient is going home with a different brand of NPWT, remove and place a saline moistened gauze for discharge. 

What is done for a patient being discharged with a wound VAC?

500
A shallow wound, typically on the lower leg (gaiter area), which is irregular in shape and moist. These wounds are painful.
What is a venous insufficiency ulcer