Stage that wound
Full thickness tissue loss. Sub-q fat may be visible but bone, tendon, muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Requires a call to the MD and WON
What is a stage 3 pressure ulcer?
Vaseline gauze or adaptic, dry gauze/kerlix
dressing changed daily
What is typical dressing for a skin tear?
A risk assessment completed on hospital admission, every 24 hrs and with each change in condition
What is the Braden Scale?
One Fitted Sheet One Draw Sheet One Coviden Pad-holds 1L of fluid and wicks moisture from the skin! Remove diapers while in bed
Increased layers will increase risk for friction related skin injury and increase heat!
What is how many layers are appropriate on the bed?
A partial or full thickness wound in which a flap may or may not be present
What is a skin tear?
Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as intact or open/ruptured serum-filled blister. Requires a call to the MD follow wound care protocols.
What is a stage 2 pressure ulcer?
Can be changed every 5-7 days, harsh on the skin, handles small to scant drainage, appropriate (but not the best choice) for stage 1 or 2 pressure ulcers on the coccyx/sacral area
What is a hydrocolloid dressing?
An avatar that shows specific location of wounds, access devices for all providers to see
White soft tissue surrounding a wound
What is macerated tissue?
Erythema and inflammation of the buttocks which may or may not lead to open lesions
What is moisture associated dermatitis?
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue. Requires MD notification and WON consult.
What is a Deep Tissue Injury?
This dressing should never be placed directly over a skin tear
Correct description, measurements and location of wounds
What is how to document wounds to patients?
This skin problem appears as superficial peeling of tissue as it resolves
What is candida auris or yeast?
Intact skin with non-blanchable redness to localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching, its color may differ from the surrounding skin.
Contact MD to make aware and follow hospital protocol.
What is a stage 1?
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed making it difficult to accurately assess stage of wound. Notify MD and WON consult.
Stable (dry, adherent, intact w/o erythema) eschar on heels should not be removed
What is unstageable?
An alternative to a dressing which can be placed over Stage 1 pressure ulcers, intact skin at risk for breakdown and DTI which have not progressed to eschar
What is barrier wipe/spray?
What is complete admission assessment documentation of wounds?
The rate of hospital acquired pressure injuries over a period of time. Staff will see each patient and assess for HAPI. Done quarterly and led by Wound Team.
What is prevalence study?
An open wound typically located on the plantar foot or toes that is surrounded by hyperkeratotic tissue. It is slow to heal and can be a complication of diabetes.
What is diabetic foot ulcer?
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Requires MD notification and WON consult.
What is Stage 4 Pressure Injury?
Don't use if excess stooling requiring dressing change more than 2x daily
Applicable to High risk inclusion criteria of Braden Score <18
OR procedure lasting >3 hrs
Vented/Sedated Immobile: unable to self reposition/bed or chairbound
H/O previous Sacral Pressure Injuries
What is Mepilex Border for sacrum preventative?
What is the 2RN skin assessment?
Preventatives including requesting a cat 2 bed, utilizing a TAPS, Q2 T&P, removing items from the bed, checking medical equipment not in contact w/ patient skin.
What are measures to prevent wounds from occurring?
A shallow wound, typically on the lower leg which is irregular in shape and moist. These wounds are painful.
What is a venus ulcer?