Stage That Wound
Apply a non adherent dressing ie Vaseline Gauze or Adaptic, dry gauze, Kerlix every 1-2 days
What is the typical dressing for a Skin Tear
A skin risk assessment completed on hospital admission, every 24 hours, and with each change in condition
What is the Braden Scale
Number of times gloves should be changed while performing a dressing change
What is 3 times (before, after removing the old dressing, and at completion of dressing change)
A partial or full thickness wound in which a skin flap may or may not be present
What is a skin tear
A shallow open area, over a bony prominence, involving the epidermis and dermis
What is a Stage II pressure ulcer
Can be changed every 3-5 days, handles no to small drainage, appropriate for partial thickness wounds such as Stage I and II pressure ulcers
What is a Hydrocolloid
Documentation of wound type on the Avatar over a bony area
What is Pressure Injury
White soft moist tissue surrounding a wound
What is Maceration Tissue
Erythema and inflammation of the buttocks which may or may not lead to open lesions usually seen with incontinence
What is Incontinence Associated Dermatitis
An area of purple/maroon, nonblanchable area on a bony prominence
What is a Deep Tissue Injury
This dressing should never be placed on a Skin Tear
What is a Transparent dressing ie- Tegaderm
One of these two options in the Wound LDA must be chosen when entering a wound in the LDA - they directly impact incidence rates
What are "Present On Admission" -Yes or No
This skin problem appears as superficial skin breakdown with pinpoint papules with itching
What is Candidasis or Yeast
A wound usually located on the lower leg of a patient that is painful with a punch out appearance
What is an arterial ulcer
An wound with mostly yellow or black tissue over a bony area-may or may not have a measurable depth
What is an unstageable pressure injury
A dressing which can be placed over Stage I pressure ulcers, intact skin at risk for breakdown, and Deep Tissue Injuries
What is Silicon adhesive Foam dressing
A day of the week when pressure injuries are measured, assessed and photographed
What is the on admission, Wound Wednesday and on discharge from the facility
The rate of hospital-acquired pressure ulcers measured at a specific point in time
What is prevalence
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
An area over a bony prominence which has some depth with subcutaneous tissue
What is a Stage 3 pressure injury
Can be changed every 1-2 days, gentle on the wound, handles moderate to large drainage, Stage III and Stage IV pressure ulcers
What is an Alginate dressing
Charted intervention for pressure injury prevention
What is under daily care flowsheet
The rate of hospital-acquired pressure ulcers measured over a period of time
What is incidence
A shallow wound, typically on the lower leg (gaiter area), which is irregular in shape and moist. These wounds are not painful. Usually drain a lot
What is a venous insufficiency ulcer