Stage That Wound
What is 2 or 3 step wrap system, artiflex, profore, unna boot, kerlix and ACE, jobst stockings or farrow wraps
This is the correct way to document a wound that measures five centimeters vertically, six centimeters horizontally and nine tenths of a centimeter at the deepest point (answer should be in order of L x W x D)
What is 5 cm x 6 cm x 0.9 cm
Black or brown nonviable tissue that is not a scab
What is eschar?
Can be changed every 5-7 days, harsh on the skin, handles small to scant drainage and can soften eschar, appropriate (but not the best choice) for Stage I and II pressure ulcers on the coccyx/sacrum
What is a Hydrocolloid dressing
The number of days including the day of admission that you have to gather wound information for OASIS
White soft tissue in periwound area
What is Maceration Tissue
Large, shallow wounds with irregular margins that typically develop on the lower leg or ankle
What is Venous Stasis Ulcer
Full-thickness skin and tissue loss over a bony promience in which the extent of tissue damage cannot be confirmed because there is slough/eschar making visualization of wound bed impossible
What is an unstageable pressure ulcer
Gold standard treatment for skin tears
The M0090 date for an admission done on 4/1 when wound measurements are gathered on 4/3
What is 4/3.
Green, oozing, copious drainage with a foul odor
What are signs of a wound infection?
Bullet wound, traumatic skin tear, traumatic amputation
What are types of traumatic wounds?
Can be used for wound care of Stage I pressure ulcers following cleansing of the skin (name at least 3)
What is skin protectant spray, liquid skin protectant, skin protectant wipes, barrier creams, dressings (tegaderm, mepelex, bordered, foam), powders
A client's wound should be measured this often
What is at least weekly - should also be measured with any condition change of the wound (if the wound appears to be getting larger/infected).
Wounds should also be assessed by and RN weekly
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
Nonblanchable redness, often over a bony prominence
What is a stage 1 pressure ulcer
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
Wound with deep round/punched out, dry appearance and sharply demarcated borders and usually painless
What is an arterial ulcer