301 Test 2 wounds Flashcards
Intact skin with non-blanchable redness (erythema) of a localized area usually over a bony prominence
stage 1
Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area
stage 1
The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
stage 1
A localized area of redness from pressure is observed over the right iliac crest of an elder male patient.
The skin surface is intact.
The reddened area of skin is nonblanchable.
stage 1
an area of reddened skin on the right heel.
The alteration in skin color persists under applied light pressure.
There is no break in the skin surface.
stage 1
The skin is reddened.
The area of redness does not blanch under applied light pressure.
The epidermis remains intact.
No blistering of the skin is observed.
stage 1
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough
stage 2
may also present as an intact or open/ruptured serum-filled or serosangineous-filled blister
stage 2
The pressure ulcer is approximately 2 cm in length and 1.5 cm in width.
Tissue loss extends into the dermis.
There is no slough in the wound bed.
stage 2
Area of epidermal and dermal skin loss noted over the left buttock.
No alteration in skin integrity was observed over the right buttock or perineum.
stage 2
This wound is shallow. Tissue loss extends into the dermis.
The wound bed is reddish. No slough is observed.
stage 2
Full thickness tissue loss
stage 3
Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed
stage 3
stage 3 MIGHT include 3 things:
slough, undermining, tunneling
Subcutaneous tissue is visible in the wound bed. Muscle, tendon, and bone are not exposed.
stage 3
Tissue loss extends through the dermis to subcutaneous tissue.
Not cartilage or bone is visualized.
stage 3
Subcutaneous tissue is visible in the wound bed. Muscle, tendon, and bone are not evident.
A small amount of slough is present.
stage 3
Full thickness tissue loss with exposed bone, tendon, or muscle
stage 4
These ulcers often include undermining and tunneling
stage 4
exposed muscle is observed in this very large pressure ulcer.
Slough/eschar are present.
Undermining is noted at the superior wound edge.
stage 4
Full thickness tissue loss in which the base of the ulcer is completely covered by slough
unstageable
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
Suspected Deep Tissue Injury (sDTI)
A wound caused by shear, friction, and/or blunt force resulting in separation of skin layers.
Skin Tears
partial thickness wound is stage
2
full thickness wound is stage
3 or 4
