FN1 Flashcards
Stage 1
Surface. Stays deep pink/red when blanching. Warmth, edema, and induration may occur.
Stage 2
Partial-thickness. (top layer gone) Wound bed is pink/red, moist, may appear intact or ruptured blister.
Stage 3
Full-thickness. Looks like a deep crater, may extend to fascia, fat is visible, undermining or tunneling, damaged or necrotic.
Stage 4
Full-thickness. Extensive tissue necrosis,damage to muscle, bone or supporting structures. Dry/wet, eschar, slough.
Unstageable
Loss of full-thickness. Base of injury is covered in eschar or slough and depth cannot be determined.
Deep Tissue
Localized discolored intact skin that looks maroon, purple or a blood filled blister. Results from damage of pressure or shearing.
Induration
Red around the outside.
Eschar
Dry, dark scab of dead skin. Black or brown.
Erythema
Redness of skin
Cyanosis
Bluish tinge of skin
Jaundice
Yellowish tinge of skin
Pallor
Paleness of skin
Vitiligo
White/loss of skin color in blotches
Dusky
Grayish, cloudy coloring of skin
Pigmentation
deposition of coloring matter in the skin
Mottled
Uneven discolored patches of skin (low blood flow to skin surface)
Blanching
Interference with circulation causes skin to turn white or pale
Ecchymosis
Purplish color from collection of blood (bruising)
Petechiae
Hemorrhagic spots caused by capillary bleeding
Warm and Dry
Normal skin
Diaphoresis
Increase perspiration/sweating
Tugor
Fullness of elasticity
Lesions
Areas of diseased or injured tissue
Fissure
Narrow slit
Shearing
Two surfaces moving in opposite direction
Maceration
Caused by incontinence/wet skin loosening connective tissue
AMB
Ambulatory
CBR
Complete bed rest
Up ad lib
Up as directed
ac
before meals
bx
biopsy