Non-Systems

Question 1

Gauze dressings

Answer 1

An effective secondary dressing for constantly changing wounds, or if exudate is heavy

Indication: infected wounds,

Purpose: space filling, mechanical debridement( because it sticks to the wound), exudate absorption, cushioning

Question 2

Transparent film

Answer 2

Do not allow bacteria or moisture into the wound

Facilitate a moist wound bed, trapping fluid to help with autolytic debridement, wound bed homeostasis, and angiogenesis.

Cannot be used on high exudate wounds

Indication: burns, stage 1 or 2pressure injury, diabetic ulcers, and donor sites

Purpose: autolytic debridement, protection for newly formed tissue, friction reduction, insulation promote warmth, pain reduction,

Question 3

Foam

Answer 3

Highly absorbent, can create an environment for moist wound healing

Can be a primary or secondary dressing

Cannot be used on a dry wound alone

Indication: burns, all pressure injuries, venous ulcers, diabetic ulcer, and arterial ulcers

Purpose: space filling (some), exudate absorption, autolytic debridement, protection (some), insulation to promote warmth, pain reduction, cushioning,

Question 4

Hydrogel

Answer 4

Used to increase moisture, soften necrotic tissue, and autolytic debridement

Gel must be contained with a secondary dressing,

Indication: infection, burns, stage 2,3, and 4 pressure injury, arterial ulcers, venous ulcers, donor sites

Question 5

Hydrocolloids

Answer 5

Works best on mild or moderate exudate wounds

A yellow mass forms in wound when mixed with the hydrocolloid

Indication: burns, stage 2,3, and 4 pressure injuries, venous ulcers, diabetic ulcers, and donor sites

Purpose: exudate absorption, autolytic debridement, protection, friction reduction, insulation to promote warmth, pain reduction, odor reduction, and cushioning

Question 6

Alginates

Question 7

Stage 1 pressure injury

Answer 7

Non-blanchable erythema on intact skin

Changes in temperature, firmness, and sensation

No deep purple or maroon color

Question 8

Stage 2 Pressure Injury

Answer 8

Partial thickness loss of skin with exposed dermis

Wound bed is viable, pink, moist

Intact or ruptured blister

NOT VISIBLE: fat, deeper tissues, granulation tissue, Eschar, slough

Result from microclimate and shear in the skin over pelvis or shear in heel

Question 9

Stage 3 Pressure Injury

Answer 9

Full thickness skin loss

VISIBLE: fat, granulation tissue, epibole,

Possible: slough, eschar, undermining, tunneling

NOT VISIBLE: fascia, muscle, tendon, ligament, cartilage, bone

Question 10

Stage 4 Pressure Injury

Answer 10

Full thickness skin and tissue loss

VISIBLE: palpable fascia, muscle, tendon, ligament, cartilage, bone

Possible: slough, eschar, epibole, undermining, tunneling

Question 11

Unstageable Pressure Injury

Answer 11

Obscured full thickness skin and tissue loss

The extent of tissue damage cannot be confirmed because it obscured by slough and eschar