Sync Flashcards
Abnormal firmness of the tissues with palpable margins
Induration
Woody fibrosis of the skin
Lipodermatosclerosis
Red moist tissue raised above the level of the skin
Hypergranulation
Abnormal thickening of the epidermis
Hyperkeratosis (callous)
When would a pressure wound be considered unstageable?
Covered with Eschar or slough (cannot see the wound)
What are the components required to describe a wound?
Wound location
Wound size
Tissue present
Wound edge
Periwound
Odor or exudate
Serous exudate
Thin, watery, clear
Sanguineous exudate
Thin, bright red, fresh bleeding
Serosanguinous exudate
Thin, watery, pale red to pink
Perulent exudate
Thick or thin, yellow
Foul purulent exudate
Yellow to green with bad odor
What does scant mean in wound drainage?
Wound tissue moist (no measurable drainage)
What does minimal mean in wound drainage?
Wound tissue very moist (<25% of dressing saturated with drainage)
What does moderate mean in wound drainage?
Wound tissue is wet (25-75% dressing saturated with drainage)
What does large mean in wound drainage?
Wound tissue is filled with fluid (>75% dressing saturated with drainage)
When would you consider debridement?
On black or yellow tissue (not red)
What is red tissue?
Granulation (firm, red, moist)
What are the different ways red tissue may present?
Paly dusky or beefy red
What is yellow tissue?
Slough
What are ways to describe yellow tissue?
Dry and adhered or stringy and wet
What is black tissue?
Eschar
What are ways to describe black tissue?
Firm or loosely attached
Wet or dry
What is epithelialization?
New, pink to white, shiny migrating healthy epithelium
What categories are chronic wounds classified into?
Pressure, diabetic/neuropathic, arterial, and venous
What test would you use for pressure ulcers?
National pressure injury advisory panel staging system
Braden or Norton scale
What tests would you use for arterial ulcers?
Rutherford grade and category 0-6
Fontaine classification Foot
What test would you use for venous ulcers?
CEAP classification
What test would you use for diabetic ulcers?
Diabetic Wagner scale 0-5
What test would you use for burns?
Depth (thickness)
Superficial, superficial partial, deep partial, full thickness
What may the ridge indicate on a surgical wound?
Normal healing
What is a type of mechanical debridement?
Pulsed lavage
What is the best type of debridement for an infected large sacral pressure injury covered in necrotic tissue?
Surgical
What is one reason you would never use autolytic debridement?
Infection
What dressings would you use with low exudate?
Hydrogel, transparent film, or hydrocolloid
What dressings would you use with high exudate?
Alginate, foam, or super absorbent
What does erythema mean?
Redness
What does ecchymosis mean?
Bruising
What does hemosiderin mean?
Darkened staining color
What is the main mechanism by which chronic wounds fail to heal?
Prolonged inflammatory process
Why would you do cross hatching or scoring on a wound?
To allow for enzymatic debridement to under the top
What are the best debridement methods for Eschar?
Sharp or enzymatic (do not debride if there is inadequate blood supply)
What is the fastest way to reduce slough?
Sharp debridement
What is debridement?
Removal of necrotic tissue from a wound to improve the healing process
What are the types of debridement?
Mechanical
Autolytic
Enzymatic
Surgical/sharp
Biologic
What does negative pressure wound therapy do?
Promotes wound contraction pulling granulation tissue to fill dead spaces
What does negative pressure wound therapy create?
Moist environment (fluid removal and edema reduction)
