Wound Drainage + Stages Flashcards
Stage I Pressure Ulcers
The beginning
Intact skin has developed redness or blue - gray discoloration that does not go away within 30 minutes after pressure has been relieved
Is usually reversible if the area is identified quickly and pressure is relieved
Stage II Pressure Ulcers
Skin is reddened and there are abrasions, blisters, or a shallow crater at the site
Surface skin often peels or cracks open
Surrounding skin may also be reddened
Can quickly progress if it isn’t addressed
Stage III Pressure Ulcers
All layers of the skin are destroyed and a deep crater has formed
The underlying fat and tissue are visible
Muscle, tendon and bone are NOT visible
Stage IV Pressure Ulcers
Resembles a crater with damage all the way to the muscle and bone
Patient is at the greatest risk of infection
Serous Exudate/Drainage
Clear, thin, watery
This type of drainage is normal/typical response from the body during the normal inflammatory healing stage
Sanguineous
-Bright Red
Normal if it occurs during the inflammatory healing stage where a small amount of blood may leak from a full ( all layers are affected) or partial thickness wound ( epidermis and some dermis is affected)
Fresh blood and will usually stop after a few hours
Deeper wounds or bigger incisions will last longer
** If outside the inflammatory phase could be a result of trauma to a wound
Serosanguinous
Thin, pink/reddish, and watery in presentation- more red- active bleed
Most common type of drainage from a wound
Where the dressing needs to be changed on a more regular basis
Damage to capillaries- normal part of healing process- dressing or tape get stuck and damages surface area
Think of taking a bandaid off and scab comes off a little- a little fresh blood is not uncommon
Purulent
Milky, typically thicker in consistency and can be gray, green, brownish or yellow in appearance
**If fluid becomes very thick this can be a sign of infection
