Wound Staging Exam 2 Flashcards
What is the definition of a pressure injury?
Localized injury to the skin and underlying tissue, usually over a bony prominence
What scale is used to assess a client’s risk for pressure injuries?
Braden Scale
Name a contributing factor that compresses small blood vessels and hinders blood flow.
Pressure
What effect does moisture have on the skin in relation to pressure injuries?
Macrates the skin
What is shear in the context of pressure injuries?
When one layer of skin slides horizontally over another, compressing tissue
List risk factors for pressure injuries.
- Impaired circulation
- Reduced oxygen supply
- Limited mobility or reduction in sensation
*Poor nutrition, dehydration and
Advanced age
What characterizes Stage 1 of a pressure injury?
Localized area of intact skin with nonblanchable redness
What does Stage 2 pressure injury involve?
Partial-thickness loss of dermis, a blister is stage 2
What is visible in Stage 3 pressure injuries?
Adipose tissue seen, full thickness loss with damage of subcutaneous tissue.
What distinguishes Stage 4 pressure injuries?
Full-thickness skin loss with exposed bone or tendon
What is a Deep Tissue Injury (DTI)?
Intact skin that is persistently discolored, purplish or deep red
What defines an unstageable pressure injury?
Full-thickness skin loss with base obscured by slough or eschar
What are examples of medical devices associated with pressure injuries?
- Feeding tubes
- Intravenous catheters
- Orthopedic devices
What are Hospital Acquired Pressure Injuries (HAPIs)?
Pressure injuries that occur during hospitalization
What is a mucosal membrane pressure injury?
Injury to a mucous membrane caused by pressure from a foreign device
What is the gold standard method for obtaining a wound culture?
Tissue biopsy
Name one antiseptic solution that should not be used on healing tissue.
Hydrogen peroxide
What is the purpose of normal saline in wound cleaning?
It is safe and will not harm injured or healing tissue
Fill in the blank: _______ is isotonic and similar to the body.
Normal saline
What are the goals of wound dressing?
- Prevent drying of the wound bed
- Absorb drainage
- Protect from contamination
What is a physiological wound environment?
Maintains the right amount of moisture for cells to flourish
What is a wet-to-dry dressing?
Coarse gauze moistened with normal saline packed into the wound
What is a method of debridement that uses maggots?
Biotherapy
What is SANTYL Ointment used for?
Removes dead tissue from wounds for healing
What is Algidex Ag+ wound dressing designed to support?
An optimal moist wound environment
Friction is?
when skin is moist, fragile, or rubbed against another surface (wrinkled sheets).
Interventions for wound care
What nutrition is important to give for wound healing?
Protein
Blanchable vs nonblanchable?
nonblanchable- no circulation
blanchable- color returns- has circulation
What is a HAPI
Hospital acquired pressure injury during stay. chronic conditions diabetes are at risk
Common injuries come from
incubation and Foley insertions.
Wound Culture
done by provider- standard for a tissue biopsy
Prevent wound bed from drying out
Wet to Dry dressing
NS is packed in towel to wound and removed after drying
