Wounds Flashcards
Partial thickness
tissue destruction through epidermis
Full thickness
tissue destruction through dermis to involve subq tissue and possibly bone/muscle
Stage I
erythema of intact skin; no blanching; warmth, edema, induration or hardness may also be indicators
Stage II
partial thickness to epidermis, dermis or both; superficial; clinically presents as an abrasion, blister or shallow crater
Stage III
full thickness w/ damage or necrosis of subq, may extend to underlying fascia; presents as a deep crater w/ or w/o undermining
Stage IV
full thickness w/ extensive necrosis or damage to muscle, bone or supporting structures; can have undermining or sinus tract
Non-stageable
wound is covered w/ eschar and/or slough and cannot be accurately staged until deepest viable layer is visable
Deep tissue injury
pressure-related deep tissue injury under intact
How do you measure wounds?
L x W x Depth; Length = head to toe; W = hip to hip
Tunneling
pathway that can extend in any direction from wound; results in dead space
Undermining
tissue destruction underlying intact skin along wound margines
Sinus tract
drainage pathway from deep focus of acute infection through tissue and/or bone to an opening on the surface
Sanguineous exudate
thing, bright red
Serosanguineous exudate
thin, watery, pale red to pink
Serous exudate
thin, watery, clear
Purulent exudate
thick or thin, opaque tan to yellow
Foul purulent exudate
thick opaque yellow to green w/ offensive odor
Scant amount
no measurable drainage
Small amount
drainage <25% of dressing
Moderate amount
drainage 25-75% of dressing
Large amount
drainage >75% of dressing
Nonadherent
easily separated from wound base
Loosely adherent
pulls away from wound but attached to wound base
Firmly adherent
does not pull away from wound
Slough
lighter in color; thinner and stringy consistency; color can be yellow, gray, white, green, brown
Eschar
darker in color; thicker and hard consistency; black or brown
Granulation tissue
beefy red, granular, bubly in appearance; should be differentiated from smooth red wound bed; color of tissue red, pink, pale or full dusky red
Indicators of infection
fever, streaking, redness, increased drainage, odor, warmth, elevated WBC, induration, malaise, edema, weeping, increased pain, discolorations
Epithelialization
can appear as deep pink & progress to pearly pink/light purple from edges in full thickness wound or may form islands in the wound base w/ superficial wounds
