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27 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Maceration |
Skin breakdown due to excessive moisture |
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Prevalence |
TOTAL number of cases that exist at any given time in a facility |
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Incidence |
rate of occurrence of new cases in a specific time frame |
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Shearing |
Skin moves in opposite direction from underlying tissue. Results in ripping of inner tissues |
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Periwound |
Tissue surrounding the wound itself that keeps the wound from spreading |
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Eschar |
Adherent, necrotic covering; can be black or yellow |
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Tunneling |
Erosion of tissue creating subcutaneous tracts/tunnels under wound margins |
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Undermining |
Erosion under wound margins |
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Skin ligaments (L. Retinacula cutis) |
Small fibrous bands which extend through the subcutaneous layer and attach the deep surface of the dermis to the underlying fascia |
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Tension Lines (Langer Lines) |
Keep skin under tension. Pattern like arrangement of collagen fibers, surgeons make incisions parallel with these lines as the body will heal with less scarring |
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How often do bed-bound and chair-bound person need repositioned? |
Bed-bound: every 2 hours Chair-bound: every hour |
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How often should chair-bound individuals shift their weight? |
Every 15 minutes |
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Patient positioning for bed bound patients to avoid pressure ulcers |
Do not use donut-type devices Reposition every 2 hours Keep boney prominence from direct contact with each other Avoid positioning on the trochanter Use devices that relieve pressure on heels Elevate head of bead as little and for as short a time as possible |
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Stage 1 Pressure Injury |
Non-blanching, closed wound (pink)
Superficial wound
Sensation changes may occur before redness appears |
Viable dressings: Semi-Permeable Films, Hydrocolloids, Composites, Specialty Absorptives, Wound Fillers |
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Stage 2 Pressure Injury |
Partial thickness w/ exposed dermis
Red in color
Usually result from.adverse microclimate and shear in skin over pelvis and/or heels |
Viable Dressings: Semi-Permeable Films, Composites, Specialty Absorptives, Wound Fillers |
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Stage 3 Pressure Injury |
Full thickness skin loss in which adipose is visible and granulation tissue and epibole (rolled wound edges) are often present.
Slough or eschar may be visible
Yellow in color |
Viable Dressings: Hydrogels, Hydrocolloids, Composites, Specialty Absorptives, Wound Fillers |
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Stage 4 Pressure Injury |
Full thickness skin and tissue loss.
Exposed muscle, bone, tendon, etc.
Slough and eschar may be visible
Epibole, undermining and/or tunneling can occur
Black in color |
Viable Dressings: Hydrogels, Composites, Specialty Absorptives |
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Unstageable Pressure Injury/Necrotic |
Obscured full thickness skin and tissue loss. If slough and/or eschar are removed it will reveal a Stage 3 or 4 wound Stable eschar should not be removed |
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Deep Tissue Pressure Injury (DTPI) |
Persistent, non-blanchable deep red, maroon, or purple discoloration. Injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface May evolve rapidly or resolve without issue |
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Mucosal Membrane Pressure Injury |
Pressure Injury found in mucosal membrane with a history of medical device in use at location of injury. Cannot be staged |
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Red Wound |
Granulation tissue and revascularization with definite borders of wound bed
Management Keep moist, clean, and protected |
Progress a yellow wound to a red wound |
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Yellow Wound |
Pus, debris, exudates with ivory to yellow or yellow-green wound bed. Management Cleanse, minor debridement, absorption of drainage |
Progress a black wound to a yellow wound |
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Black Wound |
Necrotic tissue/black eschar Management Debridement |
Progress a black wound to a yellow wound |
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Serous Exudate (transudate) |
Clear to pale yellow Thin & Transparent Does not adhere to wound bed No odor |
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Serosanguineous Exudate |
Clear/Red to Yellow/Red Thin to thick, may be transparent Does not adhere to wound bed No odor |
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Fibrinous Proteinaceous Exudate |
White to white/yellow Viscous, gelatinous, opaque Adheres to wound bed No odor |
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Purulent Exudate |
Yellow, brown, green Viscous and nontransparent Does not adhere to wound bed Has an odor, indicative of infection of exudate |
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