Day 1-4 - Answer-wound is red, has swelling or edema and drainage
Days 5-14 - Answer-Bright pink, continues to get lighter and lighter in color
Days 15 to a year - Answer-pale pink, lighter color
serous exudate - Answer-clear color, thin in consistency, like watery substance
sanguinous ...
stage one pressure ulcer - Answer-no blister
Non-blanchable erythema
Can be painful, may feel warmer or colder than surrounding skin
For dark skin individuals, look at surrounding skin, assess for difference in temperature,
can feel squishy, touch it and if you cannot see a color change it is non-blanchable
erythema.
stage two pressure ulcer - Answer-Intact blister
OPEN wound
wound edges are not intact
wound bed is red, moist
Cant see anything deeper like muscle tendon or bone. Very shallow and minimal of
tissue.
stage three pressure ulcer - Answer-full thickness loss, very open wound
Tunneling is present as well as undermining
Wound is red/pink and is painful, very moist, no drainage present
Slough (yellow stringy substance that becomes thick and attaches to tissues) is not a
sign of infection, a good sign
Use wet to dry dressings to remove slough
Infection has an odor
Granulation tissue should appear pink and moist.
, stage four pressure ulcer - Answer-visible tendon, bone and muscle. Leads to tunnels,
undermining, white skin surrounding wound= not healing.
slough - Answer-yellow stringy substance that becomes thick and attaches to tissues
eschar - Answer-black leather thick scab, NEVER remove unless in the operating room
dry wound dressing - Answer--Used for wounds healing by primary intention
-Dry gauze used to absorb minimal drainage
wet wound dressing - Answer-add moisture if the wound bed is too dry, soak dressing is
sterile saline
Be gentle when removing if dressing has become dry to prevent damage to tissue.
open wound dressing - Answer-you can see through it, mesh-like, air and drainage can
go through it, use for wet to dry dressings because it allows air flow to go through
semi-open wound dressing - Answer-has three layers, in the middle has a nice thick
layer, outside has open style
semi-occulsive wound dressing - Answer-primarily used to cover a wound
- films
- hydrocolloids
- alignate
- hydrofiber
- foams
- polymeric membranes
- hydrogels
films dressing - Answer-Transparent dressing
Can see through it
IV in place, transparent dressing will be placed over IV, does not pick up any moisture,
often used for skin tears, Does not promote wound healing
Used as a protectant light
hydrocolloids dressing - Answer-water-filled dressing for a dry wound
add moisture to the wound bed
Promotes granulated tissue growth, when it breaks down, it becomes like a jelly-like
substance, don't confuse with infection
alignate dressing - Answer-Irreversible hydrocolloid material used for taking preliminary
impressions
made of algae, soaks up drainage
Can stay on for several days, does not need change often; minimizes pulling/destroying
of skin that occurs with changing dressing
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