Assessment of Pressure injurys/wounds - answers-- Is Skin hot, tenderto touch
- Damaged Tissue
- Guarding
- Color Changes
- Swelling
- Itchy
- Type, Location, Size,Degree, Drainage
- Predictive
Measures
▪ Braden Scale, etc.
- Mobility
- Nutritional status
- Body fluids
- Pain
- Sensation
- What Caused the Wound?
Primary Intention - answers-approximated edges kept together to heal
Secondary Intention - answers-left open, healed with scar formation
Tertiary Intention - answers-Delayed closure of a wound after infection.
Stages of Healing - answers-Inflammatory phase, proliferative phase, maturation
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