Sync Flashcards
(46 cards)
Abnormal firmness of the tissues with palpable margins
Induration
Woody fibrosis of the skin
Lipodermatosclerosis
Red moist tissue raised above the level of the skin
Hypergranulation
Abnormal thickening of the epidermis
Hyperkeratosis (callous)
When would a pressure wound be considered unstageable?
Covered with Eschar or slough (cannot see the wound)
What are the components required to describe a wound?
Wound location
Wound size
Tissue present
Wound edge
Periwound
Odor or exudate
Serous exudate
Thin, watery, clear
Sanguineous exudate
Thin, bright red, fresh bleeding
Serosanguinous exudate
Thin, watery, pale red to pink
Perulent exudate
Thick or thin, yellow
Foul purulent exudate
Yellow to green with bad odor
What does scant mean in wound drainage?
Wound tissue moist (no measurable drainage)
What does minimal mean in wound drainage?
Wound tissue very moist (<25% of dressing saturated with drainage)
What does moderate mean in wound drainage?
Wound tissue is wet (25-75% dressing saturated with drainage)
What does large mean in wound drainage?
Wound tissue is filled with fluid (>75% dressing saturated with drainage)
When would you consider debridement?
On black or yellow tissue (not red)
What is red tissue?
Granulation (firm, red, moist)
What are the different ways red tissue may present?
Paly dusky or beefy red
What is yellow tissue?
Slough
What are ways to describe yellow tissue?
Dry and adhered or stringy and wet
What is black tissue?
Eschar
What are ways to describe black tissue?
Firm or loosely attached
Wet or dry
What is epithelialization?
New, pink to white, shiny migrating healthy epithelium
What categories are chronic wounds classified into?
Pressure, diabetic/neuropathic, arterial, and venous