Classify Ulcer: Non-blanchable redness of a localized area, usually on a bony prominence
Stage 1 ulcer
Classify Ulcer: partial-thickness skin loss involving epidermis, dermis, or both?
Stage 2 pressure ulcer
Classify Ulcer; full-thickness tissue loss
Stage 3 pressure ulcer
Classify ulcer: full-thickness tissue loss with exposed bone, tendon, or muscle, slough or eschar may be present
Stage 4 pressure ulcer
Red moist tissue composed of new blood vessles, the presence of which indicates progression toward healing?
Stringy substance attached to wound bed?
Black or borwn necrotic tissue?
The amount, color, consistency and odor of wound drainage and is part of wound assessment?
surgical wound (a wound with little tissue loss, clean incision; skin edges are approximated/close/little risk for infection)?
Primary intention wound healing
burn, pressure ulcer, severe laceration (wound involving loss of tissue; left open until becomes filled with scar tissue. Skin edges not approximated/longer healing time/greater chance for infection)?
Secondary intention wound healing
contaminated wounds (wound left open for several days, then wound edges are approximated)?
Tertiary intention wound healing
Pressure ulcers are also known as:
defined = impaired skin integrity due to unrelieved prolong pressure