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28 Cards in this Set
- Front
- Back
What is the descriptive term for the yellow tissue?
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Slough
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What is the descriptive term for exudate that is clear, thin, and watery?
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Serous
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What is the descriptive term for exudate that is thin, watery, pale red to pink?
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Serosanguineous
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Wound measurements should be recorded in what order?
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Length X Width X Depth
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Wounds should be measured utilizing inches, centimeters, or fruit comparisons?
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Centimeters
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Length of a wound is measured from head to toe (12:00 - 6:00) or side to side (3:00-9:00)?
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Consider wound as face of clock. 12:00 points to patients head, 6:00 points toward patient’s feet.
Length = 12:00 – 6:00 using patients head & feet as guides Width = 3:00 – 9:00 side to side |
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What is the correct terminology for the black tissue?
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Eschar
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What is the correct terminology for the red bubbly tissue?
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Granulation
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What is the correct terminology for the light pink tissue seen at the edge of this wound?
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Epithelial
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What is the terminology for the white pale tissue?
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Maceration
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What is the red striated tissue seen in this wound?
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Muscle
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What is the name of the rolled tissue around the wound edges?
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Epibole
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What am I? A course or pathway that can extend in any direction from the wound, results in dead space with potential for abscess formation.
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Tunnel
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What am I? Tissue destruction underlying intact skin along the wound margins.
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Undermining
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What pressure ulcer stage?
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Stage I
Intact skin with non-blanchable redness of a localized area usually over a bony prominence |
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What pressure ulcer stage?
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Suspected deep tissue injury
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. |
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What pressure ulcer stage?
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Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
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What pressure ulcer stage?
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Un-stageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
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What pressure ulcer stage?
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Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
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What pressure ulcer stage?
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Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.
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What is the terminology for the brown discoloration around this wound?
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Hemosiderin staining
Hyper-pigmentation stain of skin from leakage of red blood cells into the tissue (Results from venous hypertension) |
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Where are venous ulcers typically located?
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Medial lower leg, ankle, malleolar area
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What type of wounds are categorized using the Payne-Martin Classification?
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Skin Tears
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What is the Braden Scale used for?
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Determining pressure ulcer risk
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Where are arterial ulcers typically located?
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Between toes or tips of toes, over phalangeal heads, around lateral malleolus or areas subjected to trauma/rubbing footwear.
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What is the anatomical terminology for toward the middle? Away from the middle?
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Medial - toward middle
Lateral - away from middle |
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How often should wounds be assessed?
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Upon every dressing change, and documented at least weekly.
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Where are neuropathic (diabetic) ulcers typically located?
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Planter aspect of foot, under metatarsal heads, under heel and toes.
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