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Terms in this set (178)

Stage 1
-Intact skin with nonblanchable redness: just stays red if pressed on, indicated deeper tissue damage
-Warmth
-Edema
-Hardness over area: tautness from buildup
-Painful to touch

Stage 2
-Partial thickness loss
-Loss of dermis layer: blister that popped
-Shallow open ulceration: Red-pink wound bed; Shiny or dry shallow: shallow big blister that popped and caused opening; NO sloughing: whitish connective tissue; NO bruising
-Blistering: Serum filled
-Serosanguineous filled

Stage 3
-Full thickness loss
-Loss of subcutaneous fat: Staging varies by anatomical location: some areas like abdomen and hip have more SQ fat, more rapid in areas without fat
-Bone, tendon, muscle are NOT exposed; Sloughing may be present: whitish stringy material is sloughing, needs to be removed for wound to heal

Stage 4
-Exposed bone, tendon, muscle and SQ fat
-Directly palpable
-Undermining and tunneling
-Depth varies by anatomical location: needs to be addressed, moves faster where there is less fat
-Damage can extend to fascia, tendon
-joint capsule: can be permanent
-Osteomyelitis or osteitis: infection of bone, septic or limb loss
-Osteitis: inflammation of bone

Suspected deep tissue injury
-Purple or maroon localized area
--Skin is intact
--Blood filled blistering: could be from hemorrhaging
-Caused by damage to soft tissue
--Pressure
--Shear force
-Painful
-Firm, mushy, boggy
-Warm or cool when compared to skin: cool would be with ischemia

Un-stageable
-there is lots of sloughing and eschar built up so you can't see actual wound bed to stage it: wound requires debridement so you can stage it
-Depth of ulcer is obscured: Slough; Eschar: has to be debrided
-Debridement is needed for evaluated depth
-Use wet healing with eschar

*packing sterile gauze b/c Want wound to heal FROM INSIDE OUT