NRSG 301 Complex Dressings – Questions With
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Terms in this set (54)
What should you document on wounds after Medical - Location, measurements, periwound and edges
change the dressing? characteristics, wound bed characteristics (100%), drainage
characteristics (TACO), cleansing solution used, cover drsg
used
Surgical - locations, # of closures, REEDA, drainage
characteristics (serous, sanguineous, serosang, purulent),
drain type/amount/characteristics
What does a Braden Scale do? A Braden scale will help you determine the risk your patient
has for breakdown so that early intervention can reduce the
risk.
-must be done regularly to be effective, most hospitals have
moved to every shift or 24 hours
What are the stages of wound healing and Stage 1
how are they down staged? Stage 2
Stage 3
Stage 4
Stage X or N (unstageable)
Stage SDTI (suspected deep tissue injury)
As pressure ulcers heal they are not down staged, they are
classified granulated stage ___
because lost muscle, fat and dermis are not replaced,
granulation tissue just fills in the defect
How do you categorize a stage 1 pressure - Non blanchable erythema of intact skin
ulcer? - Discoloration of skin, warmth or hardness also may be
indicators
- Area of intact skin with local, non-blanchable erythema
[redness] with a change in temperature or firmness
- With darker pigmented skin, the colour of the area may differ
from adjacent skin
, How do you categorize a stage 2 pressure - Partial thickness skin loss involving epidermis and/or dermis
ulcer? - Presents as an abrasion, blister or shallow crate
- tissue loss showing viable, pink or red, moist with a distinct
wound margin
- May present as an intact or ruptured serum-filled blister
- Slough/eschar are not present
How do you categorize a stage 3 pressure Full thickness skin loss involving damage or necrosis of
ulcer? subcutaneous tissue that may extend down to, but not
through, underlying fascia
- Slough/eschar is initially present
- Healing wounds show granulation tissue
- Rolled edges may be visible in chronic wounds
how do you categorize a stage 4 pressure Full thickness skin loss with extensive destruction, tissue
ulcer? necrosis or damage to muscle, bone or supporting structure
(tendon, joint capsule)
- damage through SC adipose layer, fascia, muscle, tendon,
ligament, cartilage or bone may be present
- Slough/eschar is initially may be present
- Healing wounds show granulation tissue
- Rolled edges may be visible in chronic wounds
How do you categorize a stage X or N Unable to determine depth of the wound due to presence of
pressure ulcer? thick eschar
What is suspected deep tissue injury? - Usually intact skin
- Purple or maroon localized are of discoloration of intact skin
or blood-filled blister that indicated deep tissue damage
- Painful, firm or mushy/boggy
- Can deteriorate rapidly
- Dusky, boggy or discolored area of purple, maroon,
ecchymosis or a blood filled blister
- If wound bed is covered with slough/eschar it is unstageable
until visible and then restaged as 3 or 4
What is the treatment of stage 1 pressure Stage 1 - relieve pressure protect with barrier cream, prevent
ulcers? from becoming worse, protect
What is the treatment of stage 2 pressure Stage 2 - relieve pressure, no dressing or dressing to absorb
ulcers? drainage, debride slough if present, protect
What is the treatment of stage 3 pressure Stage 3 - relieve pressure, debride slough/eschar if present,
ulcers? pack sinus tracts and undermining, dressing to absorb
drainage, decrease bacterial load, protect
What is the treatment of stage 4 pressure same as stage 3
ulcers?
What is general treatment of pressure Ensure assessment of risk factors for poor healing as well and
ulcers? address those issues
What are the risk factors for pressure Poor nutritional status, advanced age, impaired O2 status,
ulcers? smoking/substance use, impaired immobility, decreased
activity tolerance, moisture, shearing , friction
Comprehensive Solutions
Save
Students also studied
WSC 2026: Are we there yet? Social Science Nationalism Vocab T... WSC 2026 Next Year
Teacher 156 terms 21 terms Teacher 50 terms
Amy_Woodall4 Preview Keiya_Raja Preview Sandywu1205
Terms in this set (54)
What should you document on wounds after Medical - Location, measurements, periwound and edges
change the dressing? characteristics, wound bed characteristics (100%), drainage
characteristics (TACO), cleansing solution used, cover drsg
used
Surgical - locations, # of closures, REEDA, drainage
characteristics (serous, sanguineous, serosang, purulent),
drain type/amount/characteristics
What does a Braden Scale do? A Braden scale will help you determine the risk your patient
has for breakdown so that early intervention can reduce the
risk.
-must be done regularly to be effective, most hospitals have
moved to every shift or 24 hours
What are the stages of wound healing and Stage 1
how are they down staged? Stage 2
Stage 3
Stage 4
Stage X or N (unstageable)
Stage SDTI (suspected deep tissue injury)
As pressure ulcers heal they are not down staged, they are
classified granulated stage ___
because lost muscle, fat and dermis are not replaced,
granulation tissue just fills in the defect
How do you categorize a stage 1 pressure - Non blanchable erythema of intact skin
ulcer? - Discoloration of skin, warmth or hardness also may be
indicators
- Area of intact skin with local, non-blanchable erythema
[redness] with a change in temperature or firmness
- With darker pigmented skin, the colour of the area may differ
from adjacent skin
, How do you categorize a stage 2 pressure - Partial thickness skin loss involving epidermis and/or dermis
ulcer? - Presents as an abrasion, blister or shallow crate
- tissue loss showing viable, pink or red, moist with a distinct
wound margin
- May present as an intact or ruptured serum-filled blister
- Slough/eschar are not present
How do you categorize a stage 3 pressure Full thickness skin loss involving damage or necrosis of
ulcer? subcutaneous tissue that may extend down to, but not
through, underlying fascia
- Slough/eschar is initially present
- Healing wounds show granulation tissue
- Rolled edges may be visible in chronic wounds
how do you categorize a stage 4 pressure Full thickness skin loss with extensive destruction, tissue
ulcer? necrosis or damage to muscle, bone or supporting structure
(tendon, joint capsule)
- damage through SC adipose layer, fascia, muscle, tendon,
ligament, cartilage or bone may be present
- Slough/eschar is initially may be present
- Healing wounds show granulation tissue
- Rolled edges may be visible in chronic wounds
How do you categorize a stage X or N Unable to determine depth of the wound due to presence of
pressure ulcer? thick eschar
What is suspected deep tissue injury? - Usually intact skin
- Purple or maroon localized are of discoloration of intact skin
or blood-filled blister that indicated deep tissue damage
- Painful, firm or mushy/boggy
- Can deteriorate rapidly
- Dusky, boggy or discolored area of purple, maroon,
ecchymosis or a blood filled blister
- If wound bed is covered with slough/eschar it is unstageable
until visible and then restaged as 3 or 4
What is the treatment of stage 1 pressure Stage 1 - relieve pressure protect with barrier cream, prevent
ulcers? from becoming worse, protect
What is the treatment of stage 2 pressure Stage 2 - relieve pressure, no dressing or dressing to absorb
ulcers? drainage, debride slough if present, protect
What is the treatment of stage 3 pressure Stage 3 - relieve pressure, debride slough/eschar if present,
ulcers? pack sinus tracts and undermining, dressing to absorb
drainage, decrease bacterial load, protect
What is the treatment of stage 4 pressure same as stage 3
ulcers?
What is general treatment of pressure Ensure assessment of risk factors for poor healing as well and
ulcers? address those issues
What are the risk factors for pressure Poor nutritional status, advanced age, impaired O2 status,
ulcers? smoking/substance use, impaired immobility, decreased
activity tolerance, moisture, shearing , friction
