Key Terms
Examples
Sterile petrolatum gauze, Telfa gauze; used with staples/sutures
NOTE
"closed wound" also refers to wound edges brought together (sutures, staples).
Assessment should include
Time since occurrence, damage to underlying structures, contamination potential, date of last tetanus shot.
DEFINITION
Localized ischemic lesion of skin and underlying tissue caused by external pressure impairing blood and lymph flow. Resu
Also called
Decubitus ulcers, bed sores, pressure sores.
Common bony prominences
Heels, sacrum, coccyx, greater trochanter.
Example
65 kg patient, 25% TBSA 4 x 65 x 25 = 6,500 mL over 24 hours First 8 hours: 3,250 mL; next 16 hours: 3,250 mL
Nursing response
Check skin frequently, keep linens dry and wrinkle- free, pad bony prominences, use proper lifting technique.
Additional risk factors
Advanced age, poor skin hygiene, loss of sensation, fractures, immunosuppression, diabetes, corticosteroid history, mult
BLANCHING
Temporary whitening of skin when pressure is applied. Normal = blood flow returns promptly after pressure released.
UNDERMINING
Erosion beneath the skin surface beyond visible wound edges
TUNNELING
Erosion in channels beneath intact skin surrounding a wound
SINUS TRACT
Cavity leading from abscess beneath the wound to the surface
Total score range
6 to 23. LOWER SCORE = GREATER RISK.
Thirteen items
Size, Depth, Edges, Undermining, Necrotic tissue type, Necrotic tissue amount, Exudate type, Exudate amount, Skin color