• Deep tissue injury may be difficult to detect in individuals with dark skin tone. Blue-green drainage combined with a musty odor usually indicates presence of Pseudomonas in the wound. The skin surrounding a wound is particularly vulnerable and although it may appear healthy, periwound problems occur frequently. If the skin flap is viable (category 1 or 2), gently ease it back into place to use as a dressing (using a gloved finger, dampened cotton tip, tweezers or silicone strip). pink / red tissue on the edges may indicate epithelialisation; maceration may be indicative of an ineffective dressing regime. The description of the spectrum as a single number is obtained by adding a weighting number to each octave band and logarithmically adding the octaves together. The skin contains abundant nerve endings and receptors to detect stimuli related to temperature, touch, pressure and pain. Here are some terms referring to wounds that you should become familiar with. WOUND/SKIN RECORD NAME–Last First Middle Attending Physician Record No. The wound bed is viable, pink or red, and moist, or injury may manifest as an intact or ruptured serum-filled blister. Secondary Intention. The bed is the base of the wound, often tissue that contains viable cells. ANS: 2. Skin • Describe the differences of wound healing by primary and secondary intention. Utilize correct anatomical descriptions and verbiage for documentation. Adipose (fat) is not visible, and deeper tissue is not visible. If the skin is very fragile, consider using a non-adhesive dressing such as Biatain Non-adhesive or Biatain Alginate. What is the description of a Stage 2 pressure injury? (1) Abrasion. WOUND/SKIN HEALING RECORD DIRECTIONS: Use a separate sheet for each pressure injury site. C. Physical Characteristics 1. Start antibiotics. • Describe the pressure ulcer staging system. 2. a. In a closed wound or bruise, the soft tissue below the skin surface is damaged, but there is no break in the skin. The A weighting is widely used. Peri Wound Skin Classification Grade Type Description 0 Normal skin 1 At risk skin 2 (Exudate Centred) A Dessication B Maceration C Allergy 3 Inflammed 4 Infection 5 Atypical Dr. Harikrishna K.R.Nair 2015 49. Table 1. Close. The weighting recognises that the ear is more sensitive to sound in the range 1–4 kHz than at higher or lower frequencies. Determine anatomical wound location. Surrounding skin: The surrounding skin should be examined carefully as part of the process of assessment and appropriate action taken to protect it from injury. The condition of the skin surrounding the wound provides important information about underlying disease and the effectiveness of current treatment regimes, e.g. Source: International advisory board of wound bed preparation 2003 50. This wound occurs when shearing, friction or trauma causes a separation of skin layers. Granulation tissue, slough, and eschar are not present. Compare and contrast a normal and an… Infection: Wounds are often prone to infection, which can significantly disrupt the healing process. Inferior – Down c. Anterior – Front d. Posterior – Back e. Medial - Towards middle f. Lateral - Away from middle D. Wound Measurement - Linear 1. NEW Skin Condition, Wound(s)/Pressure Ulcers(s) ONLY Identification This front section (Identification) is to be completed by the person(s) who observe any NEW skin condition, wound(s)/pressure ulcer(s). Record text where indicated (line). absorb exudate; to produce a moist environment that facilitates healing but does not cause maceration of surrounding skin; protect the wound from bacterial contamination, foreign debris, and urine or feces; prevent shearing. With proper wound treatment and use of dressings with superior absorption and exudate management, the skin surrounding a wound may be perfectly healthy and suitable for adhesive dressings such as Biatain Adhesive or Biatain Super Adhesive. Show More Wound Terminology. Clean and or irrigate the wound. List six factors to consider when assessing darkly pigmented skin. 2. Hydrogel sheets and nonadhesive forms are useful for securing a wound dressing when the surrounding skin is fragile. Superior – Up b. Surgical site infection (SSI) This complication occurs after a medical procedure, causing the surgical wound, tissue or nearby organ space to become infected. Several studies have examined the impact of chronic wound fluid on the wound environment. However, compression therapy remains the Consider the wound location, size, depth, exudate level, and presence of infections. 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