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28 Cards in this Set

  • Front
  • Back
What is the descriptive term for the yellow tissue?
What is the descriptive term for exudate that is clear, thin, and watery?
What is the descriptive term for exudate that is thin, watery, pale red to pink?
Wound measurements should be recorded in what order?
Length X Width X Depth
Wounds should be measured utilizing inches, centimeters, or fruit comparisons?
Length of a wound is measured from head to toe (12:00 - 6:00) or side to side (3:00-9:00)?
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
What is the correct terminology for the black tissue?
What is the correct terminology for the red bubbly tissue?
What is the correct terminology for the light pink tissue seen at the edge of this wound?
What is the terminology for the white pale tissue?
What is the red striated tissue seen in this wound?
What is the name of the rolled tissue around the wound edges?
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.
What am I? Tissue destruction underlying intact skin along the wound margins.
What pressure ulcer stage?
Stage I
Intact skin with non-blanchable redness of a localized area usually over a bony prominence
What pressure ulcer stage?
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.
What pressure ulcer stage?
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.
What pressure ulcer stage?
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.
What pressure ulcer stage?
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.
What pressure ulcer stage?
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.
What is the terminology for the brown discoloration around this wound?
Hemosiderin staining
Hyper-pigmentation stain of skin from leakage of red blood
cells into the tissue
(Results from venous hypertension)
Where are venous ulcers typically located?
Medial lower leg, ankle, malleolar area
What type of wounds are categorized using the Payne-Martin Classification?
Skin Tears
What is the Braden Scale used for?
Determining pressure ulcer risk
Where are arterial ulcers typically located?
Between toes or tips of toes, over phalangeal heads, around lateral malleolus or areas subjected to trauma/rubbing footwear.
What is the anatomical terminology for toward the middle? Away from the middle?
Medial - toward middle
Lateral - away from middle
How often should wounds be assessed?
Upon every dressing change, and documented at least weekly.
Where are neuropathic (diabetic) ulcers typically located?
Planter aspect of foot, under metatarsal heads, under heel and toes.