| A | B |
|---|
| Braden scale | Risk factor predictor |
| Stage I ulcer | change in skin temperature (warm or cool), firm or baggy tissue, persistant redness |
| Stage II ulcer | partial thickness skin loss, abrasion, blister, or shallow crater, involves epidermis or dermis |
| Stage III ulcer | Full thickness skin loss involving damage or necrosis of sc tissue that may extend to but not through underlying fascia |
| Stage IV ulcer | Full thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structure such as tendon or joint capsule |
| Ischemia | Deficient blood supply |
| Abrasion | Open surface wound due to scraping |
| Excoriation | Area of superficial skin loss |
| Slough | Yellow liquid or semi liquid accompanied by purulent drainage/exudate |
| Exudate | Material such as fluid and cells that has escaped from blood vessels during inflammatory process |
| Eschar | Thick, dry tissue that results from tissue death due to ischemia, bacteria putrefaction-may appear yellow or black-prevents wound healing |
| Necrotic | Dead tissue that appears dry and black in color-prevents wound healing |
| Granulation | Young connective tissue with new capillaries formed in wound healing process-tissue is red in color, fragile and bleeds easily |
| Autolytic debridement | Selective method that takes longest, but causes the least damage to healthy surrounding tissue-not appropriate for infected wounds |
| Mechanical debridement | Accomplished through scrubbing force or wet to damp dressings-non selective and can be painful |
| Enzymatic debridement | Chemical and natural enzymes that breakdown necrotic tissue is more selective than sharp or mechanical techniques |
| Sharp debridement | Uses a scalpel or scissors to seperate and remove dead tissue |
| RYB method-Red wounds | Cover (protect), wounds are generally in the late regeneration phase of tissue repair. |
| RYB method-Yellow wounds | Characterized by liquid to semi liquid slough that is often accompanied by purulent drainage |
| RYB method-Black wounds | Wounds are covered with thick necrotic tissue, or eschar |
| RYB method | Color code of wounds, based on the color of the open wound, rather than the size or depth |
