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-ve pressure wound edges are drawn in
Debridement
Disposeable paper ruler
Dressing left intact 3-5 days
Epithelium should be pink/mauve colour
Granulation
Hypergranulation
Macerated
Measure length on the Sagittal plane
Measure width length on the transverse plane
Necrotic eschar
Necrotic slough
Opsite/Mepore/Fixomull/Mefix suitable for surgical dressing
PI Stage 1 - skin is intact recovery aim
PI Stage 2 - clean superficial partial thickness
Poor quality granulation is grey/brown/red colour
Pressure injuries have 6 classifications
Risk factors for poor wound health - obesity poor diet diabetes smoking age
Simple abrasion management includes Mepitel
Stage 1 - injury in epidermis
Stage 11 - injury to epidermis and dermis
Stage 111 - injury extends to the subcutaneous tissues
Stage 1V - injury extends to muscle and bone
Surgical wounds heal through inflammation proliferation epithelialisation maturation
Transverse plane runs at 90 degrees to Sagittal plane