Wound Care

• Stages of Wound Healing

  Inflammatory Phase - Initiated immediately after the injury and lasts 3-6 days
• Stages of Wound Healing

  Proliferative Phase - 2nd phase; extends from day 3 or 4 to about day 21 post-injury
• Stages of Wound Healing

  Maturation or Remodelling Phase - Begins on about day 21 and can extend 1 or 2 years after injury
• Stages of Wound Healing

  Maturation Phase - Keloid formation
• Pressure Ulcer Staging

  Stage I - Redenned areas that do not blanch with pressure and do not clear in the alloted amount of time
• Pressure Ulcer Staging

  Stage II - Partial thickness skin loss and have the appearance of abrasions, blisters, or shallow craters
• Pressure Ulcer Staging

  Stage III - Involves subcutaneous tissue, fat
• Pressure Ulcer Staging

  Stage IV - Involves muscle, bone, tendons, or the joint capsule
• Pressure Ulcer Staging

  Unstageable - Eschar present
• Wound Exudate

  Serous - Water
• Wound Exudate

  Serosanguineous - Watery with RBC
• Wound Exudate

  Sanguineous - Red due to high RBC
• Wound Exudate

  Purosanguineous - Pus with RBC
• Wound Exudate

  Purulent - Thick; can be green or yellow; e.g. pus