Skin integrity and wound care Exam Test Marking Scheme New Update

Skin integrity and wound care Exam Test Marking Scheme New Update What is a pressure injury? - Answer -localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device What are other terms that have been used in the past for a pressure injury? - Answer -pressure sore, pressure ulcer, decubitus ulcer, or bedsore What is the description of a Stage 1 pressure injury? - Answer -Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury What is the description of a Stage 2 pressure injury? - Answer -Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, and moist, or injury may manifest as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissue is not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel What is the description of a Stage 3 pressure injury? - Answer -Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer, and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (skin separates from the underlying tissue at the wound margins creating areas of tissue damage below the skin surface and less damage at the surface) and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, or bone is not exposed. What is the description of a Stage 4 pressure injury? - Answer -Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and tunneling often occur. Depth varies by anatomical location. What is eschar? - Answer -dead tissue (it is usually dry, thick, leathery, brown, or black) What is slough? - Answer -soft, moist, devitalized tissue that may be yellow, tan, or green and either loose or firmly adherent What is epibole? - Answer -rolled or curled-under closed wound edges that may be dry, callused, or hyperkeratotic What stage is a pressure injury if it is covered with eschar or slough? - Answer -It is unstagable What is intertriginous dermatitis (ITD)? - Answer -inflammation of skin where two surfaces rub such as groin, beneath breasts, and underarm area What is osteomyelitis? - Answer -an infection of the bone osteomyelitis may be present in stage 4 pressure injuries What is a deep tissue pressure injury? - Answer -Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.