wound
ATI skills module / Complete Study
Guide / 110+ Questions & Detailed
Answers
QUESTION ANSWER
physical visual assessment for location, size, shape, color, exudate, bleeding, any tissue
the wound should include impair healing and any tissue that helps healing
any tissue that impairs healing necrosis, erythematous, infected tissue, tunneling,
includes undermining edema
any tissue that helps healing
granulating tissue and clean wound edges
includes
temperature includes warm- indication of infection cold- vascular compromise
textual changes includes raising, tunneling or deep * interrupts skin color
knowing the cause of the wound and can detect specific
odor includes
infectious organisms
coping with stress , body image changes, self concept
psychosocial impacts include
and sexuality
what device is used to measure
rulers, measure length, width and depth
stages of wounds
an area that is compromised typically over a bony
pressure injury is
prominence due to prolonged pressure
, the two risk factors of pressure
friction and shearing
injuries are
the rubbing of the skin's surface, irritating the epithelial
friction is
tissue
common sites for pressure occipital bone, spinous process, heel, medial/lateral
injuries include malleolus, ischium, sacrum, trochanter
when the skin stays in place but the subcutaneous
shearing is
tissue shifts
stretching and breakage of the blood vessels leading to
shearing can lead to
soft tissue ischemia
the risk of shearing can be keeping the HOB less than 30 to prevent gravity from
reduced by shifting a person down
moisture related breakdown can wound drainage, gastric drainage, incont x2 and
occur from perspiration
2 hrs especially when they are immobile to prevent
reposition clients every
pressure injury from occuring
who created the pressure injury
national pressure injury advisory panel
staging system
an area that is discolored , skin is intact but is due to
suspected deep tissue injury is
damage to the underlying tissue
nonblanchable redness that is caused by pressure
stage 1 pressure injury is
typically over a bony prominence
partial thickness skin loss with visible or fluid filled
stage 2 pressure injury is
blister
full thickness skin loss without exposed muscle or bone
stage 3 pressure injury is
with a possibility of undermining or tunneling
full thickness skin loss with exposed muscle or bone
stage 4 pressure injury is with a possibility of undermining or tunneling and
eschar or slough
ATI skills module / Complete Study
Guide / 110+ Questions & Detailed
Answers
QUESTION ANSWER
physical visual assessment for location, size, shape, color, exudate, bleeding, any tissue
the wound should include impair healing and any tissue that helps healing
any tissue that impairs healing necrosis, erythematous, infected tissue, tunneling,
includes undermining edema
any tissue that helps healing
granulating tissue and clean wound edges
includes
temperature includes warm- indication of infection cold- vascular compromise
textual changes includes raising, tunneling or deep * interrupts skin color
knowing the cause of the wound and can detect specific
odor includes
infectious organisms
coping with stress , body image changes, self concept
psychosocial impacts include
and sexuality
what device is used to measure
rulers, measure length, width and depth
stages of wounds
an area that is compromised typically over a bony
pressure injury is
prominence due to prolonged pressure
, the two risk factors of pressure
friction and shearing
injuries are
the rubbing of the skin's surface, irritating the epithelial
friction is
tissue
common sites for pressure occipital bone, spinous process, heel, medial/lateral
injuries include malleolus, ischium, sacrum, trochanter
when the skin stays in place but the subcutaneous
shearing is
tissue shifts
stretching and breakage of the blood vessels leading to
shearing can lead to
soft tissue ischemia
the risk of shearing can be keeping the HOB less than 30 to prevent gravity from
reduced by shifting a person down
moisture related breakdown can wound drainage, gastric drainage, incont x2 and
occur from perspiration
2 hrs especially when they are immobile to prevent
reposition clients every
pressure injury from occuring
who created the pressure injury
national pressure injury advisory panel
staging system
an area that is discolored , skin is intact but is due to
suspected deep tissue injury is
damage to the underlying tissue
nonblanchable redness that is caused by pressure
stage 1 pressure injury is
typically over a bony prominence
partial thickness skin loss with visible or fluid filled
stage 2 pressure injury is
blister
full thickness skin loss without exposed muscle or bone
stage 3 pressure injury is
with a possibility of undermining or tunneling
full thickness skin loss with exposed muscle or bone
stage 4 pressure injury is with a possibility of undermining or tunneling and
eschar or slough
