RNSG 1430: Exam 5 - TISSUE INTEGRITY questions with
verified answers
After a wound culture, results of the specific organism and its sensitivity report is
given. What is given on the sensitivity report? Ans✓✓✓ tests that determines
"sensitivity" of bacteria to antibiotic
suggests what antibiotic to use to kill bacteria.
Antifungals Ans✓✓✓ Treats athlete's foot (Tinea Pedis)
- creams, sprays
Braden Scale: What does it assess? Ans✓✓✓ Assesses pressure ulcer risk by
looking at...
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction & Shear
Calcium Alginate Ans✓✓✓ Highly absorbent of wound exudate in heavily
draining wounds
- alginate forms soft gel when in contact with fluid
- used to pack deeper wounds
Corticosteroids Ans✓✓✓ - topical steroids often used to treat
dermatitis/irritating symptoms of pruritus (itching)
,- Oral/parenteral steroids when hives manifests on the skin indicating systemic
reaction
USED FOR: Psoriasis, hives
Describe a Deep Tissue Injury (DTPI). Ans✓✓✓ can be intact & non-intact
** non-blanchable deep red, maroon, PURPLE discoloration
** Common cause is friction and shearing
Describe a LACERATION. Ans✓✓✓ Jagged, irregular break or tear of tissue,
usually caused by blunt trauma
- Amount of bleeding depends on depth and location
EX: slicing of skin, slash
Describe a PUNCTURE. Ans✓✓✓ Piercing/penetration injury
- bleeding depends on depth, size, location
- primary dangers are internal bleeding and infection
EX: stab wound, nail puncture
Describe a stage I wound. Ans✓✓✓ Non-blanchable
erythema (reddening of skin)
SKIN is INTACT
Describe a stage II wound. Ans✓✓✓ ** PARTIAL skin thickness; dermis exposed
open ulcer has red/pink wound bed
** NO slough, eschar, or granulation present
, Adipose/deeper tissue NOT visible
Describe a stage III wound. Ans✓✓✓ ** FULL thickness SKIN loss
** Adipose is VISIBLE
Granulation & epibole (rolled edges) often present
Slough & eschar may be visible
Undermining/Tunneling may occur
Muscle, tendon, bone NOT exposed
Describe a stage IV wound. Ans✓✓✓ ** FULL thickness SKIN and TISSUE loss
** BONE, muscle, tendon exposed, eschar and slough present
Epibole (rolled edges), tunneling may be visible
^IF slough/eschar obscures extent, it's UNSTAGEABLE^
Describe an ABRASION. Ans✓✓✓ A partial thickness wound that denudes (strips)
the skin
- superficial w/little bleeding
- appears weepy because of plasma leakage from capillaries
EX: carpet burn, road rash
Describe an UNSTAGEABLE wound. Ans✓✓✓ obscured/blocked FULL thickness
SKIN & TISSUE loss
** depth is UNKNOWN
Slough & eschar present and BLOCKING wound bed
verified answers
After a wound culture, results of the specific organism and its sensitivity report is
given. What is given on the sensitivity report? Ans✓✓✓ tests that determines
"sensitivity" of bacteria to antibiotic
suggests what antibiotic to use to kill bacteria.
Antifungals Ans✓✓✓ Treats athlete's foot (Tinea Pedis)
- creams, sprays
Braden Scale: What does it assess? Ans✓✓✓ Assesses pressure ulcer risk by
looking at...
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction & Shear
Calcium Alginate Ans✓✓✓ Highly absorbent of wound exudate in heavily
draining wounds
- alginate forms soft gel when in contact with fluid
- used to pack deeper wounds
Corticosteroids Ans✓✓✓ - topical steroids often used to treat
dermatitis/irritating symptoms of pruritus (itching)
,- Oral/parenteral steroids when hives manifests on the skin indicating systemic
reaction
USED FOR: Psoriasis, hives
Describe a Deep Tissue Injury (DTPI). Ans✓✓✓ can be intact & non-intact
** non-blanchable deep red, maroon, PURPLE discoloration
** Common cause is friction and shearing
Describe a LACERATION. Ans✓✓✓ Jagged, irregular break or tear of tissue,
usually caused by blunt trauma
- Amount of bleeding depends on depth and location
EX: slicing of skin, slash
Describe a PUNCTURE. Ans✓✓✓ Piercing/penetration injury
- bleeding depends on depth, size, location
- primary dangers are internal bleeding and infection
EX: stab wound, nail puncture
Describe a stage I wound. Ans✓✓✓ Non-blanchable
erythema (reddening of skin)
SKIN is INTACT
Describe a stage II wound. Ans✓✓✓ ** PARTIAL skin thickness; dermis exposed
open ulcer has red/pink wound bed
** NO slough, eschar, or granulation present
, Adipose/deeper tissue NOT visible
Describe a stage III wound. Ans✓✓✓ ** FULL thickness SKIN loss
** Adipose is VISIBLE
Granulation & epibole (rolled edges) often present
Slough & eschar may be visible
Undermining/Tunneling may occur
Muscle, tendon, bone NOT exposed
Describe a stage IV wound. Ans✓✓✓ ** FULL thickness SKIN and TISSUE loss
** BONE, muscle, tendon exposed, eschar and slough present
Epibole (rolled edges), tunneling may be visible
^IF slough/eschar obscures extent, it's UNSTAGEABLE^
Describe an ABRASION. Ans✓✓✓ A partial thickness wound that denudes (strips)
the skin
- superficial w/little bleeding
- appears weepy because of plasma leakage from capillaries
EX: carpet burn, road rash
Describe an UNSTAGEABLE wound. Ans✓✓✓ obscured/blocked FULL thickness
SKIN & TISSUE loss
** depth is UNKNOWN
Slough & eschar present and BLOCKING wound bed
