Management (Etiologies) UPDATED
ACTUAL Questions and CORRECT
Answers
What are the Nutritional aspects that effect wound healing? - CORRECT ANSWER -
What are the Wound Etiology categories? - CORRECT ANSWER - Pressure
Arterial
Venous
Neuropathic (Instead of Diabetic)
Infection
Dermatological
What is the Stage 1 of a Pressure Ulcer?
What is liva mortis? - CORRECT ANSWER - Non-blanchable erythema - Intact skin with
non-blanchable redness of a localized area usually over a bony prominence.
Darkly pigmented skin may not have visible blanching, its color may differ from the surrounding
area.
. 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.
when pressure is applied there is not any color that returns to the area when pressure released??
What is stage 2 of a pressure ulcer? - CORRECT ANSWER - Partial thickness loss of
dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also
present as an intact or open/ruptured serum filled or sero-sanguinous filled blister.
, Stage II - Pressure Injury: Partial-thickness skin loss with exposed dermis
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist
and may also present as an intact or ruptured serum-filed blister. Adipose (fat) is not visible and
deeper tissues are 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. This stage should not be used to describe moisture associated skin damage
(MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD),
medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears burns , abrasions)
What is stage 3 of a pressure ulcer? - CORRECT ANSWER - Full-thickness tissue loss.
Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage 3 Pressure Injury: Full-thickness skin loss
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 and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage
and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an
Unstageable Pressure Injury.
What is stage 4 of a pressure ulcer? - CORRECT ANSWER - Full thickness tissue loss
with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes
undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by
anatomical location.
Stage 4 Pressure Injury: Full thickness skin and tissue loss
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 /or tunneling often occur. Depth varies by anatomical location. If
slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.