Wound Care Certification Exam Complete
Questions and Correct Answers
what are 6 risk factor components of Braden Scale for pressure ulcer?
sensory perception, moisture, mobility, activity, nutrition, and shear/friction
What is the name of the organization that developed the pressure ulcer staging?
NPUAP (national pressure ulcer advisory panel)
pathological effect of excessive pressure on soft tissue can be attributed by 3
factors? what are they?
tissue tolerance, duration of pressure, and intensity of pressure
what are the extrinsic factors that impact pressure ulcers?
increase in moisture, friction and shearing
how does friction play a role in shearing which eventually leads to pressure ulcer?
friction alone causes only superficial abrasion, but with gravity it plays a
synergistic effect leading to shearing. When gravity pushes down on the body and
resistance (friction) between the patient and surface is exerted, shearing occurs.
because skin does not freely move, primary effect of shearing occurs at the
deeper fascial level.
,what are the intrinsic factors of pressure ulcers?
nutritional debilitation, advanced age, low BP, stress, smoking, elevated body
temperature
Aging skin undergoes what elements affecting risk for pressure ulcer?
dermo epidermal junction flattens, less nutrient exchange occurs, less resistance
to shearing, changes in sensory perception, loss of dermal thickness, increased
vascular fragility; ability of soft tissue to distribute mechanical load w/out
compromising blood flow is impaired
What does non-blanching erythema indicate in the skin r/t PU?
when pressure is applied to the erythematic area skin becomes white (blanched),
but once relieved, erythema returns -indicating blood flow; however in non-
blanching erythema, skin does not blanche-indicating impaired blood flow-
suggesting tissue destruction
why does sitting in a chair pose more of a risk in skin break down than lying?
deep tissue injury or PU is likely to occur sooner sitting down because tissue
offloading over boney prominences is higher
Describe what you will see in deep tissue injury?
purple or maroon localized area of discolored intact skin or blood filled blister;
may be preceded by painful, firm, mushy, or boggy; skin may be warmer to cooler
,in adjacent tissue. In dark skin, thin blister or eschar over a dark wound bed may
bee seen
Describe stage I pressure ulcer?
Intact skin with non-blanchable redness of localized area. Will not see blanching in
dark skin, but changes in skin tissue consistency (firm vs boggy when palpated),
sensation (pain), and warmer or cooler temperature may differ from surrounding
area
Describe stage II pressure ulcer?
partial-thickness wound where epidermis and tip of dermis is lost with red-pink
wound bed w/out slough. may also present as intact or open/ruptured serum -
filled blister
Describe stage III pressure ulcer?
full-thickness wound where both epidermis and dermis is lost and subcutaneous
tissue may be visible, but deeper structures such as muscle, bone, and tendon are
not exposed; slough my be present but it doesn't obscure depth and tunneling
and undermining may be present
Describe stage IV pressure ulcer?
full-thickness wound with exposed bone, tendon, and muscle; slough or eschar
may be seen in some parts of the wound bed. you will often see tunneling and
undermining. Osteomyelitis may be diagnosed at this stage, since bone is palpable
, Describe unstageable ulcers?
full-thickness wound where base of the ulcer is covered by slough and/or eschar,
obscuring depth
When should eschars not be removed?
when it's stable with dry, adherent, and intact w/out erythema on the heel; this
serves as the body's natural cover and should not be removed.
Therapeutic function of pressure distribution is accomplished by what 2 factors?
immersion and envelopment
Define immersion?
depth of penetration or sinking into surface allowing pressure to be spread out
over surrounding area rather than directly over boney prominence
Define envelopment?
is the ability of support surface to conform to irregularities without causing
substantial increase in pressure
what is bottoming out?
This Occurs When Depth Of Penetration Or Sinking Is Excessive, Allowing
Increased Pressure To Concentrate Over Boney Prominences
Questions and Correct Answers
what are 6 risk factor components of Braden Scale for pressure ulcer?
sensory perception, moisture, mobility, activity, nutrition, and shear/friction
What is the name of the organization that developed the pressure ulcer staging?
NPUAP (national pressure ulcer advisory panel)
pathological effect of excessive pressure on soft tissue can be attributed by 3
factors? what are they?
tissue tolerance, duration of pressure, and intensity of pressure
what are the extrinsic factors that impact pressure ulcers?
increase in moisture, friction and shearing
how does friction play a role in shearing which eventually leads to pressure ulcer?
friction alone causes only superficial abrasion, but with gravity it plays a
synergistic effect leading to shearing. When gravity pushes down on the body and
resistance (friction) between the patient and surface is exerted, shearing occurs.
because skin does not freely move, primary effect of shearing occurs at the
deeper fascial level.
,what are the intrinsic factors of pressure ulcers?
nutritional debilitation, advanced age, low BP, stress, smoking, elevated body
temperature
Aging skin undergoes what elements affecting risk for pressure ulcer?
dermo epidermal junction flattens, less nutrient exchange occurs, less resistance
to shearing, changes in sensory perception, loss of dermal thickness, increased
vascular fragility; ability of soft tissue to distribute mechanical load w/out
compromising blood flow is impaired
What does non-blanching erythema indicate in the skin r/t PU?
when pressure is applied to the erythematic area skin becomes white (blanched),
but once relieved, erythema returns -indicating blood flow; however in non-
blanching erythema, skin does not blanche-indicating impaired blood flow-
suggesting tissue destruction
why does sitting in a chair pose more of a risk in skin break down than lying?
deep tissue injury or PU is likely to occur sooner sitting down because tissue
offloading over boney prominences is higher
Describe what you will see in deep tissue injury?
purple or maroon localized area of discolored intact skin or blood filled blister;
may be preceded by painful, firm, mushy, or boggy; skin may be warmer to cooler
,in adjacent tissue. In dark skin, thin blister or eschar over a dark wound bed may
bee seen
Describe stage I pressure ulcer?
Intact skin with non-blanchable redness of localized area. Will not see blanching in
dark skin, but changes in skin tissue consistency (firm vs boggy when palpated),
sensation (pain), and warmer or cooler temperature may differ from surrounding
area
Describe stage II pressure ulcer?
partial-thickness wound where epidermis and tip of dermis is lost with red-pink
wound bed w/out slough. may also present as intact or open/ruptured serum -
filled blister
Describe stage III pressure ulcer?
full-thickness wound where both epidermis and dermis is lost and subcutaneous
tissue may be visible, but deeper structures such as muscle, bone, and tendon are
not exposed; slough my be present but it doesn't obscure depth and tunneling
and undermining may be present
Describe stage IV pressure ulcer?
full-thickness wound with exposed bone, tendon, and muscle; slough or eschar
may be seen in some parts of the wound bed. you will often see tunneling and
undermining. Osteomyelitis may be diagnosed at this stage, since bone is palpable
, Describe unstageable ulcers?
full-thickness wound where base of the ulcer is covered by slough and/or eschar,
obscuring depth
When should eschars not be removed?
when it's stable with dry, adherent, and intact w/out erythema on the heel; this
serves as the body's natural cover and should not be removed.
Therapeutic function of pressure distribution is accomplished by what 2 factors?
immersion and envelopment
Define immersion?
depth of penetration or sinking into surface allowing pressure to be spread out
over surrounding area rather than directly over boney prominence
Define envelopment?
is the ability of support surface to conform to irregularities without causing
substantial increase in pressure
what is bottoming out?
This Occurs When Depth Of Penetration Or Sinking Is Excessive, Allowing
Increased Pressure To Concentrate Over Boney Prominences
