WND581 Quiz 2 – Questions With Verified
Solutions
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Terms in this set (30)
risk factor most shear forces from HOB over 30 degrees
responsible for
undermining in the
pressure injury
non-blanchable erythema of intact skin, does not
stage 1 pressure injury
include maroon color
serous filled blister or partial thickness wound, red
moist wound bed, no adipose tissue exposed
Stage 2 pressure injury
blood-filled blister is a sign of DTPI
full thickness tissue loss with visible fat, may have
Stage 3 pressure injury
slough or eschar
Full-thickness skin and tissue loss with exposed or
directly palpable fascia, muscle, tendon, ligament,
Stage 4 pressure injury
cartilage or bone in the ulcer. Slough and/or eschar
may be visible.
base of ulcer covered by slough and/or eschar in
unstageable pressure
the wound bed obscuring visualization of
injury
underlying structures
care plan for a patient T&P Q2-4 hrs depending on tissue tolerance,
with pressure risk should regardless of the support surface
always include
intact, nonblanchable, DTPI because it is PURPLE not red
persistent purple
discoloration over
coccyx
Solutions
Save
Terms in this set (30)
risk factor most shear forces from HOB over 30 degrees
responsible for
undermining in the
pressure injury
non-blanchable erythema of intact skin, does not
stage 1 pressure injury
include maroon color
serous filled blister or partial thickness wound, red
moist wound bed, no adipose tissue exposed
Stage 2 pressure injury
blood-filled blister is a sign of DTPI
full thickness tissue loss with visible fat, may have
Stage 3 pressure injury
slough or eschar
Full-thickness skin and tissue loss with exposed or
directly palpable fascia, muscle, tendon, ligament,
Stage 4 pressure injury
cartilage or bone in the ulcer. Slough and/or eschar
may be visible.
base of ulcer covered by slough and/or eschar in
unstageable pressure
the wound bed obscuring visualization of
injury
underlying structures
care plan for a patient T&P Q2-4 hrs depending on tissue tolerance,
with pressure risk should regardless of the support surface
always include
intact, nonblanchable, DTPI because it is PURPLE not red
persistent purple
discoloration over
coccyx
