EMORY DPT GMC: NUTRITION AND
WOUND MANAGEMENT (ETIOLOGIES)
QUESTIONS AND ANSWERS 100%
CORRECT
What are the Nutritional aspects that effect wound healing? - ANSWER-
What are the Wound Etiology categories? - ANSWER-Pressure
Arterial
Venous
Neuropathic (Instead of Diabetic)
Infection
Dermatological
What is the Stage 1 of a Pressure Ulcer?
What is liva mortis? - 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? - 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? - 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? - 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.
What is an Unstageable Pressure Injury? - ANSWER-Obscure full thickness skin and
tissue loss
Full thickness tissue loss in which the extent of tissue damage without the ulcer cannot
be confirmed because it is obscured by slough or eschar. If slough or eschar is
removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (ie dry,
adherent, intake without erythema or fluctuance) on the heel or ischemic limb should not
be softened or removed.
What is the Rubor of Dependency? - ANSWER-With the foot dangling, (length of time is
not an issue) observe the bottom of the foot. If it is a red color, as if the foot is
"blushing", they may arterial deficiencies.
Etiology - as the blood is attempting to travel down the artery it meets the occlusion and
is shunted out into the tissues giving that red or "blushing" color.
How is Venous Filling Time related to a wound? - ANSWER-Begin with the patient in
supine. Inspect the foot for veins that are raised. Raise the same leg in question above
the level of the heart until the vein is drained and no longer raised. Put the leg down by
sitting the patient up and dangling the leg below the heart. Observe the top of the foot
WOUND MANAGEMENT (ETIOLOGIES)
QUESTIONS AND ANSWERS 100%
CORRECT
What are the Nutritional aspects that effect wound healing? - ANSWER-
What are the Wound Etiology categories? - ANSWER-Pressure
Arterial
Venous
Neuropathic (Instead of Diabetic)
Infection
Dermatological
What is the Stage 1 of a Pressure Ulcer?
What is liva mortis? - 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? - 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? - 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? - 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.
What is an Unstageable Pressure Injury? - ANSWER-Obscure full thickness skin and
tissue loss
Full thickness tissue loss in which the extent of tissue damage without the ulcer cannot
be confirmed because it is obscured by slough or eschar. If slough or eschar is
removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (ie dry,
adherent, intake without erythema or fluctuance) on the heel or ischemic limb should not
be softened or removed.
What is the Rubor of Dependency? - ANSWER-With the foot dangling, (length of time is
not an issue) observe the bottom of the foot. If it is a red color, as if the foot is
"blushing", they may arterial deficiencies.
Etiology - as the blood is attempting to travel down the artery it meets the occlusion and
is shunted out into the tissues giving that red or "blushing" color.
How is Venous Filling Time related to a wound? - ANSWER-Begin with the patient in
supine. Inspect the foot for veins that are raised. Raise the same leg in question above
the level of the heart until the vein is drained and no longer raised. Put the leg down by
sitting the patient up and dangling the leg below the heart. Observe the top of the foot
