Mod 5 - Skin Integrity

Question 1

Pressure ulcer development

Answer 1

Prone
Supine
Later
*Typically boney prominents

Question 2

Braden Scale

Answer 2

Identifies patient risk to develop ulcer

Question 3

Stage 1

Answer 3

Non-blanchable redness
Skin still intact

Question 4

Suspected tissue injury

Answer 4

Purple or discoloured

Question 5

Stage 2

Answer 5

Partial skin lost
Dermis & epidermis

Question 6

Stage 3

Answer 6

Full thickness gone
SC fat can be seen

Question 7

Stage 4

Answer 7

Full thickness gone
Tendon or bome or muscle visble

Question 8

Unstageable

Answer 8

Covered in Slough & eschar

Question 9

Slough

Answer 9

Pale white, can be removed for healing

Question 10

Eschar

Answer 10

Black, flakey

Question 11

Would healing phases

Answer 11

Inflammatory
Proliferative - clear watery
Maturation - scabbing

Question 12

Wound repair intentions

Answer 12

Primary - stitches
Secondary - large irregular wound
Tertiary -risk of contamination, wound open

Question 13

Wound types (5)

Answer 13

Skin tear
Fistula
Venous
Arterial
Diabetic

Question 14

Granualation

Answer 14

Red tissue, sign of healing