PRESSURE INJURIES - INTEG

Question 1

Describe a stage 1 pressure injury

Answer 1

• skin is intact
• non-blanchable erythema

Question 2

Describe a stage 2 pressure injury

Answer 2

• partial thickness loss of skin with exposed dermis
• wound bed is viable, pink or red, moist, and may have a blister
• no granulation, slough, or eschar
• usually from shear

Question 3

Describe a phase 3 pressure injury

Answer 3

• Full thickness loss of skin
• adipose is visible as well as granulation and epibole often
• may have slough and eschar
• undermining and tunneling may occur

Question 4

Describe a stage 4 pressure injury

Answer 4

• full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone
• undermining/tunneling often present

Question 5

Describe an unstageable pressure injury

Answer 5

slough or eschar is covering the wound and unable to determine if it is stage 3 or 4

Question 6

What is a deep tissue pressure injury

Answer 6

intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration