Skin Integrity

Question 1

What is a suspected deep tissue injury?

Answer 1

Intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.

Question 2

What is a stage 1 pressure injury?

Answer 2

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin.

Question 3

What is a stage 2 pressure injury?

Answer 3

Partial-thickness loss of skin with exposed dermis. The wound bed is visible, pink, or red, and moist and may also present as an intact or ruptured serum-filled blister.

Question 4

What is a stage 3 pressure injury?

Answer 4

Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.

Question 5

What is a stage 4 pressure injury?

Answer 5

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.

Question 6

What is an unstageable injury?

Answer 6

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed b/c it is obscured by slough or eschar

Question 7

What is primary intention?

Answer 7

Wound healing with little tissue loss because the wound edges are closed

Question 8

What is secondary intention?

Answer 8

Wound healing with loss of tissue could result in severe scarring because the wound is left open to be filled in with scar tissue

Question 9

What is tertiary intention?

Answer 9

Wounds that are left open and then closed after debridement so after healing the tissue is viable.

Question 10

What is tissue perfusion?

Answer 10

Oxygenated blood is being delivered to the skin