Skin Integrity Exam

Question 1

Risk factors for pressure ulcers

Answer 1

Moisture, friction, alteration in LOC, impaired mobility

Question 2

Stage 1 pressure ulcer

Answer 2

Intact skin with nonblanchable redness. Warm to touch.

Question 3

Stage 2 pressure ulcer

Answer 3

Partial-thickness skin loss involving epidermis, dermis or both. Shallow, open ulcer

Question 4

Stage 3 pressure ulcer

Answer 4

Full-thickness tissue loss with visible fat. Wound may be deep in fatty areas

Question 5

Stage 4 pressure ulcer

Answer 5

Full-thickness tissue loss with exposed bone, muscle or tendon

Question 6

Full thickness and what can cause

Answer 6

Extends through the epidermis to the dermis layer. Heals through scar formation. (Stage 3/4 pressure ulcer, 2nd/3rd degree burn, large trauma areas)

Question 7

Partial thickness.

Answer 7

Mostly the top layer of the epidermis. Heals through regeneration (clean surgical wound/incision or an abrasion)

Question 8

Primary intention

Answer 8

Easily closed. Edges approximate. Minimal tissue loss.

Question 9

Secondary intention

Answer 9

Longer healing time, increased scarring, greater susceptibility to infection, significant tissue loss (burn, pressure ulcer, trauma wound)

Question 10

Tertiary intention

Answer 10

Wound open for an amount of time and then closed. Observe for growth of infection