Tissue

Question 1

Suspected Deep Tissue Injury

Answer 1

Purple or maroon localized area of discolored intact skin or blood-filled blister
Indicates damage of underlying soft tissue from pressure and/or shear
May be preceded by tissue that is painful, firm, mushy, and boggy
May be difficult to detect in patients with dark skin tones

Question 2

Skin Assessment for patients with dark skin

Answer 2

Darker areas of skin
Skin temperature
Skin/Tissue consistence
Patient Sensation

Question 3

Stage I

Answer 3

Intact skin - non-blanchable redness of a localized area
over bony prominence
May be painful, firm, soft, warmer, or cooler as compared to adjacent tissue

Question 4

Stage II

Answer 4

Partial-thickness loss of dermis
Shallow open ulcer with red/pink wound bed
May also present as an intact or ruptured serum-filled blister
Can be a shiny or dry shallow ulcer without slough or bruising
Adipose (fat) is not visible, and deeper tissues are not visible
granulation tissue, slough, and eschar are not present

Question 5

Stage III

Answer 5

Full-thickness skin loss
Subcutaneous tissue may be visible, but bone, tendon, or muscle are not
Presents as deep crater with possible undermining or adjacent tissue
Ulcer depth varies by location, depending on depth of tissue in that area

Question 6

Stage IV

Answer 6

Full-thickness loss, extends to muscle, bone, or supporting structures
Bone, tendon, or muscle may be visible or palpable
Slough or eschar may be present on some parts of the wound bed
Undermining and tunneling may also occur

Question 7

Unstageable Ulcer

Answer 7

Full-thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed
Slough may be yellow, tan, green, grey, or brown
Eschar may be tan, brown, or black in the wound bed
Slough or eschar must be removed to expose the base of the wound in order to stage
Note: Stable, dry eschar on heels should not be removed