NR 224 QUIZ 2 LATEST EXAM
pressure injuries - ANSWER: tissue injuries that form from local interference with
circulation. It is Localized damage to the skin
o Underlying soft tissue usually over bony prominence or related to medical device
Pressure injury appearance - ANSWER: o Intact skin, reddened
o Blister
o Open ulcer
Cause for pressure injury - ANSWER: o Intense or prolonged pressure
o Pressure + shearing
o Pressure injury caused by PRESSURE not by immobility
Pressure injury is affected by - ANSWER: o Microclimate
o Nutrition
o Perfusion
o Co-morbidities
o Condition of soft tissue
Risk factors of pressure injury - ANSWER: o Decrease mobility
o Decrease sensory perception
o Fecal/urine incontinence
o Poor nutrition
o Alter LOC
o Shearing
o Friction
People at risk of pressure injury - ANSWER: o Older adults experience trauma
o Spinal cord injuries
o Sustained hip fractures
o LTC
o Hospice
o Diabetics
o Critical care setting
Top down damage - ANSWER: o Superficial
o Caused by superficial shear or friction
o Presents as red skin
Bottom-up deep damage - ANSWER: o Pressure intensity: how much pressure
applied
o Pressure duration: how long the pressure is applied
o Tissue tolerance: how the tissue reacts and holds up with pressure
, Dark color skin assessment - ANSWER: o Cannot assess darker clients by examining
only skin color
o Assess change in sensation, temp, tissue consistency
o Examine sites like under arms for underlying skin color
o Color remains unchanged when pressure applied
o Color change at site different from normal color
o Localized area may be purple/blue or violet instead of red
o Localized area may appear to be warm but be replaced by coolness d/t
devitalization
o Edema with induration >15mm
o Skin may appear taut and shiny
stage 1 ulcer - ANSWER: intact skin, non-blanchable erythema
stage 2 pressure ulcer - ANSWER: partial thickness loss with exposed dermis
Would bed viable, pink, red, moist
Can be intact or ruptured blister
Common with microclimate and shearing
stage 3 pressure ulcer - ANSWER: full thickness loss
Adipose tissue
Granulation tissue
Epibole present
Slough or eschar may be present
Undermining or tunneling present
stage 4 pressure ulcer - ANSWER: Full-thickness tissue loss with exposed bone,
muscle, or tendon
deep tissue pressure injury
Persistent non blanchable deep red
Maroon, deep purple discoloration
Necrotic tissue
SubQ tissue, granulation, fascia, muscle visible
Unstageable ulcer - ANSWER: Full thickness tissue loss in which the base of the
ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan,
brown or black) in the wound bed.
acute wound - ANSWER: Wound proceeds through orderly and timely reparative
response
Cause: trauma, surgical incision
Healing: wound edges clean and intact
chronic wound - ANSWER: Wound fail to proceed through an orderly and timely
process
Cause: vascular compromise, chronic inflammation, damage to tissue
Healing: continue exposure to insult impedes wound healing
pressure injuries - ANSWER: tissue injuries that form from local interference with
circulation. It is Localized damage to the skin
o Underlying soft tissue usually over bony prominence or related to medical device
Pressure injury appearance - ANSWER: o Intact skin, reddened
o Blister
o Open ulcer
Cause for pressure injury - ANSWER: o Intense or prolonged pressure
o Pressure + shearing
o Pressure injury caused by PRESSURE not by immobility
Pressure injury is affected by - ANSWER: o Microclimate
o Nutrition
o Perfusion
o Co-morbidities
o Condition of soft tissue
Risk factors of pressure injury - ANSWER: o Decrease mobility
o Decrease sensory perception
o Fecal/urine incontinence
o Poor nutrition
o Alter LOC
o Shearing
o Friction
People at risk of pressure injury - ANSWER: o Older adults experience trauma
o Spinal cord injuries
o Sustained hip fractures
o LTC
o Hospice
o Diabetics
o Critical care setting
Top down damage - ANSWER: o Superficial
o Caused by superficial shear or friction
o Presents as red skin
Bottom-up deep damage - ANSWER: o Pressure intensity: how much pressure
applied
o Pressure duration: how long the pressure is applied
o Tissue tolerance: how the tissue reacts and holds up with pressure
, Dark color skin assessment - ANSWER: o Cannot assess darker clients by examining
only skin color
o Assess change in sensation, temp, tissue consistency
o Examine sites like under arms for underlying skin color
o Color remains unchanged when pressure applied
o Color change at site different from normal color
o Localized area may be purple/blue or violet instead of red
o Localized area may appear to be warm but be replaced by coolness d/t
devitalization
o Edema with induration >15mm
o Skin may appear taut and shiny
stage 1 ulcer - ANSWER: intact skin, non-blanchable erythema
stage 2 pressure ulcer - ANSWER: partial thickness loss with exposed dermis
Would bed viable, pink, red, moist
Can be intact or ruptured blister
Common with microclimate and shearing
stage 3 pressure ulcer - ANSWER: full thickness loss
Adipose tissue
Granulation tissue
Epibole present
Slough or eschar may be present
Undermining or tunneling present
stage 4 pressure ulcer - ANSWER: Full-thickness tissue loss with exposed bone,
muscle, or tendon
deep tissue pressure injury
Persistent non blanchable deep red
Maroon, deep purple discoloration
Necrotic tissue
SubQ tissue, granulation, fascia, muscle visible
Unstageable ulcer - ANSWER: Full thickness tissue loss in which the base of the
ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan,
brown or black) in the wound bed.
acute wound - ANSWER: Wound proceeds through orderly and timely reparative
response
Cause: trauma, surgical incision
Healing: wound edges clean and intact
chronic wound - ANSWER: Wound fail to proceed through an orderly and timely
process
Cause: vascular compromise, chronic inflammation, damage to tissue
Healing: continue exposure to insult impedes wound healing
