Author Question: While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. ... (Read 90 times)

casperchen82 · **on:** Jul 23, 2018

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis.

Which of the following is the correct name of this wound?

A) Stage II pressure ulcer
B) Stage I pressure ulcer
C) Stage III pressure ulcer
D) Stage IV pressure ulcer

Question 2

A nurse is treating the pressure ulcer of an African American client. How would the nurse assess for deep tissue injury in this client?

A) Upon inspection the nurse would notice a purple or maroon localized area of discolored, intact skin.
B) Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
C) Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or cooler as compared with adjacent tissue.
D) Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

cassie_ragen · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: A
Stage I is defined as intact skin with a localized area of nonblanchable redness, usually over a bony prominence. Stage II is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. Stage III is defined as full-thickness loss without exposed bone, tendon, or muscle. Stage IV is defined as full-thickness tissue loss with exposed bone, tendon, and muscle.

Answer to Question 2

Ans: C
Deep tissue injury may be difficult to detect in individuals with dark skin tones. The area may be preceded by tissue that is painful, firm, boggy, warmer or cooler as compared with adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by a thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.