NAME_________________________ DATE_______________
NAME_________________________ DATE_______________
STAGING PRESSURE ULCERS
POST TEST
MATCHING- MATCH THE PRESSURE ULCER STAGE TO THE DESCRIPTIONS BY PLACING THE CORRECT LETTER IN THE BLANKS.
_____full thickness, base covered with slough
A. STAGE I _____ruptured blister, bloody drainage, purple bed
B. DTI _____redness that does not blanch
C. STAGE II _____shallow crater, pink base
D. STAGE III _____dark purple intact skin
E. STAGE IV _____20% yellow, 75% pink, 5% bone
F. UNSTAGEABLE _____full thickness with slight undermining from 2-4
o’clock, 100% granulating
_____thin blister with maroon base
_____previous ST IV, now with only 15% slough,
85% granulation, small amount drainage
_____previous DTI, now pink wound bed with under-
mining 1cm from 4-7o’clock
_____unobservable
_____serous fluid-filled blister on heel
TRUE / FALSE- PLACE A T OR AN F IN THE BLANKS.
_____1. The top layer of a DTI is blanchable.
_____2. A Stage IV is healing, partial thickness 100% pink. It should now
be documented a Stage II to indicate healing/positive outcome.
_____3. The Staging section of a pressure ulcer covered with eschar and
slough should be left blank since it is unstageable.
_____4. A patient with incontinence has developed excoriation on the
buttocks. She now has a Stage II.
_____5. A dark skinned patient has an area on his trochanter that is normal
colored, but feels warm-to-touch and slightly firm. He has a St I.
_____6. Since the patient’s pressure ulcer is dry and scabbed, it can be
documented as healed and treatment stopped.
_____7. Any patient with a pressure ulcer of any stage should be assessed
for specialty surface needs.
_____8. Patients who eat half their meals, can move the right side of their
bodies and only slide down a few inches in bed don’t need to be
constantly assessed for pressure ulcer formation.
_____9. The patient with a pressure ulcer with 60% granulating tissue, 5%
slough and 35% exposed adipose has a Stage IV.
This post test is geared toward Home Health setting and how we have to document things for the Oasis.
Answers: F,B,A,C,B,E,D,B,E,D,F,C
#5 and #7 are TRUE others are FALSE
Pam McFarland RN, WOCN
Corporate Wound, Ostomy, Continence Nurse
United Home Care Services
4212 West Congress Blvd., Ste. 3300-C
Lafayette, LA 70506
337-989-1222 Ext. 1309
337-989-2672 Fax
337-278-4258 Cell
pamm@
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