Wound care Assessment & Documentation

Explanation
The statement is false because maceration of the peri wound skin can actually have a negative impact on wound healing. Maceration refers to the softening and breaking down of the skin due to excessive moisture. This can lead to increased risk of infection, delayed wound healing, and breakdown of healthy tissue. Therefore, it is important to prevent and manage maceration in order to promote optimal wound healing.

Explanation
A wound covered 100% by slough or black eschar is considered unstageable because it is not possible to determine the depth or extent of the wound underneath the slough or eschar. This makes it difficult to accurately assess the wound and determine the appropriate treatment plan.

Explanation
A nurse may suspect deep tissue injury when they observe a purple or maroon area of discolored, intact skin. This discoloration is an indication of damage to the underlying tissue, even though the skin appears to be intact. Therefore, the statement is true.

Explanation
Nurses do not need to update a stage of a wound as granulation improves. The stages of wound healing (such as granulation, epithelialization, and maturation) are not updated or changed once they have been identified. Instead, nurses monitor the progress of the wound healing process and document any changes or improvements in the wound's appearance, size, or other characteristics.

Explanation
A stage two pressure ulcer is not a shallow open ulcer with a red or pink wound bed that may have slough. Instead, a stage two pressure ulcer is characterized by a shallow open ulcer with a red-pink wound bed, without slough. Therefore, the correct answer is False.

Explanation
The statement is true because when wound edges are detached, it means that the base of the wound is deeper than the edge. This can occur when there is significant tissue damage or when the wound is healing from the inside out. Detached wound edges can make it more challenging for the wound to heal properly and may require additional medical intervention to promote healing.

Explanation
A stage four pressure ulcer is the most severe type of pressure ulcer, involving extensive tissue damage and often exposing muscle or bone. While undermining and tunneling can occur in some cases of stage four pressure ulcers, it is not always present. Therefore, the statement that a stage four pressure ulcer always has undermining and/or tunneling is false.

Explanation
The given statement describes the characteristics of full thickness tissue loss, not partial thickness tissue loss. Partial thickness tissue loss is when the dermis is exposed and the wound appears as a shallow open ulcer. It does not involve the exposure of subcutaneous fat, tendon, muscle, or bone. Therefore, the correct answer is False.

Explanation
A pressure ulcer is indeed defined as a lesion that occurs due to unrelieved pressure, which leads to damage in the underlying tissues. This can happen when there is prolonged pressure on a specific area of the body, such as when a person remains in the same position for an extended period of time. The pressure restricts blood flow to the area, causing tissue damage and the formation of an ulcer. Therefore, the statement "A pressure ulcer can be defined as a lesion caused by unrelieved pressure resulting in damage of underlying tissues" is true.

Explanation
The nurse would write that the wound near the ankle is distal to the wound located on the thigh because distal refers to a position farther away from the center of the body or a specific reference point, in this case, the thigh. Since the ankle is farther away from the thigh, it is considered distal. Therefore, the statement is true.