Wound Care and Skin Integrity in Rehabilitation Flashcards

A patient has a venous stasis ulcer on the medial gaiter area of the right leg. Which treatment is FUNDAMENTAL to healing this wound type?

Answer: Multilayer compression therapy to reduce venous hypertension

Venous leg ulcers are caused by chronic venous hypertension; multilayer compression therapy (e.g., 30–40 mmHg) is the cornerstone treatment that addresses the underlying pathophysiology.

A CRRN documents a deep tissue pressure injury (DTPI) on the heel. Which description BEST matches this classification?

Answer: A localized area of discolored, intact or non-intact skin due to underlying soft tissue injury from pressure

DTPI presents as persistent non-blanchable deep red, maroon, or purple discoloration from injury to underlying tissue, which may evolve rapidly even when skin appears intact.

A rehabilitation patient has a surgically debrided wound with no signs of infection and no contraindications to healing. Which wound bed characteristic indicates OPTIMAL healing progress?

Answer: Bright red, moist granulation tissue filling the wound base

Bright red, moist granulation tissue indicates robust vascular ingrowth and healthy wound healing; yellow fibrin and eschar indicate stalled or complicated healing.

A patient with a diabetic foot ulcer has signs of wound infection. Which assessment finding BEST confirms local wound infection?

Answer: Increased wound pain, warmth, purulent exudate, and periwound erythema > 2 cm

Local wound infection is confirmed by classic signs: increased pain, warmth, purulent exudate, odor, and periwound erythema extending more than 2 cm from the wound edge.

A rehabilitation nurse is performing a Braden Scale assessment. Which subscale DIRECTLY assesses the patient's level of physical activity?

Answer: Activity

The Braden Scale 'Activity' subscale directly scores the degree of physical activity, ranging from bedfast (1) to walks frequently (4), indicating mobility-related pressure injury risk.

A patient with heel pressure injuries is being positioned in bed. Which position is BEST to protect the heels?

Answer: Float the heels completely off the surface using pillows placed under the calves

Floating the heels by placing pillows under the calves completely offloads the heel from the mattress surface; donut devices create a pressure ring around the wound.