Unit 4.1: Wound Care and Tissue Viability

• Topic 01

  Wound Assessment

  45 questions
• Topic 02

  Pressure Ulcer Prevention and Staging

  60 questions
• Topic 03

  Wound Dressing Selection Principles

  46 questions
• Topic 04

  Leg Ulcer Management

  46 questions

A few questions from this unit, with the answer and a full explanation. The complete bank is available when you start practising.

1. A nurse observes a pressure ulcer with exposed tendon and bone. Which EPUAP category does this represent?

   • A
     Unstageable
   • B
     Category 2
   • C
     Category 4
     Correct answer
   • D
     Suspected deep tissue injury (sDTI)
   Explanation

   Category 4 pressure ulcer is characterised by full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. The wound often includes undermining and tunnelling. Category 4 represents the most severe stage of pressure ulceration with the greatest tissue destruction. It requires TVN referral, specialist care, and in NHS England, documentation as a Serious Incident if deemed avoidable.

2. A wound assessment documents: 70% granulation tissue, moderate exudate, wound dimensions stable over 4 weeks, wound edges pale and non-advancing, periwound skin indurated. The patient has type 2 diabetes and peripheral neuropathy. What is the MOST likely explanation for the stalled healing, and what is the priority action?

   • A
     The patient's diabetes is irrelevant; apply an antimicrobial dressing and review in 2 weeks
   • B
     The wound is healing normally; no action is required for 4 weeks
   • C
     Ischaemia or biofilm is the most likely cause of stalled healing; the patient should be referred to the Tissue Viability Nurse and vascular assessment considered
     Correct answer
   • D
     The indurated periwound skin confirms cellulitis; urgent medical referral for IV antibiotics is needed
   Explanation

   In a diabetic patient with peripheral neuropathy, stalled healing despite apparently healthy granulation tissue suggests underlying ischaemia (impaired microcirculation) or biofilm. Non-advancing edges after 4 weeks per NICE NG200 should trigger specialist review. Referral to the TVN and consideration of vascular assessment (ABPI) is the priority. Induration may indicate early cellulitis but without systemic signs, the clinical picture does not confirm this. Biofilm may appear as healthy granulation yet prevent healing — this requires specialist-guided intervention.

3. A patient has Category 1 non-blanchable erythema over the sacrum. A colleague argues that gently massaging the area with an emollient will reverse the early ischaemia by increasing blood flow. Using the evidence base, explain why this rationale is INCORRECT and what the correct action is.

   • A
     Massage does not increase blood flow to ischaemic tissue — it applies additional mechanical force to already-compromised vasculature, potentially causing further damage. Evidence shows massage can worsen Category 1 damage. The correct action is immediate pressure relief and repositioning, not massage
     Correct answer
   • B
     The emollient component of the treatment is the effective part; it is the massage technique that helps, not the cream
   • C
     The colleague is correct — massage with emollient is the first-line treatment for Category 1 pressure ulcers
   • D
     Massage is contraindicated for other reasons (infection risk) but is effective at improving blood flow
   Explanation

   The physiological basis for the contraindication is: Category 1 non-blanchable erythema indicates that the microcirculation is already compromised by sustained pressure. Applying massage adds further mechanical force to tissue with damaged, fragile microvascular structures — this can cause shear within the dermis, further disrupting capillaries and worsening ischaemic damage. Studies have consistently shown that massage over erythematous skin does not improve blood flow and is associated with harm. The correct and only evidence-based first-line action for Category 1 is immediate pressure relief — repositioning off the affected area — with assessment and care plan escalation. Emollient cream should be applied by patting, not massage.