complex wound Flashcards
1
Q
stage 1 wound
A
intact ski
non blanchable
localized over bony prominence
2
Q
stage 2 wound
A
partial thickness loss shallow, open red pink wound no slough may present as an intact serum filled blister
3
Q
stage 3 wound
A
full thickness loss subcutaneous fat visible muscle tiss not exposed slough maybe present may include tunnelling or undermining
4
Q
stage 4
A
full thickness exposed
can see muscle or bone tissue slough and escar present
5
Q
Unstageable
A
Wound is to full of dead tiss and eschar to properly stage
Wound bed is open, inflamed
Tunneling present