Integ. Unit 2 Wound Classification Flashcards
What are different classifications systems used in wound identification?
- Depth of Tissue Loss
- Type of wound
- Severity of wound
- Color of Tissue
With the Red, Yellow, Black classification system, what does Red indicate?
The wound is clean, healing and granulating
- Overall healthy wounds
With the Red, Yellow, Black classification system, what does Yellow indicate?
Possible Infection, need for cleaning or debridement, or the presence of necrotic tissue
With the Red, Yellow, Black classification system, what does Black indicate?
Wound is necrotic and needs cleaning and debridement
What is the National Pressure Ulcer Advisor Panel?
NPUAP
This is a wound classification system for pressure ulcers
- This is used to describe wound severity, organize treatment protocols, and select and reimburse treatment products
With the National Pressure Ulcer Advisor Panel, what is Grade 1?
Non-Blachable Erythema
- Intact skin with non-blanchable redness, usually over a bone prominence
With the National Pressure Ulcer Advisor Panel, what is Grade 2?
Partial Thinkness Skin Loss
- Loss of epidermins/dermis presenting as a shallow open ulcer with a red/pink wound bed without slough or bruising
With the National Pressure Ulcer Advisor Panel, what is Grade 3?
Full Thickness skin Loss
- Subcutaneous fat may be visable but bone, tendon or muscle is not visable or palpable; slough may be present but does not obscure the depth of tissue loss.
- May include undermining or tunneling
With the National Pressure Ulcer Advisor Panel, what is Grade 4?
Full Thickness Tissue Loss
- Extensive destruction with exposed or palpable bone, tendon or muscle; slough may be present but does not obscure the depth of tissue loss.
- May include undermining or tunneling
With the National Pressure Ulcer Advisor Panel, what is Suspected Deep Tissue Injury?
Epidermis will be intact but the affected area can appear purple of maroon or be filled blister over a dark wound bed. Over time this skin with degrade and develop into deeper tissue loss
With the National Pressure Ulcer Advisor Panel, what is Ungradable?
Full thickness skin/tissue loss where the depth of the ulcer is completely obscured by slough and necrotic tissue
- This may be a grade 3 or 4 after debrided
What is the Wagner Ulcer Grade Classification?
Originally developed for diagnosis and treatment of the dysvascular foot
- Now used to establish the presence of depth and infection in a wound
-Uses 6 grades (0-5)
- Commonly used for assessment of diabetic foot ulcers
Wagner Ulcer Grade Classification
What is a Grade 0 is this scale?
Preulcerative lesion; healed ulcers; presence of boney deformity
Wagner Ulcer Grade Classification
What is a Grade 4 is this scale?
Gangrene of digit
Wagner Ulcer Grade Classification
What is a Grade 1 is this scale?
Superficial ulcer without subcutaneous tissue involvement
Wagner Ulcer Grade Classification
What is a Grade 2 is this scale?
Penetration through the subcutaneous tissue; may expose bone, tendon, ligament or joint capsule
Wagner Ulcer Grade Classification
What is a Grade 3 is this scale?
Osteitis (infection within the bone), abscess (tender or painful masses associated with the wound) or ostomyelitis (infection of the bone marrow)
Wagner Ulcer Grade Classification
What is a Grade 5 is this scale?
Gangrene of the foot requiring disarticulation
What is the Univ. of Texas Treatment-Based Diabetic Foot Classification system?
This is used when neuropathy is present and information is needed about infection and circulation
- Each ulcer is given a numeric grade (0-3) and an alphabetical stage (A-D)
(A) = Wound Depth
(B) = Infection
(C) = Ischemia
(D) = Infection and Ischemia
