stages of ulcers

Question 1

Wagner ulcer grade classification

Answer 1

0-5- based on wound depth and presence of infection
most commonly associated with assessment of diabetic foot ulcers

neuropathic, ischemic, or arterial etiology

Question 2

0

Answer 2

no open lesion, may possess pre-ulcerative lesions; healed ulcers; presence of bony deformity

Question 3

1

Answer 3

superficial ulcer not involving subcutaneous tissue

Question 4

2

Answer 4

deep ulcer with penetration through the subcutaneous tissue; potentially exposing bone; tendon, ligament, or joint, capsule

Question 5

3

Answer 5

deep ulcer with osteitis, abscess or osteomyelitis

Question 6

4

Answer 6

gangrene of digit

Question 7

5

Answer 7

gangrene of foot requiring disarticulation

Question 8

stage 1 pressure injury

Answer 8

non-blancable erythema of intact skin

-sensation, temperature, changes in firmness may preceded visual changes

Question 9

stage 2 pressure injury

Answer 9

partial-thickness skin loss with exposed dermis

- wound bed is viable, pink/red, moist, intact or ruptured

Question 10

stage 3 pressure injury

Answer 10

full-thickness skin loss

- adipose tissue, granulation tissue, epibole, may be slough and/or eschar, undermining and tunneling may occur

Question 11

stage 4 pressure injury

Answer 11

full- thickness skin and tissue loss
- exposed/ palpable fascia, muscle, tendon, ligament, cartilage or bone present, probably slough and eschars epibole, undermining, tunneling

Question 12

unstageable pressure injury

Answer 12

obscured full-thickness skin and tissue loss

- can not be confirmed bc covered by slough and eschar

Question 13

deep tissue pressure injury

Answer 13

persistent non-blanchable deep red, maroon, pr purple discoloration
- not used to describe vascular, traumatic, neuropathic or dermatologic conditions.