Stages of Ulcers

Question 1

Wagner Grade of 0

Answer 1

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

Question 2

Wagner Grade of 1

Answer 2

• superficial ulcer not involving subcutaneous tissue

Question 3

Wagner grade of 2

Answer 3

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

Question 4

Wagner grade 3

Answer 4

• deep ulcer with osteitis, abscess or osteomyelitis

Question 5

Wagner grade 4

Answer 5

• gangrene of digit

Question 6

Wagner grade 5

Answer 6

• gangrene of foot requiring disarticulation

Question 7

Stage 1 pressure ulcer

Answer 7

• non-blanchable erythema of intact skin
• presence of blanchable erythema or changes in sensation, temp, or firmness may precede visual changes
• color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury

Question 8

Stage 2 pressure ulcer

Answer 8

• partial- thickness loss of skin with exposed dermis
• wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister
• adipose is not visible and deeper tissues are not visible
• granulation tissue, slough and eschar are not present
• commonly result from adverse microclimate and shear over the pelvis and shear in the heal
• this stage should not be used to describe moisture associated skin damage, including incontinence associated dermatitis, intertriginous dermatitis, medical adhesive related skin injury or traumatic wounds

Question 9

Stage 3 pressure ulcer

Answer 9

• full thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present
• slough and eschar may be visible
• undermining and tunneling may occur
• fascia, muscle, tendon, ligament, cartilage and bone are not exposed

Question 10

Stage 4 pressure ulcer

Answer 10

• full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer
• slough and eschar may be visible
• epibole, undermining and tunneling often occur

Question 11

Unstageable pressure injury

Answer 11

• full thickness skin and tissue low in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough and eschar
• stage 3 or 4

Question 12

deep tissue pressure injury

Answer 12

• intact or non intact skin with localized area of persistent non blanchable deep red, maroon, or purple discoloration or epidermis separation revealing a dark wound bed or blood filled blister
• pain and temp change often precede color change
• the injury results from intense or prolonged pressure and shear forces at the bone-muscle interface