Ulcer staging

Question 1

Transudate

Answer 1

Color: Clear
Thickness: thin, watery

Question 2

Serosanguineous

Answer 2

Color: clear or tinge of red/ brown
Thickness: thin/ watery

Question 3

Exudate

Answer 3

Color: creamy, yellowish
Thickness: moderate to very tick, expected with autolytic debridement

Question 4

Pus

Answer 4

Color: yellow, brown
Thickness: moderate to very thick

Question 5

Infected pus

Answer 5

Color: hues or yellow, blue, green
Thickness: thick, indicates infection (however may be normal as WBC macrophage necrotic cells and turn them into slough) drainage can be foul smelling yet wound may not be infected

Question 6

Suspected deep tissue injury

Answer 6

purple or maroon localied area of discolored intact skin or blood- filled blister due to damage of underlying soft tissue from pressure and or shear, may be preceded by tissue that is painful, firm, mushy, boggy, warmer/ cooler than adjacent tissue

Question 7

Stage I ulcer

Answer 7

Intact skin with nonblanchable redness of a localized area usually over bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from surrounding area

Question 8

Stage II ulcer

Answer 8

Partial- thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ ruptured serum- filled blister

Question 9

Stage III ulcer

Answer 9

Full- thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

Question 10

Stage IV ulcer

Answer 10

Full- thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

Question 11

Unstageable ulcer

Answer 11

Full- thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound

Until enough slough and or eschar is removed to expose the base of the wound, the true depth and therefore stage cannot be determined

Question 12

If an ulcer has a contracture, what is the treatment?

Answer 12

bracing

Question 13

If an ulcer has reduced metabolic supply, what is the treatment?

Answer 13

hyperbaric oxygen

Question 14

If an ulcer has further skin breakdown, what is the treatment?

Answer 14

Pressure off- loading