ulcers 1/22

Question 1

wagner scale levels

Answer 1

scale for extent of pressure ulcer
W=0, W/out an ulcer or a healing ulcer. 
A=1, A superficial ulcer forms. 
G=2, Goes deeper to subQ tissue. 
N=3, Now osteomyelitis is present. 
E=4, Ewe there is gangrene of digits. 
R=5, Removal of gangrene of foot.

Question 2

what standardized tool?

• risk of developing pressure injuries.
• scored in the categories of sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
• total possible scores?
• recommended intervention protocols for each established level of risk.

Answer 2

Braden Scale

6-23

Question 3

braden score
< 9  risk? 
10-12?
13-14?
15-18?

Answer 3

< 9  very high risk
10-12 high risk
13-14 moderate
15-18 mild risk
19-23 no risk

Question 4

Wagner scale #?
deep ulcer with penetration through the subcutaneous tissue; potentially exposing bone, tendon, ligament or joint capsule.

Answer 4

grade 2

Question 5

Wagner scale #?

superficial ulcer not involving the subcutaneous tissue.

Answer 5

grade 1

Question 6

Wagner scale #?

deep ulcer with osteitis, abscess or osteomyelitis.

Answer 6

grade 3

Question 7

Wagner scale #?

presence of gangrene in a digit.

Answer 7

grade 4

Question 8

why would Hyperbaric oxygen therapy (HBOT) be used for chronic diabetic foot ulcer?

Answer 8

HBOT is primarily used to treat chronic wounds caused by tissue hypoxia.

• diabetic ulcers become chronic wounds because of tissue hypoxia and infection
• HBOT increases oxygenation to the tissue, which also helps to treat infection through increased leukocyte activity.
• oxygen therapy in which the patient is required to inhale 100% oxygen. To achieve this, the patient is placed inside a chamber that covers the entire body or a hood that administers the oxygen is placed over the patient’s head.

Question 9

what stage pressure ulcer?

• alteration of intact skin
• change in skin color, temperature, stiffness or sensation as compared to adjacent tissues.

Answer 9

stage I pressure ulcer

Question 10

what stage pressure ulcer?

• partial-thickness skin loss involving the epidermis or dermis.
• blister, abrasion or shallow crater

Answer 10

stage II pressure ulcer

Question 11

what stage pressure ulcer?

• full-thickness skin loss extending to, but not through the fascia that underlies the subcutaneous tissue.
• deep crater and may include necrosis or undermining.

Answer 11

stage III pressure ulcer

Question 12

what stage pressure ulcer?

• full-thickness skin loss with extensive tissue destruction that extends to muscle, bone or other supporting structures
• includes significant necrosis.

Answer 12

stage IV pressure ulcer