Wound Assessment

Question 1

What are the classification of wounds?

Answer 1

Superficial
Partial-Thickness
Full-thickness
Subcutaneous

Question 2

Superficial Wound

Answer 2

Trauma to the skin with the epidermis remaining intact.

Question 3

Partial Thickness Wound

Answer 3

Wound that extends through the epidermis and possibly into the dermis.

Question 4

Full-thickness Wound

Answer 4

Wound that extends through the dermis into deeper structures such as subcutaneous fat. Typically wounds deeper than 4mm.

Question 5

Subcutaneous Wound

Answer 5

Wound that extends through integumentary tissues and involve deeper structures like fat, muscle, tendon, or bone.

Question 6

What is the Wagner Ulcer Grade Classification System?

Answer 6

Categorizes dysvascular ulcers based on wound depth and presence of infection. Scale goes from 0-5 (0 is best 5 is worst)

Question 7

Pressure Injury Staging

Answer 7

Stage 1: Non blanchable erythema of intact skin
Stage 2: Partial-thickness skin loss with exposed dermis
Stage 3: Full-thickness loss
Stage 4: Full-thickness skin and tissue loss
Unstageable: Obscured full-thickness skin and tissue loss
Deep tissue: Persistent non-blanchable deep red, maroon, or purple discoloration

Question 8

Types of Exudates ( fluid that comes out of wound)

Answer 8

Serous: clear, light color and a thin, watery consistency. Considered normal in a healthy wound.
Sanguineous: Red color and a thin, watery consistency. Due to presence of blood which can turn brown if allowed to dehydrate.
Serosanguineous: Light red or pink color and thin, watery consistency. Considered normal in a healthy wound.
Seropurulent: Cloudy or opaque, with a yellow or tan color and thin, watery consistency. Early signs of infection.
Purulent: Yellow or green color and a thick, viscous consistency. Indicator of wound infection.

Question 9

Types of Necrotic Tissue

Answer 9

Eschar: Hard or leathery, black/brown. dehydrated tissue adhered to wound bed.
Gangrene: Death and decay of tissue resulting in an interruption in blood flow to an area of the body.
Hyperkeratosis: aka Callus, typically gray/white color and can vary in texture from firm to soggy.
Slough: Moist, stringy or mucinous, white/yellow tissue that tends to be loosely attached to wound bed.