Wound Assessment/Classification

Question 1

List/describe the 6 stages of breakdown according to AHCPR Guidelines and WOCN/NPUAP

Answer 1

STAGE I non-blanchable redness over bony prominence (painful, firm/soft, warmer/cooler)

sDTI purple maroon localized area intact skin or blood-filled blister (painful, firm/mushy/boggy, warmer/cooler)

STAGE II (P/T epidermis, possible dermis)
pink w/ no slough, shallow ulcer, open serum blister (painful)

STAGE III (F/T skin/tissue loss) 
SQ visible w/ no bone/tendon/muscle exposure (includes tunneling/undermining)

STAGE IV (F/T tissue loss w/ exposed bone/tendon/muscle) slough/eschar present (includes tunneling/undermining)

Unstageable (F/T tissue loss)
covered w/ slough (yellow/tan/grey/brown/green) or eschar (tan/brown or black)

Question 2

List key assessment parameters

Answer 2

Location
Duration
Dimension cm/cm
Undermining/tunneling/sinus tract
Status of wound base in percentage
Wound edges: open or closed
Drainage/exudate (volume, character, odour, consistency)
Systemic Ix (fever, elevated WBC, sudden unexplained hyperglycemia)
Surrounding tissues
Pain

Question 3

Identify problems/limitations of currently used staging systems

Answer 3

cannot accurate stage wound until derided
cannot stage granulating wound for initial Ax (did not see actual injury)
cannot reverse a stage
Incorrectly implies begin at skin to deeper tissue damage