Wound Classification

Question 1

NPUAP Stage 1

Answer 1

Non-blanchable erythema of intact skin

Area may be painful, warmer, cooler, firmer, and softer compared to adjacent area

Only epidermal damage

Question 2

NPUAP Stage 2

Answer 2

Superficial ulcer that presents as a shallow crater w/o slough, eschar or bruising

May be ruptured or intact

Partial thickness ulcer involving the epidermis, dermis, or both

No adipose or deeper tissue visible

Question 3

NPUAP Stage 3

Answer 3

Deep ulcer that presents as a deep crater; may have undermining or tunneling

If slough or eschar obscures the depth of tissue involvement, this should be described as unstageable

Full thickness skin loss involving dermis, epidermis, & subcutaneous tissue

No bone, tendon, ligament, muscle are visible/palpable

Question 4

NPUAP Stage 4

Answer 4

Deep ulcer w/ extensive necrosis

Often w/ undermining or sinus tracts

If slough or eschar obscures the depth of tissue involvement, this should be described as unstageable

Full thickness skin loss involving epidermis, dermis, subcutaneous tissue, fascia, & underlying muscle, tendon, joint capsule, ligament, cartilage, bone

Question 5

NPUAP Unstageable

Answer 5

Base obscured by eschar or slough

Full thickness

Once devitalized tissue is removed, the wound would be stage 3 or 4

Question 6

Wagner 0

Answer 6

No open lesions

May have deformity or cellulitis

None, superficial, or partial thickness

Question 7

Wagner 1

Answer 7

Superficial ulcer

Partial or full thickness

Question 8

Wagner 2

Answer 8

Deep ulcer to tendon, capsule, or bone

Full thickness

Question 9

Wagner 3

Answer 9

Deep ulcer w/ abscess, osteomyelitis, or joint sepsis

Full thickness

Question 10

Wagner 4

Answer 10

Localized gangrene

Full thickness

Question 11

Wagner 5

Answer 11

Gangrene of the entire foot

Full thickness