Wound Classification Systems and Wound Types

Question 1

Pressure Ulcer staging…

This is used for what kind of ulcers? (4)

Answer 1

1. Pressure ulcers
2. Arterial and Ischemic Ulcers (w/ pressure component)
3. Diabetic Ulcers (neuropathic) (w/pressure component)
4. Skin tear and tape damage*Matheny doesn’t like this one. Stage II classification.

Question 2

Wagner Ulcer Dysvascular Classification System…

It is used for what kind of ulcers? (2)

Answer 2

Arterial and Ischemic Ulcers

Diabetic Ulcers (Neuropathic)

Question 3

University of Texas Diabetic Classification is used for what kind of ulcers?

Answer 3

Diabetic Ulcers (neuropathic)

Question 4

Depth of Tissue Injury

What is it used for?

Answer 4

Full thickness wounds of all 4 kinds of ulcers.

Also skin tears, burns, and other skin wounds, surgical secondary intention healing.

Question 5

Which classification method does the National Pressure Ulcer Advisory board prefer ?

WHy?

Answer 5

Depth of tissue injury.

It can be used across the board for everything.

Question 6

Red, Yellow, and Black. What is this classification system used for?

Answer 6

Pressure ulcers
Venous ulcers
Arterial and Ischemic Ulcers
Diabetic Ulcers (neuropathic)

Question 7

Classification of Depth of Tissue Loss

What are the 4 Thickness of Skin Loss Classifications?

Answer 7

Superficial wound
Partial-Thickness skin loss
Full-Thickness skin loss
Subcutaneous Tissue Wounds

Question 8

Superficial wounds

Define

Answer 8

Effects only the epidermis

Question 9

Superficial wounds
Clinical examples (3)/ healing process

Answer 9

Sunburn
Stage 1 pressure ulcer
Stage 0 Diabetic ulcer
Heal by Inflammation.

Question 10

Partial-Thickness Skin Loss

Define

Answer 10

Extends through the epidermis, into, but not through, the dermis.

Question 11

Partial-Thickness Skin Loss
Clinical examples (5)/healing process

Answer 11

Skin tears
Abrasions
Tape damage
Blisters
Perineal dermatitis from incontinence
Heal by epidermal resurfacing or epithelialization

Question 12

Full-thickness skin loss

Define

Answer 12

Extends through the epidermis and dermis into subcutaneous fat and deeper structures.

Question 13

Full-thickness skin loss
Clinical examples (3)/Healing Process

Answer 13

Donor sites
Venous Ulcers
Surgical wounds
Heal by granulation tissue formation and contraction

Question 14

Subcutaneous Tissue Wounds

Define

Answer 14

Additional classification level for full-thickness wounds that extend into, or beyond the subcutaneous tissue.
(Matheny doesn’t really recommend this one. We mostly use Superficial, Partial-thickness and Full-thckness.)

Question 15

Subcutaneous Tissue Wounds

Clinical examples /Healing Process

Answer 15

Surgical wounds
Arterial/Ischemic wounds
Heal by granulation tissue formation and contraction

Question 16

Name the 6 examples of Chronic Wounds named after its pathophysiology.

Answer 16

1. Diabetic vascular and neuropathic ulcers.
2. Ischemic arterial ulcers
3. Pressure ulcers
4. Rheumatoid ulcers
5. Vasculitic ulcers
6. Venous ulcers

Question 17

Marion Laboratories Red, Yellow, and Black Wound Classification System. (not used often)

Red

Answer 17

Clean; Healing granulation

Question 18

Marion Laboratories Red, Yellow, and Black Wound Classification System. (not used often)

Yellow

Answer 18

Possible infection
Needs cleaning
Necrotic

Question 19

Marion Laboratories Red, Yellow, and Black Wound Classification System. (not used often)

Black

Answer 19

Needs cleaning

Necrotic

Question 20

Describe the Wagner Ulcer Grade Classification
scale
disease
appendage

Answer 20

0-6
presence of depth and infection
diabetic, neuropathic foot

Question 21

Venous Ulcer Characteristics

5

Answer 21

Irregular Borders
Lower medial "gaiter" area.
Hemosidrin staining.
Moist/Wet.
Longterm and recurring.

Question 22

Arterial Ulcer Characteristics

6

Answer 22

Plantar surface and Lateral Malleolus.
More distal than venous.
Toes, Heels, side of Foot.
Dry.
Borders may be more irregular. 
Rarely be very black from eschar.

Question 23

Neuropathic Ulcer Characteristics

3

Answer 23

Diabetes commorbidity.
Plantar of foot…Met head.
Surrounding tissue is callused.

Question 24

Pressure Ulcer Characteristics

15!!

Answer 24

1. Punch out (round)
2. Bony prominences
3. Stage for depth.
4. Edema.
5. Redness (erythema)
6. Tunneling/Undermining
7. Specific location
8. Necrotic/Slough
9. Eschar.
10. Granulation tissue.
11. Edges.
12. Exudate (serous, serosanguinous, sanguinous)
13. Size
14. Phase of healing
15. Maceration