Wound Classification Systems and Wound Types Flashcards
(24 cards)
Pressure Ulcer staging…
This is used for what kind of ulcers? (4)
- Pressure ulcers
- Arterial and Ischemic Ulcers (w/ pressure component)
- Diabetic Ulcers (neuropathic) (w/pressure component)
- Skin tear and tape damage*Matheny doesn’t like this one. Stage II classification.
Wagner Ulcer Dysvascular Classification System…
It is used for what kind of ulcers? (2)
Arterial and Ischemic Ulcers
Diabetic Ulcers (Neuropathic)
University of Texas Diabetic Classification is used for what kind of ulcers?
Diabetic Ulcers (neuropathic)
Depth of Tissue Injury
What is it used for?
Full thickness wounds of all 4 kinds of ulcers.
Also skin tears, burns, and other skin wounds, surgical secondary intention healing.
Which classification method does the National Pressure Ulcer Advisory board prefer ?
WHy?
Depth of tissue injury.
It can be used across the board for everything.
Red, Yellow, and Black. What is this classification system used for?
Pressure ulcers
Venous ulcers
Arterial and Ischemic Ulcers
Diabetic Ulcers (neuropathic)
Classification of Depth of Tissue Loss
What are the 4 Thickness of Skin Loss Classifications?
Superficial wound
Partial-Thickness skin loss
Full-Thickness skin loss
Subcutaneous Tissue Wounds
Superficial wounds
Define
Effects only the epidermis
Superficial wounds Clinical examples (3)/ healing process
Sunburn
Stage 1 pressure ulcer
Stage 0 Diabetic ulcer
Heal by Inflammation.
Partial-Thickness Skin Loss
Define
Extends through the epidermis, into, but not through, the dermis.
Partial-Thickness Skin Loss Clinical examples (5)/healing process
Skin tears Abrasions Tape damage Blisters Perineal dermatitis from incontinence Heal by epidermal resurfacing or epithelialization
Full-thickness skin loss
Define
Extends through the epidermis and dermis into subcutaneous fat and deeper structures.
Full-thickness skin loss Clinical examples (3)/Healing Process
Donor sites
Venous Ulcers
Surgical wounds
Heal by granulation tissue formation and contraction
Subcutaneous Tissue Wounds
Define
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.)
Subcutaneous Tissue Wounds
Clinical examples /Healing Process
Surgical wounds
Arterial/Ischemic wounds
Heal by granulation tissue formation and contraction
Name the 6 examples of Chronic Wounds named after its pathophysiology.
- Diabetic vascular and neuropathic ulcers.
- Ischemic arterial ulcers
- Pressure ulcers
- Rheumatoid ulcers
- Vasculitic ulcers
- Venous ulcers
Marion Laboratories Red, Yellow, and Black Wound Classification System. (not used often)
Red
Clean; Healing granulation
Marion Laboratories Red, Yellow, and Black Wound Classification System. (not used often)
Yellow
Possible infection
Needs cleaning
Necrotic
Marion Laboratories Red, Yellow, and Black Wound Classification System. (not used often)
Black
Needs cleaning
Necrotic
Describe the Wagner Ulcer Grade Classification
scale
disease
appendage
0-6
presence of depth and infection
diabetic, neuropathic foot
Venous Ulcer Characteristics
5
Irregular Borders Lower medial "gaiter" area. Hemosidrin staining. Moist/Wet. Longterm and recurring.
Arterial Ulcer Characteristics
6
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.
Neuropathic Ulcer Characteristics
3
Diabetes commorbidity.
Plantar of foot…Met head.
Surrounding tissue is callused.
Pressure Ulcer Characteristics
15!!
- Punch out (round)
- Bony prominences
- Stage for depth.
- Edema.
- Redness (erythema)
- Tunneling/Undermining
- Specific location
- Necrotic/Slough
- Eschar.
- Granulation tissue.
- Edges.
- Exudate (serous, serosanguinous, sanguinous)
- Size
- Phase of healing
- Maceration
