Basecamp: Stages of Ulcers Flashcards

Questions and Answers

What is epibole?

Rolled edges of wound

What is a superficial wound?

Trauma only to the epidermis which remains intact such as with a non blistering sunburn

What is a Partial Thickness wound?

A wound that extends through the epidermis and possibly into but not through the dermis such as in an abrasion, blister, or skin tear.

What is a Full Thickness wound?

A wound that extends through the dermis into deeper structures such as subcutaneous fat and is deeper than 4 cm. Signup and view all the answers

What is a subcutaneous wound?

A wound that extends through integumentary tissues and involves deeper structures such as subcutaneous fat, muscle, tendon, or bone. Signup and view all the answers

How do superficial wounds heal?

As a part of the inflammatory process Signup and view all the answers

How do partial thickness wounds heal?

Re-epithelialization or epidermal resurfacing Signup and view all the answers

How do full thickness wounds heal?

Secondary intention Signup and view all the answers

How do subcutaneous wounds heal?

Secondary intention Signup and view all the answers

What is the Wagner Ulcer Grade Classification System?

A scale that categorizes dysvascular ulcers based on wound depth and the presence of infection. Stage 0-5 Signup and view all the answers

What assessment tool is most commonly associated with diabetic foot ulcers?

Wagner Ulcer Grade classification Signup and view all the answers

What is a Stage 1 pressure injury?

Non-blanchable erythema of intact skin Signup and view all the answers

What is a Stage 2 pressure injury?

Partial-thickness skin loss with exposed dermis Signup and view all the answers

What is a Stage 3 pressure injury?

Full thickness skin loss Signup and view all the answers

What is a Stage 4 pressure injury?

Full thickness skin and tissue loss Signup and view all the answers

When is a pressure injury unstageable?

When the full thickness skin and tissue loss is obscured by slough and eschar limiting confirmation of depth. Signup and view all the answers

What is a Deep Tissue Pressure injury?

Persistent non-blanchable deep red maroon, or purple discoloration Signup and view all the answers

When should you not use the Deep Tissue Pressure Injury classification?

When describing vascular, traumatic, neuropathic, or dermatologic conditions Signup and view all the answers

Match the pressure injury stage to the corresponding description:

Stage 1 = Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Stage 2 = Partial-thickness tissue loss of the dermis presenting as a shallow open ulcer with a red or pink wound bed. Stage 3 = Subcutaneous fat may be visible but bone, tendon or muscle are NOT exposed. Stage 4 = Full thickness tissue loss with exposed bone tendon or muscle that is visible or directly palpable. Signup and view all the answers

Which of the following is a characteristic of an arterial insufficiency ulcer?

Decreased skin temperature Signup and view all the answers

Based on Wagner's ulcer grade classification scale, gangrene of a digit would be associated with what grade?

4 Signup and view all the answers

Based on Wagner's Ulcer grade classification scale, a superficial ulcer not involving subcutaneous tissue would be associated with what grade?

1 Signup and view all the answers

A grade of 4 on the Wagner Ulcer Grade Classification System is most indicative of:

Gangrene of a digit Signup and view all the answers

A pressure injury that is covered with devitalized necrotic tissue would best be classified as:

Unstageable Signup and view all the answers

Which description is not associated with a wound classified as 'yellow' using the Red-Yellow-Black System?

Dry Signup and view all the answers

Study Notes

Wound Definitions and Classifications

Epibole: Characterized by rolled edges of a wound, indicating chronicity.
Superficial Wound: Involves only the epidermis, remaining intact, such as a non-blistering sunburn.
Partial Thickness Wound: Extends through the epidermis and potentially into the dermis, examples include abrasions or blisters.
Full Thickness Wound: Involves injury through the dermis into deeper structures, is deeper than 4 cm.
Subcutaneous Wound: Penetrates through integumentary tissues affecting deeper structures like subcutaneous fat, muscle, or bone.

Healing Processes

Superficial Wounds: Heal through the inflammatory process.
Partial Thickness Wounds: Heal by re-epithelialization or epidermal resurfacing.
Full Thickness and Subcutaneous Wounds: Heal through secondary intention, involving granulation and contraction.

Pressure Injury Stages

Wagner Ulcer Grade Classification System: Categorizes dysvascular ulcers based on depth and infection presence, with stages ranging from 0 to 5.
Stage 1 Pressure Injury: Presents as non-blanchable erythema on intact skin.
Stage 2 Pressure Injury: Characterized by partial-thickness skin loss with exposed dermis.
Stage 3 Pressure Injury: Features full thickness skin loss without bone, tendon, or muscle exposure.
Stage 4 Pressure Injury: Involves full thickness skin and tissue loss with visible or palpable bone, tendon, or muscle.
Unstageable Pressure Injury: When full thickness loss is obscured by slough or eschar, preventing depth assessment.
Deep Tissue Pressure Injury: Indicates persistent non-blanchable deep red, maroon, or purple discoloration.

Classification Specifics

Wagner Ulcer Grade and Gangrene: Grade 4 correlates with gangrene of a digit.
Superficial Ulcers: Not involving subcutaneous tissue correspond to Grade 1.
Pressure Injuries Covered with Necrotic Tissue: Labeled unstageable as the depth cannot be reliably assessed.

Characteristics of Ulcers

Arterial Insufficiency Ulcer: Typically presents with decreased skin temperature.
Wound Descriptions: In the Red-Yellow-Black System, yellow wounds may be characterized by slough, debris, or exudate, but not dry.

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Description

Test your knowledge of the stages of ulcers with these flashcards. Each card defines important terms related to wound healing, such as 'epibole' and 'partial thickness wounds'. Perfect for students or professionals in the medical field.