Podcast
Questions and Answers
What is a superficial wound?
What is a superficial wound?
What are examples of partial-thickness wounds?
What are examples of partial-thickness wounds?
Abrasions, blisters, and skin tears
A full-thickness wound is one that extends through the dermis into deeper structures.
A full-thickness wound is one that extends through the dermis into deeper structures.
True
What does stage 1 pressure ulcer staging involve?
What does stage 1 pressure ulcer staging involve?
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What characterizes a stage 2 pressure ulcer?
What characterizes a stage 2 pressure ulcer?
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What may be visible in a stage 3 pressure ulcer?
What may be visible in a stage 3 pressure ulcer?
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In a stage 4 pressure ulcer, bone and muscle are often visible.
In a stage 4 pressure ulcer, bone and muscle are often visible.
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An unstageable pressure ulcer has its base covered by _____ and/or eschar.
An unstageable pressure ulcer has its base covered by _____ and/or eschar.
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What is a deep tissue injury?
What is a deep tissue injury?
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Study Notes
Wound Classification
- Superficial wound: Epidermis intact; heals through inflammatory process (e.g., non-blistering sunburn).
- Partial-thickness wound: Extends through epidermis into dermis; involves abrasions, blisters, and skin tears; heals via re-epithelialization.
- Full-thickness wound: Extends through dermis into deeper structures (subcutaneous fat); depth >4mm; heals by secondary intention.
- Subcutaneous wound: Involves integumentary tissue and deeper structures (fat, muscle, tendon, bone); heals by secondary intention.
Pressure Ulcer Staging
- Stages: Categorized into Stage 1, Stage 2, Stage 3, Stage 4, Unstageable, and Deep Tissue Injury.
Stage 1 Pressure Ulcer
- Intact skin with non-blanchable redness over bony prominence; may feel firm, soft, warmer, or cooler than surrounding tissue.
- In people with dark skin, look for color difference from nearby skin areas.
Stage 2 Pressure Ulcer
- Partial-thickness tissue loss of dermis; presents as shallow open ulcer (red/pink wound bed).
- No slough present; may appear as intact or ruptured serum-filled blister, or dry/shiny ulcer without sloughing.
- Do not confuse with skin tears, tape burns, perineal dermatitis, maceration, or excoriation.
Stage 3 Pressure Ulcer
- Full-thickness tissue loss; subcutaneous fat may be visible but not bone, tendon, or muscle.
- Depth varies based on anatomical location; slough may be present but does not obscure the depth.
- May include tunneling or undermining.
Stage 4 Pressure Ulcer
- Full-thickness tissue loss; exposes bone, tendon, or muscle that is visible or palpable.
- Slough or eschar may be present; depth still visible; often includes tunneling or undermining.
- Potential for osteomyelitis as the wound can extend into fascia, tendon, or joint capsule.
Unstageable Pressure Ulcer
- Full-thickness tissue loss with the base of the ulcer covered by slough and/or eschar.
- True depth and classification undetermined until slough or eschar is removed.
Deep Tissue Injury
- Intact skin appears purple or maroon in localized area; may present with blood-filled blister.
- Caused by pressure or shear damage to underlying soft tissue; may feel painful, firm, mushy, or boggy, and can vary in temperature.
- Potential for rapid evolution; may develop thin blister over dark wound bed, progressing to eschar, exposing additional tissue layers with treatment.
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Description
Explore the different types of wounds, including superficial, partial-thickness, full-thickness, and subcutaneous wounds, along with their healing processes. Additionally, learn about the stages of pressure ulcers, from Stage 1 to Stage 4, including characteristics and identification strategies. This quiz will test your knowledge on these critical aspects of wound care.
