Wound Classification and Pressure Ulcer Staging

Questions and Answers

What is a superficial wound?

A wound where the epidermis remains intact (correct)

A wound that affects deeper structures

A wound that extends through the dermis

A wound that is fully healed

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.

True

What does stage 1 pressure ulcer staging involve?

Intact skin with non-blanchable redness over a bony prominence Signup and view all the answers

What characterizes a stage 2 pressure ulcer?

Partial-thickness tissue loss of dermis presenting as a shallow open ulcer Signup and view all the answers

What may be visible in a stage 3 pressure ulcer?

Subcutaneous fat, but not bone, tendon, or muscle Signup and view all the answers

In a stage 4 pressure ulcer, bone and muscle are often visible.

True Signup and view all the answers

An unstageable pressure ulcer has its base covered by _____ and/or eschar.

slough Signup and view all the answers

What is a deep tissue injury?

Intact skin that is purple or maroon in a localized area with potential underlying damage Signup and view all the answers

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.

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.