The Wagner Ulcer Grade Classification Scale and Wound Stages

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Arterial Insufficiency Ulcers

Occur 2⁰ to ischemia→ inadequate circulation of oxygenated blood due to complicating factors such as ATHEROSCLEROSIS
RECOMMENDATIONS
*Rest
*Limb Protection
*Rick reduction education
*Inspect Legs and feet daily
*AVOID UNNECESSARY LEG ELEVATION
*Avoid heating pads or soaking feet in hot water
*Wear appropriate sized shoes w/seamless socks

Venous Insufficiency Ulcers

Occur 2⁰ to ↓'d functioning of the venous system → inadequate circulation & eventual tissue damage & ulceration
RECOMMENDATIONS
*Limb protection
*Risk reduction education
*Inspect legs and feet daily
*Compression to control edema
*Elevate legs above the heart when resting or sleeping
*Attempt active exercise including frequent ROM
*Wear appropriate sized shoes w/seamless socks

Neuropathic Ulcers

Secondary complication asscoiated with a combo of ischemia & neuropathy; most often associated w/ DIABETES; frequently found on the PLANTAR SURFACE OF FOOT, beneath metatarsal heads
RECOMMENDATION
*Limb Protection
*Risk Reduction Education
*Inspect legs and feet daily
*Inspect footwear for debris prior to donning
*Wear approp. sized off loading footwear w/clean, cushioned , seamless socks

Pressure Ulcers

AKA→ bedsores / decubitus ulcers. localized areas of tissue necrosis that develop when soft tissue is compressed between bony prominence and external surface. Caused b→ ischemia. Found on heals, Sacrum, Hips, Ischium, Pinna of Ears & Elbows.
RECOMMENDATIONS
*Repositioning every 2 Hrs
*Mnge excess moisture
*Off-Loading→ pressure relieving devices
*Inspect skin daily for signs of pressure damage
*Limit shear, traction and fricton forces over fragile skin

Characteristics of LE Ulcers
Arterial Insufficiency Ulcers:

Location: lower 1/3 of leg, toes, web space (dist. toes/dorsal foot/Lat Malleolus.
Appearance: Smooth edges, well defined; lack gran. tend to be deep
Exudate: Minimal
pain: Severe
Pedal Pulse: Diminished or Absent
Edema: normal
Skin Temp: Decreased
Tissue Changes: Thin/shinny/hair loss/yellow nails
Misc: Leg elevation ↑'s pain

Characteristics of LE Ulcers
Venious Insufficiency Ulcers:

Location: Proximal to Med. Malleolus
Appearance: Irregular shape/shallow
Exudate: Moderate/Heavy
pain: Mild to Moderate
Pedal Pulse: Normal
Edema: Increased
Skin Temp: Normal
Tissue Changes: Flaking, dry, brownish discoloration
Misc: Leg elevation decreases pain

Characteristics of LE Ulcers
Neuropathic Ulcers

Location →: areas of the foot suseptible to pressure/sheer forces during wt. bearing
Appearance: → Well defined oval/circle; callused rim; cracked periwound tissue; little to no wound bed necrosis w/good granulation
Exudate: → Low/Moderate
Pain:→ None; dysesthesia may be reported
Pedal Pulse: → Diminished/absent; unreliable ABI
Edema; → Normal
Skin Temp: → Decreased
Tissue Changes: →dry, inelastic, shiny skin, decreased or absent sweat or oil production
Misc Loss of Protective Sensation

Wound Classification by Depth of Injury

Wounds that are not categorized as pressure or Neuropathic are classified based on DEPTH OF TISSUE

Superficial Wounds

Causes trauma to the skin w/ the epidermis remaining intact. (non-blistering sunburn)
Will typically heal as part of the inflammatory process
shearing, friction, burning - only epidermis

Partial Thickness wounds

Extends thru the epidermis (top layer) and "possible" into (but not thru) the dermis (2nd layer)
Ex: abrasions, blisters and skin tears
Will typically heal by re-epithelialization or epidermal resurfacing depending on the depth of injury.

Full Thickness Wounds

Extends thru the dermis into deeper structures such as subcutaneous fat. Wounds deeper than 4 mm are typically full-thickness and heal by 2ndary intention

Subcutaneous wound

extend through integumentary tissues and involve deeper structures such as subcutaneous fat, muscle, tendon or bone, typically require healing by secondary intention

Wagner Ulcer Grade classification System

Catergorizes dysvascular ulcers based on WOUND DEPTH and the presence of INFECTION.

Most commonly associated w/ assessment of DIABETIC FOOT ULCERS. Can appropriately be used to assiss must ulcers arising from NEUROPATHIC, ISCHEMIC, AND ARTERIAL etiology.

Grade 0

∅ open lesion, but may possess pre-ulcerative lessions, healed ulcers, prescence of bone deformity

Grade 1

Superficial ulcer → not involving subcutaneous tissue

Grade 2

Deep ulcer → penetration through the subcutaneous tissue, potentially exposing bone, tendon, ligament or joint capsule

Grade 3

deep ulcer with osteitis, abscess or osteomyelitis

Grade 4

gangrene of digit

Grade 5

gangrene of foot requiring disarticulation

What is a pressure ulcer?

Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination w/ shear and/or friction forces.
Other contributing factors: excessive moisture w/ friction/shear forces.

Pressure Ulcer Staging

Stages I, II, III, IV, Suspected Deep Tissue Injury, Unstageable

Stage I

Intact skin with NON-BLANCHABLE REDNESS of a localized area, usually over a bony prominence
CHANGES MAY INCLUDE
*Skin temperature
*Tissue Consistency
*Sensation
*Color
*May be hard to detect in darker skin tones

Stage II

Partial thickness tissue loss of the dermis
Involves epidermis, dermis or both
Ulcer is SUPERFICIAL. Red or pink wound bed
May present as an intact or ruptured SERUM FILLED BLISTER, or a shiny or dry shallow ulcer w/o sloth or BRUSING
Presents clinically as an abrasion, blister or SHALLOW crater
Do NOT use this stage to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

Stage III

Full thickness tissue loss
Subcutaneous fat → visible but bone, tendon or mm are NOT EXPOSED
Slough may be present → does not obscure depth of tissue
Involves damage to or necrosis of SUBCUTANOUS TISSUE May extend down to, but NOT through underlying fascia. May have undermining or tunneling. Depth of wound will depend on location.
Presents clinically as a DEEP crater

Stage IV

Full thickness tissue loss
involves EXTENSIVE destruction , tissue necrosis or damage to MUSCLE, BONE OR SUPPORTING STRUCTURES. BONE / TENDON / MM ARE EXPOSED
Sloth or eschar may be present on some parts of the wound bed. Depth of wound will depend on the location
UNDERMINING and sinus tracts may be present

Suspected Deep Tissue Injury

Purple / maroon localized area → discolored intact skin → BLOOD- FILLED BLISTER d/t damage of underlying soft tissue from pressure and/or shear. Area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared w/ adjacent tissue
May be difficult to detect in darker toned skin
Evolution may include a thin blister over a dark wound bed. wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even w/ optimal tx.

Unstageable

Full thickness tissue loss which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, black) in the wound bed. until enough slough and/or eschar are removed to expose the base of the wound, the true depth, and therefore the true stage cannot be determined
Stable eschar (dry adherent intact without erythema or fluctuating appearance) on the heels serves as "the body's natural (biological) cover" and SHOULD NOT BE REMOVED

Implications of Eshcar

Stage 4 and Un-stageable
Hard or leathery, black/brown dehydrated tisue → tends to be firmly adhered to wound bed.
May need surgical debrediment

Benefits of Staging system

helps to know so proper treatment can be implemented.

Limitations of Staging system

No reverse staging - e.g. - Stage IV DOES NOT heal and become a Stage II

Cannot stage a wound that is covered by eschar - must be able to accurately assess depth
*unstageable due to necrosis

Wound Examination

ASSESS SIZE (transparent grid)
DEPTH : Insert cotton tip
EXAMINE FOR TUNNELING (rimming/undermining) - underlying tissue destruction beneath intact skin
Evaluate for sinus tracts (communication with deeper structures) associated with unusual or irregular borders
Determine exudate (drainage)
ODOR
Consistency (e.g. macerated)
Determine temp (thermister probe)
Examine viability to periwound tissue
LOCATION: Use anatomical position (picture on eval sheet)
MECHANISM OF INJURY (MOI): Burn, ulcer, ....
WOUND SHAPE: Round; Oval; Keyhole; Other-Gutter wound;

Loss of Protective Sensation

Individuals w/ Peripheral Neuropathy → ↑ risk of tissue Damage.
Monofilament Testing → Reliable method of assessing / documenting changes in protective sensation.
Apply ⊥ to skin and held in place for 1 Sec → Enough force to bend Filament inot a "C" shape.
No Perception @ 10 gm monofilament →LOSS OF PROTECTIVE SENSATION → Risk for developing Neuropathic ulcer (rock in shoe)
No Perception @ 75 gm Monofilament → ∅ sensation in area

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