33 terms

The Wagner Ulcer Grade Classification Scale and Wound Stages

Arterial Insufficiency Ulcers
Occur 2⁰ to ischemia→ inadequate circulation of oxygenated blood due to complicating factors such as ATHEROSCLEROSIS
*Limb Protection
*Rick reduction education
*Inspect Legs and feet daily
*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
*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
*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.
*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
*Skin temperature
*Tissue Consistency
*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.
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)
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