- Partial Thickness: tissue destruction involving the epidermis extending into the dermis.
- Full Thickness: tissue destruction involving epidermis, dermis and subcutaneous tissue and possibly bone and muscle.
- Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin Eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
STAGE (if wound is a pressure ulcer)
- Stage I: Intact skin with non-blancheable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding areas. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk)
- Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. * This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicated suspected deep tissue injury
- Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
- Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or Eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
- Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or Eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or Eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) Eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.
WAGNER DIABETIC ULCER CLASSIFICATION
- Grade 0: Intact Skin
- Grade I: Superficial without penetration deeper layers
- Grade II: Deeper reaching tendon, bone, or joint capsule
- Grade III: Deeper with abscess, osteomyelitis, or tendonitis
- Grade IV: Gangrene of some portion of the toes or forefoot
- Grade V: Gangrene involving the whole foot or enough of the foot that no local procedures are possible
Document Size. Length x Width X Depth (cm)
- Length = head to toe direction
- Width = hip to hip direction
- Depth = measure deepest part of visible wound bed
Undermining/Tunneling/Sinus tracts. Use the “Clock System” with head = 12:00 (example: 2cm undermining at 3 o’clock)
- Tunneling- course or pathway that can extend in any direction from the wound, results in dead space.
- Undermining – tissue destruction underlying intact skin along wound margins.
- Sinus Tract – A drainage pathway from a deep focus of acute infection through tissue and/or bone to an opening on the surface.
Exudate – type, amount, or odor using descriptions below:
- Sanguineous – thin, bright red
- Serosanguineous – thin, watery, pale red to pink
- Serous – thin, watery, clear
- Purulent – thick or thin, opaque tan to yellow
- Foul Purulent – thick opaque yellow to green with offensive odor
- None – wound tissues dry
- Scant – wound tissues moist, no measurable drainage
- Small – wound tissues very moist, drainage <25% dressing
- Moderate – wound tissues wet, drainage involves 25 – 75% dressing
- Large – wound tissues filled with fluid – involves > 75% dressing
- Odor – Describe presence or absence of odor- strong, foul, pungent, fecal, musty, sweet
Types/Characteristics of tissue in wound bed including:
- Adherence of the tissue
- Non-adherent – easily separated from wound base
- Loosely adherent – pulls away from wound, but attached to wound base – Firmly adherent – Does not pull away from wound
- Amount – Describe in % (example: 50% wound bed covered with soft yellow slough, 50% beefy red granulation tissue) May also use “clock system” in describing location of necrotic tissue in wound bed.
- Tissue Types
- Slough – usually lighter in color, thinner and stringy in consistency; Color – Can be yellow, gray, white, green, brown
- Eschar – usually darker in color, thicker and hard consistency black or brown in color.
- Granulation Tissue – it is usually beefy red, granular, bubbly in appearance; should be differentiated from a smooth red wound bed; color of tissue – red, pink, pale pink or full dusky red
- Epithelialization – can appear as deep pink, then progress to pearly pink/ light purple from the edges in full thickness wound or may form islands in the wound base with superficial wounds
- Foreign Bodies
- Describe wound edges:
- Definition – Defined or undefined edges
- Attachment – Attached or unattached edges
- Rolled Under (Epibole) – Macerated – Fibrotic – Callused
- Border shape
Surrounding tissue: Color, edema, firmness, intact, induration, pallor, lesions, texture, scar, rash, staining, moisture
Infection: fever, streaking, redness, increased drainage, odor, warmth, elevated WBC, induration, malaise, edema, weeping, increased pain, discolorations
Pain – location, causative factors, intensity, quality, duration, alleviating factors, patterns, variations, interventions
Interventions for healing: dietary supplements, vitamins, lab tests, turning repositioning schedules, support surface, cushion, padding, pillows, elevation, heel protection, incontinence management, skin protection (barrier ointments)
Conditions which would affect healing: Mobility/Turning Surface and Positioning Limitations, Nutritional Status, continence, abnormal labs, infections, deterioration of medical condition, non-compliance.
Current topical treatment plan, response to treatment, modifications to plan, implementation of new orders, reason for not changing treatment plan, referrals.Patient and caregiver education.
- Lateral – toward side
- Distal – away from center
- Medial – toward middle
- Dorsal – located near
- Posterior – back, underside Superior – Top, up
- Anterior – Front, top
- Inferior – below, down
- Proximal – toward center, nearest
Specialized directions for limbs
- Proximal – Towards body
- Distal – Away from body
Specialized directions for Hand
- Palmar – towards palm, also volar
- Dorsal – opposite of palmar
Specialized directions for Foot
- Plantar – towards bottom of foot, also volar
- Dorsal – opposite of plantar