Wound Assessment & Pressure Ulcers Questions With Solutions

Wound Assessment & Pressure Ulcers
Questions With Solutions

Slough yellow or white..strings or think clumps




Granulation tissue-pink or beefy red tissue, shiny, moist, granular appearance




Epithelial tissue new pink shiny tissue grows in from the edges




Necrotic tissue (eschar) black, brown, or tan firmly adheres to the wound bed




National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer staging system,

superficial deep tissue injury, Stage I- Stage IV.




Wagner Ulcer Grade Classification 0-5 system for neuropathic, ischemic, arterial ulcers

(diabetic), [not for pressure, vascular, or venous]




Marion Lab (color wound classification) red, yellow, black

, Wound Assessment & Pressure Ulcers
Questions With Solutions
NPUAP Stage 1 non-blanchable erythema




NPUAP Stage 2 superficial ulcer, partial thickness




NPUAP Stage 3 deep ulcer, full thinkness, subcutaneous or to fascia




NPUAP Stage 4 deep ulcer with necrosis, into muscle, tendon, bone.




Wagner Scale 0 no open lesion, may have cellulites




Wagner Scale 1 superficial ulcer




Wagner Scale 2 deep ulcer to tendon, capsule, bone




Wagner Scale 3 deep ulcer with abscess, osteomyelitis




Wagner Scale 4 localized gangrene