MODULE 2 NDNQI WOUNDS
QUESTIONS AND ANSWERS
m Pressure Injury Classification - If the deepest type of tissue is visible (or directly palpable), the pressure
injury can be classified as Stage 1, 2, 3 or 4.
If the deepest tissue is not visible, the pressure injury is classified as unstageable (i.e. deepest tissue
obscured by slough or eschar);
Deep Tissue Pressure Injury (DTPI) (i.e. deep red, maroon or purple discoloration); or Non-Visible (a
special NDNQI category for pressure injuries under non-removable dressings or devices)
Pressure injuries on mucosal membranes are counted, but not staged
Wound/Skin Injury etiology - disease, moisture and trauma
Arterial Ulcers - A wound caused by impaired arterial blood flow to the lower leg and foot esp. Toes,
dorsum of the foot, lateral malleolus, distal lower leg
The impairment in blood flow results in tissue ischemia, necrosis, and loss.
Arterial Ulcer causes - Atherosclerosis
Arteriosclerosis
History of arterial insufficiency to lower extremities:
Peripheral Arterial Disease (PAD)
Lower Extremity Arterial Disease (LEAD)(1)
Risks:
Age
Smoking
Diabetes Mellitus
Hypertension
Dyslipidemia
Obesity
, Family history of cardiovascular disease(2)
Arterial Ulcer Associated Skin Assessment - Cooler skin temperature
Thin, shiny skin
Decreased or absent skin hair
Decreased pulse strength in affected extremity
Skin pallor on foot elevation; dusky rubor on dependency
Dystrophic toenails
Low Ankle-Brachial Index (ABI)
Arterial Ulcer Characteristics - Round and regular in shape
Pale wound bed
Can be shallow in depth or relatively deep
Smooth wound edges
Gangrenous/necrotic tissue may cover the wound
Minimal drainage
Severe pain
Venous Ulcer - An open skin lesion of the leg or foot that occurs in an area affected by venous
hypertension.
Prolonged venous hypertension results in vein wall damage. This increases capillary permeability and
allows the extravasation of micromolecules and macromolecules into the surrounding tissue. Damage to
these tissues leads to venous ulcer development.
Venous Ulcer Location - Lower calf and ankle (the gaiter area)
Pretibial and medial supra-malleolar area of the ankle near perforator veins.
Lower Extremity Venous Disease Risks - Family history
Older age
Obesity
History of venous disease or thromboembolism
Trauma to the legs
Female
Pregnancy
QUESTIONS AND ANSWERS
m Pressure Injury Classification - If the deepest type of tissue is visible (or directly palpable), the pressure
injury can be classified as Stage 1, 2, 3 or 4.
If the deepest tissue is not visible, the pressure injury is classified as unstageable (i.e. deepest tissue
obscured by slough or eschar);
Deep Tissue Pressure Injury (DTPI) (i.e. deep red, maroon or purple discoloration); or Non-Visible (a
special NDNQI category for pressure injuries under non-removable dressings or devices)
Pressure injuries on mucosal membranes are counted, but not staged
Wound/Skin Injury etiology - disease, moisture and trauma
Arterial Ulcers - A wound caused by impaired arterial blood flow to the lower leg and foot esp. Toes,
dorsum of the foot, lateral malleolus, distal lower leg
The impairment in blood flow results in tissue ischemia, necrosis, and loss.
Arterial Ulcer causes - Atherosclerosis
Arteriosclerosis
History of arterial insufficiency to lower extremities:
Peripheral Arterial Disease (PAD)
Lower Extremity Arterial Disease (LEAD)(1)
Risks:
Age
Smoking
Diabetes Mellitus
Hypertension
Dyslipidemia
Obesity
, Family history of cardiovascular disease(2)
Arterial Ulcer Associated Skin Assessment - Cooler skin temperature
Thin, shiny skin
Decreased or absent skin hair
Decreased pulse strength in affected extremity
Skin pallor on foot elevation; dusky rubor on dependency
Dystrophic toenails
Low Ankle-Brachial Index (ABI)
Arterial Ulcer Characteristics - Round and regular in shape
Pale wound bed
Can be shallow in depth or relatively deep
Smooth wound edges
Gangrenous/necrotic tissue may cover the wound
Minimal drainage
Severe pain
Venous Ulcer - An open skin lesion of the leg or foot that occurs in an area affected by venous
hypertension.
Prolonged venous hypertension results in vein wall damage. This increases capillary permeability and
allows the extravasation of micromolecules and macromolecules into the surrounding tissue. Damage to
these tissues leads to venous ulcer development.
Venous Ulcer Location - Lower calf and ankle (the gaiter area)
Pretibial and medial supra-malleolar area of the ankle near perforator veins.
Lower Extremity Venous Disease Risks - Family history
Older age
Obesity
History of venous disease or thromboembolism
Trauma to the legs
Female
Pregnancy
