Wound Classification

Presented by
Dr. Karen Zulkowski, D.N.S., RN
Montana State University
 Welcome!
Thank you for joining this webinar about how to
assess and measure a wound.

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 A Little About Myself…
• Associate professor at Montana
State University
• Executive editor of the Journal of the
World Council of Enterstomal
Therapists (JWCET) and WCET
International Ostomy Guidelines
(2014)
• Editorial board member of Ostomy
Wound Management and Advances
in Skin and Wound Care
• Legal consultant
• Former NPUAP board member

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 Today We Will Talk About
• How to assess a wound
• How to measure a wound
Please make a note of your questions. Your
Quality Improvement (QI) Specialists will follow
up with you after this webinar to address them.

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Assessing and Measuring Wounds
• You completed a skin assessment and found a
wound.

• Now you need to determine what type of

wound you found.

• If it is a pressure ulcer, you need to determine

the stage.

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Assessing and Measuring Wounds
This is important because—
• Each type of wound has a different etiology.
• Treatment may be very different.

However—
• Not all wounds are clear cut.
• The cause may be multifactoral.

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 Types of Wounds
• Vascular (arterial, venous, and mixed)
• Neuropathic (diabetic)
• Moisture-associated dermatitis
• Skin tear
• Pressure ulcer

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 Mixed Etiologies
Many wounds have mixed etiologies.
• There may be both venous and arterial
insufficiency.
• There may be diabetes and pressure
characteristics.

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 Moisture-Associated Skin Damage
• Also called perineal dermatitis, diaper rash,
incontinence-associated dermatitis (often
confused with pressure ulcers)
• An inflammation of the skin in the perineal
area, on and between the buttocks, into
the skin folds, and down the inner thighs
• Scaling of the skin with papule and vesicle
formation:
– These may open, with “weeping” of the skin,
which exacerbates skin damage.
– Skin damage is shallow or superficial
and edges are irregular or diffuse.
– Maceration or a whitening of skin may
also be observed.

• Results when epidermis is damaged and

bacteria are then able to penetrate
beneath the surface

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 Moisture-Associated Skin Damage
Determine what it is. Moisture

Is it pressure or moisture?
• May be difficult to
distinguish between
moisture-associated skin
damage and pressure Pressure

ulcer.
• Unlike moisture-
associated skin damage, a
pressure ulcer usually has
distinct edges.
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 Pressure Ulcers From Other
Sources of Pressure
• Boots, boot straps,
oxygen/endotracheal
tubes, stockings, and
other devices can also
lead to pressure-induced
ischemia on the skin.

• These are counted

separately for incidence
and prevalence.

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 2009 Pressure Ulcer Definition
“… localized injury to the skin and/or underlying
tissue usually over a bony prominence, as a
result of pressure, or pressure in combination
with shear.”

NPUAP/EPUAP Pressure Ulcer Prevention and Treatment Guidelines.

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 Pressure
• Perpendicular force—

– Compresses tissue
– Restricts blood flow
– Causes ischemia and
necrosis
– Ruptures cells and
vessels
– Causes tissue
deformation

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 Shear
• Force parallel to the
skin—
– Stretches and distorts
internal tissue
– May cause occlusion of
vessels perpendicular to
skin surface

• Leads to ischemia and

necrosis

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Pressure Ulcer Staging Concepts
• NPUAP classification system:
– 6 stages or categories:
• Stage I
• Stage II
• Stage III
• Stage IV
• Unstageable
• Suspected deep tissue injury (sDTI)
• Base staging on the type of tissue visualized or
palpated.
• Do not reverse stage when documenting a
healing pressure ulcer.

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 Staging is based on the type of tissue
visualized or palpated
QUICK GUIDE FOR
Partial thickness ulcer
PRESSURE ULCER STAGING
Stage I
Intact skin with non- Stage II
blanchable redness of a
Loss of dermis presenting as a
localized area usually over
shallow open ulcer with a red-
a bony prominence
pink wound bed or
open/ruptured serum-filled
blister.

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.

Unstageable
Base of wound is covered by Full thickness ulcer
dead tissue
Stage IV
Stage III Exposed bone, tendon or
Subcutaneous fat may be muscle.
visible but bone, tendon, or
muscle are not exposed.

© Zulkowski, 2012
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 Stage I
Definition
• Intact skin with nonblanchable
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 area.
Description
• Area may be more painful, firm, or
soft, or warmer or cooler than
adjacent tissue.
• Stage I may be difficult to detect
in persons with dark skin tones.

Source: National Pressure Ulcer Advisory Panel

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 Stage II
Definition
• 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 or sero-
sanguineous filled blister.
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,
incontinence-associated dermatitis,
maceration, or excoriation.
Source: National Pressure Ulcer Advisory Panel

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 Stage III
Definition
• Full thickness tissue loss. Subcutaneous fat
may be visible but bone, tendon, or muscle
are not exposed. Some slough may be
present.
• May include undermining and tunneling.
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 “adipose”
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.

Source: National Pressure Ulcer Advisory Panel

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 Stage IV
Definition
• Full thickness tissue loss with exposed
bone, tendon, or muscle.
– Slough or eschar may be present.
• Often include undermining and tunneling.
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 “adipose”
subcutaneous tissue and stage IV ulcers can be
shallow.
• Stage IV ulcers can extend into muscle
and/or supporting structures (e.g., fascia,
tendon, or joint capsule), making
osteomyelitis or osteitis likely to occur.
• Exposed bone/tendon is visible or directly
palpable.
bone
Source: National Pressure Ulcer Advisory Panel

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 Unstageable
Definition
• Full thickness tissue loss in which actual
depth of the ulcer is completely
obscured by slough (yellow, tan, gray,
green, or brown) and/or eschar (tan,
brown, or black) in the wound bed.
Description
• Until enough slough and/or eschar is
removed to expose the base of the
wound, the true depth cannot be
determined but it will be either a Stage
III or IV.
• 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.

Source: National Pressure Ulcer Advisory Panel

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Suspected Deep Tissue Injury
Definition
• 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.
Description
• The area may be preceded by tissue that is
painful, firm, mushy, or boggy, or warmer
or cooler than adjacent tissue.
• Deep tissue injury may be difficult to
detect in individuals with dark skin tone.
• Evolution may include a thin blister over
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
treatment.

Source: National Pressure Ulcer Advisory Panel

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 Suspected Deep Tissue Injury
• Difficult to say with certainty as outer skin
may be intact.
– Sometimes it really is a bruise.
– Damage is to deeper tissue and when you see
purplish area it is too late to prevent.
• Better to document exactly what you see than
have a facility-acquired wound.

Bruise

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 Causes of sDTI
• Falls

• Long OR/ER or transportation times

• Splints

• Accidents

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 Medical Device-Related Pressure Ulcers

• 9.1% of all identified Most frequent locations

pressure ulcers
Percentage of
• 11.9% of facility- Device-Related
acquired pressure Anatomic Location Pressure Ulcers
ulcers Ears 20%
Sacral/ 17%
coccyx region
Heel 12%
Buttocks 10%

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 Remember the Bariatric Patient
• Check between the skin folds
and thighs:
– Rash
– Maceration
– Infection (bacteria or
candidiasis)
– Breakdown

• Pressure ulcers may be in

unusual locations.

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 Assess the Wound
T Tissue both in and around the wound—
granulation, slough, necrotic black, pink, mix.
I Infection. Any open area always has the
potential for infection.
M Moisture (exudate). This determines type of
dressing needed to maintain balance.
E Edges. Are they contracted, rolling,
undermining?

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 Pressure Ulcer Present
Document
• Length, width, and depth
• Location
• Stage
• Exudate (amount, color, and consistency)
• Tunneling and/or undermining
• % of each type of tissue in wound (granulation,
epithelial, eschar, slough, fibrinous)
• Wound edges (attached, not attached, rolled
under, irregular, callous)

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 Know Your Assessment Terms
• Eschar. Cornified or dried out dead tissue.

• Slough. Liquefied or wet dead tissue.

• Undermining. Bigger area of tissue

destruction than can be seen (extends under
the edge).

• Tunneling. Tracts extending out from the

wound.

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How To Measure a Wound

Undermining

Tunneling

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 How To Measure a Wound
Head
Measure widest
width of the
pressure ulcer
side to side
perpendicular
(90° angle) to
length.

Toe

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 Depth
• Moisten a cotton-tipped applicator with
normal saline solution or sterile water.
• Place applicator tip in deepest aspect of the
wound and measure distance to the skin level.

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 Epithelial Tissue

© Ayello, 2013

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 Slough

© Ayello, 2013
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 Necrotic Tissue (Eschar)

Eschar

© Ayello, 2013

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 Skin Failure at Life’s End

• Kennedy terminal ulcer:

– Pressure ulcers may develop right before death.
– Some people now say this is skin failure at life’s
end

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 Selecting Dressings and Treatment
Based on—
• Overall medical condition of patient
• Location of wound
• Size of wound
• Wound etiology
• Wound bed tissue involvement
• Exudate amount
• Pain management
• Living arrangements

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 Care Planning

SKIN ASSESSMENT + RISK ASSESSMENT =

EFFECTIVE / COMPREHENSIVE CARE PLANNING

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Today We Talked About

• How to assess a wound

• How to measure a wound

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 Any Questions?

Thank you for being such great listeners.

Please refer any questions you have to your QI

Specialists.

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 Resources
• Berlowitz D, VanDeusen C, Parker V, et al. Preventing
pressure ulcers in hospitals: a toolkit for improving
quality of care. (Prepared by Boston University School
of Public Health under Contract No. HHSA
290200600012 TO #5 and Grant No. RRP 09-112.)
Rockville, MD: Agency for Healthcare Research and
Quality; April 2011. AHRQ Publication No. 11-0053-EF.
• VanGilder C, Amlung S, Harrison P, et al. Results of the
2008-2009 International Pressure Ulcer Prevalence
Survey and a 3-year, acute care, unit–specific analysis.
Ostomy Wound Manage. 2009;55(11):39-45.

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