complex wound

Question 1

stage 1 wound

Answer 1

intact ski
non blanchable
localized over bony prominence

Question 2

stage 2 wound

Answer 2

partial thickness loss
shallow, open
red pink wound
no slough
may present as an intact serum filled blister

Question 3

stage 3 wound

Answer 3

full thickness loss
subcutaneous fat visible
muscle tiss not exposed
slough maybe present
may include tunnelling or undermining

Question 4

stage 4

Answer 4

full thickness exposed

can see muscle or bone tissue slough and escar present

Question 5

Unstageable

Answer 5

Wound is to full of dead tiss and eschar to properly stage

Wound bed is open, inflamed

Tunneling present