Key Takeaways
- Pressure injury staging (NPUAP): Stage 1 (non-blanchable erythema, intact skin), Stage 2 (partial thickness, blister), Stage 3 (full thickness into subcutaneous), Stage 4 (full thickness with bone/tendon exposure), Unstageable (obscured by slough/eschar)
- The Wagner scale classifies diabetic foot ulcers: Grade 0 (at-risk), Grade 1 (superficial), Grade 2 (deep to tendon/joint), Grade 3 (deep with abscess/osteomyelitis), Grade 4 (partial gangrene), Grade 5 (whole foot gangrene)
- Wound assessment uses MEASURES: Measure (length, width, depth), Exudate, Appearance, Suffering (pain), Undermining, Re-evaluate, Edge (wound margins)
- Wound healing phases: hemostasis (minutes), inflammation (1-6 days), proliferation (4-24 days), remodeling (21 days to 2 years)
- Debridement types: sharp/surgical (fastest, selective), enzymatic (topical agents like collagenase), autolytic (moisture-retentive dressings), mechanical (wet-to-dry, pulsed lavage)
- Burns — Rule of Nines for adults: head 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, perineum 1%
- Burn depth: superficial (1st degree — epidermis, painful, red), superficial partial-thickness (2nd degree — into dermis, blisters), deep partial-thickness (into reticular dermis), full-thickness (3rd degree — painless, waxy/leathery)
- Wound dressing selection: hydrogel (dry wounds, autolytic debridement), alginate (highly exudative wounds), foam (moderate exudate), hydrocolloid (light exudate, granulating wounds)
Integumentary System: Wound Care & Burns
The integumentary domain accounts for 4-5% of the NPTE, but questions tend to be very specific and detail-oriented. Mastery of wound classification systems, healing phases, and intervention selection is essential.
Wound Classification
Pressure Injury Staging (NPUAP/NPIAP 2019)
| Stage | Description | Tissue Involved |
|---|---|---|
| Stage 1 | Non-blanchable erythema of intact skin | Epidermis — skin is not broken |
| Stage 2 | Partial-thickness skin loss with exposed dermis; may present as blister | Epidermis and part of dermis |
| Stage 3 | Full-thickness skin loss; subcutaneous fat may be visible; undermining/tunneling may occur | Through dermis into subcutaneous tissue |
| Stage 4 | Full-thickness tissue loss with exposed bone, tendon, muscle, or cartilage | Through all layers to deep structures |
| Unstageable | Full-thickness loss obscured by slough (yellow) or eschar (black) | Cannot determine depth until debrided |
| Deep Tissue Pressure Injury | Persistent non-blanchable deep red, maroon, or purple discoloration; intact or non-intact skin | Deep tissue damage under intact surface |
Key Rule: Pressure injuries can only be staged forward (worsening). A Stage 4 that heals does NOT become a Stage 3 — it is documented as a "healing Stage 4." Reverse staging is not used.
Wagner Classification (Diabetic Foot Ulcers)
| Grade | Description |
|---|---|
| Grade 0 | No open lesion; at-risk foot with deformity or callus |
| Grade 1 | Superficial ulcer (epidermis and/or dermis) |
| Grade 2 | Deep ulcer to tendon, bone, or joint capsule |
| Grade 3 | Deep ulcer with abscess, osteomyelitis, or joint sepsis |
| Grade 4 | Localized gangrene (forefoot or heel) |
| Grade 5 | Extensive gangrene of entire foot |
Wound Healing Phases
| Phase | Timeline | Key Events |
|---|---|---|
| Hemostasis | Minutes | Vasoconstriction, platelet aggregation, clot formation |
| Inflammation | 1-6 days | Vasodilation, neutrophils and macrophages clean wound, cardinal signs (redness, heat, swelling, pain) |
| Proliferation | 4-24 days | Granulation tissue formation, angiogenesis, wound contraction, epithelialization |
| Remodeling (Maturation) | 21 days to 2 years | Collagen reorganization, scar maturation; wound reaches maximum 80% of original tissue strength |
Clinical Significance: A wound stuck in the inflammatory phase for more than 3 weeks is considered a chronic wound. Factors that impair healing include diabetes, vascular disease, malnutrition (especially protein, vitamin C, zinc), infection, smoking, and medications (corticosteroids, NSAIDs).
Debridement Types
| Type | Method | Speed | Selectivity | Indications |
|---|---|---|---|---|
| Sharp/Surgical | Scalpel, scissors, curette | Fastest | Selective (can target necrotic tissue) | Thick necrotic tissue, infected wounds, urgent debridement |
| Enzymatic | Topical agents (collagenase/Santyl) | Slow | Selective | Patients unable to tolerate sharp debridement |
| Autolytic | Moisture-retentive dressings (hydrogel, hydrocolloid) | Slowest | Selective | Clean wounds with light necrotic tissue |
| Mechanical | Wet-to-dry gauze, pulsed lavage, whirlpool | Moderate | Non-selective (removes healthy and necrotic tissue) | Wounds with both necrotic and granulation tissue |
Debridement Contraindication: Do NOT debride stable, dry eschar on the heels — it serves as a biological cover. Monitor for signs of infection.
Burns
Rule of Nines (Adults)
| Body Region | Percentage of TBSA |
|---|---|
| Head and neck | 9% |
| Each upper extremity | 9% (total 18%) |
| Anterior trunk | 18% |
| Posterior trunk | 18% |
| Each lower extremity | 18% (total 36%) |
| Perineum | 1% |
| Total | 100% |
Note: The Rule of Nines is modified for children: head is proportionally larger (18% for infants) and legs are smaller.
Burn Depth Classification
| Depth | Layers Affected | Appearance | Sensation | Healing |
|---|---|---|---|---|
| Superficial (1st degree) | Epidermis only | Red, dry, no blisters | Painful | 3-7 days, no scarring |
| Superficial partial-thickness (2nd) | Epidermis + superficial dermis | Red, moist, blisters | Very painful | 7-21 days, minimal scarring |
| Deep partial-thickness (2nd) | Epidermis + deep dermis | Red/white, may be moist or waxy | Decreased sensation | 21-35 days, scarring likely |
| Full-thickness (3rd degree) | All skin layers | White, waxy, leathery, or charred | Painless (nerves destroyed) | Requires grafting |
| Subdermal (4th degree) | Skin + underlying structures | Charred, exposed structures | No sensation | Requires surgery, amputation possible |
Burn Rehabilitation Focus
- Positioning: Position OPPOSITE to anticipated contracture (anti-deformity position)
- Splinting: Used to maintain functional position and prevent contracture
- ROM exercises: Begin immediately; active and passive motion to maintain joint mobility
- Pressure garments: Applied after wound closure to minimize hypertrophic scarring (worn 23 hours/day for 12-18 months)
A patient has a pressure injury with exposed bone and tendon visible in the wound bed. This is classified as:
Using the Rule of Nines, an adult patient with burns to the entire anterior trunk and the entire right upper extremity has approximately what percentage of total body surface area (TBSA) burned?
Which type of debridement is the FASTEST and most selective method?
Match each wound dressing type to its primary indication.
Match each item on the left with the correct item on the right
A full-thickness (3rd degree) burn is typically:
Wounds achieve a maximum of approximately _____% of the original tissue tensile strength after complete remodeling.
Type your answer below
A pressure injury that is full-thickness with the wound bed obscured by yellow slough and black eschar is classified as:
In burn rehabilitation, the patient should be positioned in the _____ of anticipated contracture.
Arrange the wound healing phases in their correct chronological order:
Arrange the items in the correct order
Pressure garments after burn wound closure should be worn: