CPC Wound Care and Skin Assessment 1 — Questions and Answers

Question 1: When staging a pressure injury, which stage describes full-thickness skin loss with visible fat but no exposed bone, tendon, or muscle?

Stage 1
Stage 2
Stage 3 (Correct answer)
Stage 4

Correct answer: Stage 3

Stage 3 pressure injuries involve full-thickness skin loss with adipose tissue visible in the wound but without exposed bone, tendon, or muscle. Stage 4 involves exposure of underlying bone, muscle, or tendon.

The NPUAP/EPUAP pressure injury staging system defines: Stage 1 (non-blanchable erythema, intact skin), Stage 2 (partial-thickness loss, shallow open ulcer or intact/ruptured blister), Stage 3 (full-thickness skin loss with adipose tissue visible, may have undermining/tunneling, no exposed bone/tendon/muscle), Stage 4 (full-thickness loss with exposed bone, tendon, or muscle), Unstageable (depth unknown due to slough/eschar), and Deep Tissue Pressure Injury (purple discoloration or blood-filled blister). Community paramedics document stage, wound dimensions, wound bed appearance, periwound skin, and drainage characteristics at each visit.

Question 2: A community paramedic assesses a wound that has a yellow, stringy tissue covering the wound bed. This tissue is BEST described as:

Granulation tissue
Slough (Correct answer)
Eschar
Epithelial tissue

Correct answer: Slough

Slough is yellow, tan, or gray stringy or mucinous devitalized tissue in the wound bed. Unlike eschar (dry, dark, leathery), slough is moist and typically requires debridement for wound healing to progress.

Wound bed tissue types include: Granulation tissue (red, moist, cobblestone-appearing — healthy, indicates healing), Slough (yellow/tan/gray, stringy, moist, devitalized — impedes healing, needs debridement), Eschar (black/brown, hard, leathery, necrotic — impedes healing), Epithelial tissue (pink, shiny at wound margins — healing advancing), and Hypergranulation (beefy red, raised above wound edges — may need treatment with silver nitrate or pressure). Community paramedics document wound bed tissue composition as percentages (e.g., 40% granulation, 60% slough) to track wound trajectory.

Question 3: For a patient with a venous leg ulcer, which dressing and compression approach is MOST evidence-based?

Dry gauze dressing without compression bandaging
Moist wound dressing with multilayer compression bandaging achieving 30–40 mmHg at the ankle (Correct answer)
Petroleum gauze with elastic bandage for mild compression
Silver-impregnated dressing and no compression due to pain

Correct answer: Moist wound dressing with multilayer compression bandaging achieving 30–40 mmHg at the ankle

Venous leg ulcers are caused by venous hypertension; the evidence-based treatment is compression therapy (multilayer bandaging to 30–40 mmHg at the ankle) combined with moist wound dressings. Compression is the single most effective intervention.

Venous leg ulcers (VLUs) account for ~70% of all lower extremity ulcers. The gold standard treatment is sustained, graduated compression to counteract chronic venous hypertension — targeting 30–40 mmHg at the ankle with multilayer compression systems (e.g., Profore). Moist wound healing principles apply: moisture-retentive dressings (hydrocolloids, foams, alginates) reduce pain, promote autolytic debridement, and accelerate re-epithelialization. Dry gauze disrupts the wound environment. Before applying compression, the community paramedic must confirm adequate arterial perfusion via ABPI (ankle-brachial pressure index ≥0.8), as compression is contraindicated in significant peripheral arterial disease.

Question 4: The NERDS mnemonic for identifying critically colonized wounds includes which of the following criteria?

Non-healing wound, Edema, Redness, Drainage, Size increase
Non-healing wound, Exudate increase, Red and bleeding granulation, Debris, Smell (Correct answer)
Necrosis, Erythema, Redness, Drainage, Swelling
New wound, Eschar, Redness, Draining, Systemic signs

Correct answer: Non-healing wound, Exudate increase, Red and bleeding granulation, Debris, Smell

NERDS (Non-healing, Exudate increase, Red and bleeding granulation, Debris, Smell) identifies superficial critical colonization. The companion mnemonic STONEES identifies deeper infection extending to surrounding tissue.

The NERDS and STONEES framework (developed by Sibbald et al.) provides a systematic approach to wound infection severity: NERDS (superficial critical colonization): Non-healing wound, Exudate increase, Red/friable bleeding granulation tissue, Debris (slough/necrosis) in wound bed, Smell/odor. STONEES (deep/spreading infection): Size increasing, Temperature increase, Os (bone exposed), New breakdown areas, Exudate increase, Erythema/edema, Smell. When 3+ NERDS criteria are present, a topical antimicrobial agent (silver or iodine) is indicated. When STONEES criteria are present, systemic antibiotics and urgent referral are indicated. Community paramedics use this framework to escalate wound care appropriately.

Question 5: When assessing a diabetic foot ulcer, the Wagner Grading System classifies a wound with exposed bone and osteomyelitis as:

Grade 2
Grade 3 (Correct answer)
Grade 4
Grade 5

Correct answer: Grade 3

Wagner Grade 3 describes a deep ulcer with abscess, osteomyelitis, or joint sepsis — bone exposure with infection. Grade 4 is partial foot gangrene; Grade 5 is whole foot gangrene.

The Wagner Diabetic Foot Ulcer Classification: Grade 0 (intact skin, at-risk foot), Grade 1 (superficial ulcer, no infection), Grade 2 (deep ulcer to tendon/capsule/bone without infection), Grade 3 (deep ulcer with osteomyelitis, abscess, or joint sepsis), Grade 4 (partial foot gangrene), Grade 5 (whole foot gangrene). Osteomyelitis (bone infection) is a Grade 3 finding that requires urgent hospitalization, IV antibiotics, and surgical consultation. Community paramedics use the Wagner scale to communicate wound severity to the care team and to identify patients requiring immediate escalation versus ongoing home-based wound care.

Question 6: Before applying a compression bandage to a patient with a venous leg ulcer, the community paramedic should FIRST:

Assess the patient's pain level using the numeric pain scale
Obtain an ankle-brachial pressure index (ABPI) to rule out significant arterial disease (Correct answer)
Measure the wound dimensions and photograph it
Irrigate the wound with betadine solution

Correct answer: Obtain an ankle-brachial pressure index (ABPI) to rule out significant arterial disease

ABPI measurement is mandatory before applying compression bandaging. An ABPI <0.8 indicates significant peripheral arterial disease, in which compression is contraindicated as it could precipitate critical limb ischemia.

The ankle-brachial pressure index (ABPI) compares the highest systolic pressure at the ankle with the highest brachial artery systolic pressure. ABPI ≥0.8 indicates adequate arterial perfusion and compression is safe; ABPI 0.5–0.79 indicates significant PAD — reduced compression only with vascular specialist guidance; ABPI <0.5 is severe PAD — compression is absolutely contraindicated. Without ABPI assessment, applying full compression bandaging to a patient with occult PAD can compromise limb perfusion and result in critical ischemia, tissue necrosis, and amputation. This is a mandatory safety step in venous ulcer management protocols.

CPC Wound Care and Skin Assessment 1

When staging a pressure injury, which stage describes full-thickness skin loss with visible fat but no exposed bone, tendon, or muscle?