Week 5 Wound Classification Activity

Station #1

Mrs Lamont is an 85 year old women who lives alone. She has a history of diabetes, hypertension and
she has smoked since she was 20 years old. Her skin is cool to touch, she reports pallor in her leg on
elevation. You are unable to palpate a dorsalis pedis pulse and there is delayed capillary refill on her
right foot.

Wound classification: ______________________________________________________________

Nursing Care: _____________________________________________________________________

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Station #2

Mr Belfonte is a 77 year old man who weighs 325 lbs (obese). He is mostly immobile. He reports that
his legs are itchy, stained a reddish brown colour and his cap refill is < 3 seconds on both feet.

Wound classification: ______________________________________________________________

Nursing Care: _____________________________________________________________________

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Station # 3

Mrs Khan is a 56 year old women with left sided hemorrhagic stroke. She requires frequent turning and
repositioning. You have just turned her onto her left side and note the following on her buttocks. The
area does not blanch (nonblanching erythema) when you apply pressure. Refer to wound #5 on wound
care model.

Wound classification: ______________________________________________________________

Nursing Care: _____________________________________________________________________

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Station #4

Mr Shetty is a 78 year old man who was admitted to a long term care agency after a stroke 5 years ago.
He is incontinent and nurses were protecting a pressure point on his coccyx with a well adhering
bandage. Yesterday the nurse noted this area when she removed the bandage. Refer to wound #2 on
wound care model.

Wound classification: ______________________________________________________________

Nursing Care: _____________________________________________________________________

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Station # 5

Mrs Klein is a 67 year old women who has been in cared for at home by her family since a debilitating
stroke 3 years ago. She is immobile and incontinent of urine and stool. She has currently been admitted
to hospital for pneumonia and the nurse has noted this ulcer on her buttocks. Refer to wound #4 on
wound care model.

Wound classification: ______________________________________________________________

Nursing Care: _____________________________________________________________________

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Station # 6

Mr Ronney is 78 year old man who was in a car accident 10 years ago that left him a quadriplegic. He is
currently living in a long term care agency where the health care team is treating this wound on his
buttocks. Refer to wound #1 on wound care model.

Wound classification: ______________________________________________________________

Nursing Care: _____________________________________________________________________

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Station #7

Mr Hall is an 84 year old man who lives alone at home. He has a history of diabetes and hypertension.
He was doing some extra work at home last week and found he needed many days to recuperate. He
reported that he spent a lot of time laying on the couch and watching tv. Yesterday, he noticed that the
skin on his right ankle looked “funny”.

Wound classification: ______________________________________________________________

Nursing Care: _____________________________________________________________________

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Simple Wound Dressing Narrative Documentation (ensure that you have lab facilitator check
documentation)

F: ___________________________________________________________________________

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A: ___________________________________________________________________________

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I: ___________________________________________________________________________

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R: ___________________________________________________________________________

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