Wound Classification

• July 9, 2020
• Tony Guo
• no comments

Wound Classification

• Wounds are classified according to
  • Cause
    • Surgical or nonsurgical
    • Acute or chronic
  • Depth of tissue affected
    • Superficial, partial thickness, full thickness

Nursing Assessment

• Assess on admission and on a regular basis
• Identify factors that may delay healing

Nursing Implementation

• Purposes of wound management
  • Protecting a clean wound
  • Cleaning a wound
  • Treating infection
• Clean wound
  • Clean wounds that are granulating and re-epithelializing should be kept slightly moist and protected
  • Dryness is an enemy of wound healing
  • Topical antimicrobials and antibactericidals used with caution
  • Transparent film may be used
• Contaminated wound
  • Debridement may be necessary
  • Absorption or hydrocolloid dressing may be used
• Negative-pressure wound therapy (NPWT)
  • Suction removes drainage and speeds healing
  • Monitor serum protein levels, fluid and electrolyte balance, and coagulation studies
• Hyperbaric O2 therapy (HBOT)
  • Delivery of O2 at increased atmospheric pressure
  • Allows O2 to diffuse into serum
  • Last 90 to 120 minutes, with 10 to 60 treatments
• Drug  Therapy
  • Becaplermin (Regranex)
• Nutritional Therapy
  • Diet high in protein, carbohydrates, and vitamins with moderate fat
• Infection prevention
  • Do not touch recently injured area
  • Culture may be ordered
  • Keep environment free from possibly contaminated items
  • Antibiotics may be given prophylactically
• Psychologic implications
  • Fear of scar or disfigurement
  • Drainage or odor concerns
  • Be aware of your facial expressions while changing dressing

Patient teaching

• Teach signs and symptoms of infection
• Note changes in wound color or amount of drainage
• Provide medication teaching