Wound Classification
Wound Classification https://urgentcarenearmetx.com/wp-content/themes/corpus/images/empty/thumbnail.jpg 150 150 Tony Guo Tony Guo https://secure.gravatar.com/avatar/aa9bbdf8f1e6bbf534778ecea7c0c925?s=96&d=mm&r=g- Tony Guo
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Wound Classification
- Wounds are classified according to
- Cause
- Surgical or nonsurgical
- Acute or chronic
- Depth of tissue affected
- Superficial, partial thickness, full thickness
- Cause
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
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