Wound Classification

Wound Classification 150 150 Tony Guo

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

Leave a Reply

Your email address will not be published.