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Wound Classification

1. Wound Age

When determining the age of a wound, you need to first determine if the wound is acute or chronic. However, this determination can present a problem if you adhere solely to a time line. For instance, just how long is it before an acute wound becomes a chronic wound?

Rather than base your determination solely on time, consider a wound an acute wound if it's new or making progress as expected and a chronic wound any wound that isn't healing in a timely fashion. The main idea is that, in a chronic wound, healing has slowed or stopped and the wound is no longer getting smaller and shallower. Even if the would bed appears healthy, red, and moist, if healing fails to progress, consider it a chronic wound. (Slachta, 2003)

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2. Wound Depth

Wound depth is another fundamental characteristics used to classify wounds. In your assessment, record wound depth as partial-thickness or full-thickness.

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3. Wound Colour

Wounds are also classified by the colour of the wound bed. Wound colour helps the wound care team determine whether debridement is appropriate.

Red-Yellow-Black Classification System

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(Lukefisher.com, 2005)

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Wound Assessment

The wound assessment helps define the status of the wound and helps identify impediments to the healing process. A wound assessment of the patient's wound status includes, but is not limited to, the following parameters. (Slachta, 2003)

1. Assessing Drainage

To begin collecting information about wound drainage, inspect the dressing as it's removed and record answers to such questions as: (Slachta, 2003)

Also consider the texture of the drainage. If the drainage has a thick, creamy texture, the wound contains an excessive amount of bacteria. However, this doesn't necessarily mean a clinically significant infection is present. Document the characteristics of the drainage. Drainage might be creamy because it contains WBCs that have killed bacteria. The drainage is also contaminated with surface bacteria that naturally live in moist environments on the human body.  (Slachta, 2003)

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2. Assessing the Wound Bed

As you assess the wound bed, record information about: (Slachta, 2003)

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3. Assessing Pain

Assessing patient pain is an important part of wound assessment. You'll want to note not only pain associated with the injury itself but also pain associated with healing and with therapies employed to promote healing. To fully understand your patient's pain, talk with him/her and ask about his pain. (Slachta, 2003)

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(Motherearth.co.uk, 2005)

Holistic Assessment

Assessment of the whole patient with particular focus of the wound is imperative to achieve successful healing.

(Worley, 2004)



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