Wound Classification
Is the wound open. Is there visible GI presence.
What is Class III?
Soft, pink, fleshy projection consisting of capillaries surrounded by fibrous collagen that slowly fills the incision during the process of healing.
What is granulation?
Separation of a surgical incision or rupture of a wound closure
What is Dehiscence?
Thin, red exudate composed of serum and blood.
What is Serosanguineous?
A Hemovac or Jackson-Pratt
What is a Closed Drainage System?
Is there evidence of infection or contamination?
What is Class II?
Healing that occurs by primary intention with delayed suturing of a wound in which two layers of granulation tissue are sutured together.
What is tertiary intention
Passage or escape into the tissues; usually of blood, serum, or lymph
What is Extrvasation?
Fluid, cells, or other substances that have leaked slowly from cells or blood vessels through small pores or breaks in cell membrane.
What is Exudate?
Negative pressure wound therapy
What is a vacuum-assisted closure device or Wound VAC?
Define contamination
What is the presence of GI (gastrointestional) matter?
Healing that occurs when skin edges of the wound are not close together or when pus is formed
What is secondary intention
Protrusion of an internal organ through a wound or surgical incision
What is Evisceration?
Thin, watery exudate composing the serum portion of blood.
What is Serous?
A tube inserted through the skin to provide drainage from a wound or cavity.
What is a T-Tube?
Is there necrotic tissue. Is there signs of infection
What is Class IV
Any injury to the body’s tissues.
What is a wound?
Infection of the skin characterized by heat, pain, erythema, and edema
What is Cellulitis?
Pertaining to blood.
What is Sanguineous?
Nursing intervention done prior to dressing change
What is assess the comfort level using a scale of 0 to 10?
Is the wound clean?
What is Class I
A wound that has been made surgically and has little tissue loss; skin edges are close together and minPrimary intentionimal scarring results?
What is primary intention?
Collection of extravasated blood trapped in the tissues or in an organ that results from incomplete hemostasis after surgery or injury
What is a Hematoma
The removal of fluids from a body cavity, wound, or other source of discharge by one or more methods; it may oc-cur passively on its own or with mechanical assistance
What is Drainage?
Drainage passes through an open-ended tube into a receptacle or out onto the dressing.
What is an Open Drainage System?