Wound Classification Notes

Skin Integrity

• Open Wounds: Breaks in the skin.

• Closed Wounds: Skin remains intact.

Wound Depth

• Superficial Wounds: Involve only the epidermis.

• Partial Thickness Wounds: Involve the epidermis and dermis.

• Full Thickness Wounds: Extend into the subcutaneous layer, potentially reaching muscle, bone, and underlying structures.

Amount of Contamination

• Clean Wounds: No infection present; the risk of infection is low.

• Clean Contaminated Wounds: Surgical wounds that may contain bacteria, increasing the risk of infection.

• Contaminated Wounds: Occur when there's a break in sterile technique during surgery.

• Infected Wounds: Exhibit clinical signs of infection such as drainage, warmth, and increased drainage (which may or may not contain pus).

• Colonized Wounds: Bacteria are present on the surface of the wound, detectable via swab culture.

Healing Process

• Acute Wounds: Wounds that progress through the phases of wound healing in a rapid, uncomplicated manner.

  • Approximated: Wound edges are brought together.

  • Primary Intention: Wounds that heal via primary intention heal quickly and result in minimal scar formation.

• Chronic Wounds: Wounds that fail to progress through the healing process in a timely manner and often remain open for an extended period.

• Secondary Intention : Refers to wounds that heal by secondary intention, where new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue.

• Tertiary Intention: when a delay occurs between injury and closure.