Wound Classification and Healing Stages

A wound label is clinically useful only when it changes what the nurse does next. The cleanliness class predicts and guides infection prevention, the depth shows which tissues are involved, the wound bed and drainage show whether repair is progressing, and the cause identifies what must be corrected for healing to occur. A moist dressing cannot compensate for ongoing pressure over a sacrum, poor arterial perfusion to a toe, or uncontrolled hyperglycemia. Several different labels are in use at the same time, and each answers a different question. The surgical wound class describes how contaminated the operative field was. The depth of tissue loss describes how much skin and underlying tissue is missing. The type of closure describes how the edges are brought together. The time course separates an acute wound from one that has stalled. A nurse documents each one separately instead of choosing a single word for the whole wound.