24.3: Wound Classification

Learning Objectives

By the end of this section, you will be able to:

• Identify the different classifications of wounds
• Recognize the risk factors for pressure injury development
• Describe the staging process for pressure injuries

A wound is defined as an injury that causes a disruption of normal skin or tissue integrity. Wounds can be typed as an incision, contusion, abrasion, laceration, puncture, penetration, avulsion, burn, and ulcer (Table 24.7). In order to effectively manage wounds, nurses must first recognize the various wound classifications. They must also identify individuals at risk of pressure injury development and describe the technique for staging pressure injuries.

Wound Type	Description
Incision	A surgical cut made in skin or flesh
Contusion	A region of injured tissue or skin in which blood capillaries have been ruptured (bruise)
Abrasion	An area of skin or tissue damaged by scraping
Laceration	A deep cut or tear in the skin or flesh or underlying tissue
Puncture	A wound made by a pointed object
Penetration	A wound caused by an object that pierces the skin and lacerates or damages adjacent tissue
Avulsion	A forcible tearing off of skin or another part of the body
Burn	An injury to the skin caused by thermal, electrical, chemical, or electromagnetic energy
Ulcer	An open sore caused by poor blood flow

Table 24.7 Types of Wounds

Different Types of Wound Classification

Wounds are classified in several ways and include intentional or unintentional wounds, open or closed wounds, acute or chronic wounds, pressure injuries, and friction and shear. Wounds also may be described according to how they were acquired, how long the wound has been present, or how deeply the wound affects the skin or tissues (Table 24.8).

Classification	Description	Example
Intentional wound	An example is a planned incision (wound) as the result of a treatment or therapy. They serve a therapeutic purpose. Wounds are clean with approximated edges and are performed under aseptic or sterile procedures. Typically, the bleeding is well controlled, and surgical incisions are closed immediately after the procedure. Examples include surgical incisions, venipunctures, and lumbar punctures.	(credit: “Hip replacement, surgical staples”, by Wikimedia Commons, CC BY 3.0)
Unintentional wound	These wounds are from unexpected trauma and can result in multiple injuries. The wounds are not acquired under sterile or aseptic conditions. Wound edges are irregular and not clean like those of intentional wounds. Bleeding is not controlled in this setting. Examples include a broken bone or laceration from bicycle or automobile accidents, burns, work-related injuries, and penetrating wounds from a bullet or metal fragments.	(credit: modification of “Injury showing open finger dislocation,” by National Library of Medicine, CC BY 3.0)
Open wound	This is a break in the skin or mucous membranes caused either intentionally or unintentionally. It creates an entry for microorganisms, which combined with tissue damage and bleeding increases the risk of a prolonged healing time and infection. Examples include incisions, abrasions, punctures, lacerations, penetrating wounds, and avulsions.	(credit: “Screwdriver penetrating the chest” by P. A. Dieng et al, CC BY 3.0)
Closed wound	This results from a force or blow, such as from a fall, being hit by an object, or in a collision with a person or inanimate object. Examples include contusions and hematomas.	(credit: “Plateletpheresis hematoma 2016” by Wikimedia Commons, CC0)
Acute wound	It will generally heal within days to weeks. Progress through the normal stages of healing without disruption. Examples include traumatic injuries, burns, and surgical incisions.	(credit: “Longitudinal mini-incision” by National Library of Medicine, CC BY 2.0)
Chronic wound	Typically, this type of wound has jagged edges, a higher risk of infection, and a delayed healing time of more than thirty days. The patient does not progress through the normal stages of healing and usually experiences an interruption in the healing process. Generally, the wound stays in the inflammatory stage of healing. Examples include pressure injuries, diabetic ulcers, or ulcers from vascular insufficiency.	(credit: “Bedsore ulcer” by Wikimedia Commons, CC BY 4.0)
Pressure injury	This is a localized ischemic lesion of the skin and underlying tissue caused by external pressure that impairs blood and lymph flow. Lack of blood supply, oxygen, and nutrients to the tissues results in necrosis and eventual ulceration. This ischemia also leads to inflammation and edema. Pressure injuries may also be called decubitus ulcers, bed sores, and pressure sores. This type of wound can occur in as little as one hour and may be acute or chronic. Pressure injuries often arise when the soft tissues are compressed between an external surface and a bony prominence or from friction or shearing forces that injure blood vessels and abrade the epidermis. Examples include bony prominences, including the heels, sacrum, coccyx, and greater trochanter.	(credit: modification of “Escarre Stade 4” by Wikimedia Commons, CC BY 4.0)
Friction injury	Occurs when two surfaces rub together, which generates heat and can remove the top layer of the skin, damage superficial blood vessels, and may look like an abrasion. Examples include when a patient attempts to push themselves up in bed using their heels, arms, or hands or when personnel pull patients up in bed by a draw sheet or when transferring patients to a stretcher using a transfer or draw sheet.	(credit: “Self-captured photograph of a rope burn (friction burn)” by Jesusjonez, Public Domain)
Shear injury	This occurs when one tissue layer slides over the other. The shearing force separates the skin from its underlying tissues. Blood vessels stretch and bend or tear causing injury, thrombosis, and impaired circulation to the tissue cells. Examples include when patients are pulled when being moved up in bed or transferred from bed to stretcher or chair, when a patient slides down when sitting in a chair, or their torso slides down when sitting in bed and the head of the bed is elevated.	(credit: modification of “Blister on toe” by Wikipedia, CC BY 2.0)

Table 24.8 Wound Classifications

Intentional and Unintentional Wounds

Intentional and unintentional wounds are described according to their acquisition. A planned or intentional wound is the result of a treatment or therapy. Surgical incisions, venipunctures, and lumbar punctures are examples of intentional wounds that are necessary for a specific treatment. The wounds are made in sterile conditions, and any bleeding is controlled, which promotes adequate healing time and reduces the risk of infection. For example, surgical incisions are made deliberately with careful techniques and in aseptic conditions, then closed immediately after the procedure.

A wound from unexpected traumas (e.g., a broken bone or laceration from bicycle or automobile accidents, burns, work-related injuries, penetrating wounds from a bullet or metal fragments) is known as an unintentional wound. These types of injury can result in multiple areas of trauma and involve tissue loss. The wounds are not acquired under sterile or aseptic conditions. Wound edges are irregular and not clean like those of intentional wounds. Bleeding is not controlled in this setting. Individuals who require medical attention may experience a delay getting emergency help depending on location, availability to call for help or other resources, and if anyone nearby is able to help control blood loss. These conditions create the potential for a longer healing process and an increased risk of infection.

Open and Closed Wounds

A break in the skin or mucous membranes is called an open wound and is caused either intentionally or unintentionally. Open wounds create an entry for microorganisms. This combined with tissue damage and bleeding increase the risk of a prolonged healing time and infection. Examples of open wounds include incisions, abrasions, punctures, lacerations, penetrating wounds, and avulsions. Furthermore, the term open wound is sometimes used to convey that the wound is not covered or dressed with bandages. It may even be left open to air as part of the treatment process.

A wound that does not have a break in the skin and occurs under the skin’s surface is called a closed wound. Nevertheless, there may be bleeding, tissue damage, and internal injury under the skin’s surface. Closed wounds may result from a force or blow like from a fall, being hit by an object, or a collision with a person or inanimate object. Examples of closed wounds include contusions and hematomas. Sometimes the term closed wound may relate to how wound edges are brought together. An example is when nurses say the wound is closed with sutures or staples.

Acute and Chronic Wounds

Another way to classify wounds is by acute versus chronic. A wound that occurs suddenly and progresses through expected stages of healing is called an acute wound. These wounds should be assessed based on the way they occurred and the anatomical damage (Nagle et al., 2023). Often the full extent of acute wounds is unknown until several days after an injury. Initial issues such as swelling may mask the true extent and even depth of the wound.

In contrast to acute wounds, a chronic wound is a wound in which little to no healing occurs for at least three months (Bowers & Franco, 2020). There are a variety of ways and reasons that wounds become chronic (Table 24.9). For caregivers, these are complex to manage and may never heal completely. The goals of care for chronic wounds are to determine why the wound is not healing and identify strategies to overcome those reasons and allow the wound to heal (Nagle et al., 2023).

Cause	Explanation
Arterial insufficiency (such as scleroderma or Raynaud disease)	Insufficient arterial blood flow to the extremities impacts the transportation of oxygen and even antibiotics to diseased tissues.
Venous insufficiency	Insufficient return of blood from the extremities causes increased pressure and fluid in intravascular spaces, decreasing the body’s ability to heal effectively.
Infection	Infections in tissues and bones (cellulitis and osteomyelitis, respectively) prevent the healing process. Expect to culture for biological, viral, and fungal agents.
Pressure	Constant or frequent pressure against healing tissues impacts the ability to heal and/or tears healing tissues back open.
Radiation therapy	This may cause occlusion or damage to blood vessels, impacting the healing of localized tissues.
Systemic diseases	Diseases such as diabetes and immunodeficiencies may impact the body’s ability to heal naturally.
Nutrition	Protein malnutrition and elevated glucose levels can impact healing. For example, protein requirements to heal a chronic wound could rise as high as 250 percent normal requirements.
Age and hormones	While older age may lengthen the time it takes for an acute wound to heal, it does not cause chronic wounds. However, differences in androgens and estrogen may impact healing.
Medications	Several medications can slow down healing, including hydroxyurea, chemotherapeutic agents, and steroids.
Genetic issues	There is a genetic predisposition to issues such as keloid scarring and other skin conditions that may negatively impact wound healing.

Table 24.9 Causes of Chronic Wounds (Source: Nagle et al., 2023.)

Pressure Injury

A localized ischemic lesion of the skin and underlying tissue, known as a pressure injury, is caused by external pressure that impairs blood and lymph flow. The lack of blood supply, oxygen, and nutrients to the tissues results in necrosis and eventual ulceration. This ischemia also leads to inflammation and edema. Pressure injuries may also be called decubitus ulcers, bed sores, and pressure sores. This type of wound can occur in as little as one hour and may be acute or chronic. Healthy people who have full control of their limbs make changes in their position constantly. However, when someone remains in the same position for an extended period of time, an injury occurs. The portion of the skin where the patients’ weight and force are applied is injured. Pressure injuries often arise when the soft tissues are compressed between an external surface, such as a bed or chair, and a bony prominence or from friction or shearing forces that injure blood vessels and abrade the epidermis. Examples of bony prominences include the heels, sacrum, coccyx, and greater trochanter. Pressure injuries may occur in home settings, hospitals, and long-term care facilities. Pressure injuries require aggressive intervention and treatment to decrease unwarranted pain or discomfort, inhibit further tissue damage, accelerate wound healing, decrease length of stays, and decrease healthcare costs.

Friction and Shear

Friction and shear are mechanical forces that tear and injure blood vessels and can contribute to the development of pressure injuries. When two surfaces rub together and generate heat, friction is produced and can remove the top layer of the skin, may damage superficial blood vessels, and may look like an abrasion. Friction injuries may occur when a patient attempts to push themselves up in bed using their heels, arms, or hands. This can also happen when patients are pulled up in bed by a draw sheet or transferred to a stretcher using a transfer or draw sheet.

When one tissue layer slides over the other, shear occurs. The shearing force separates the skin from its underlying tissues. Blood vessels stretch and bend or tear causing injury, thrombosis, and impaired circulation to the tissue cells. Shear injuries may occur when patients are pulled when being moved up in bed or transferred from bed to stretcher or chair. Shear injuries may also occur if a patient slides down when sitting in a chair or their torso slides down when sitting in bed and the head of the bed is elevated.

Life-Stage Context

Life Span Considerations for Older Adults

Part of the aging process occurs when changes in skin collagen makes skin less elastic. The subcutaneous and dermal tissues are thinner, and the patient often has reduced sensations of pressure and pain. This makes older adults more susceptible to friction and shear injuries. Careful considerations for the older adult include checking skin frequently to monitor for breakdown or tears, ensuring bedding and linens are dry and wrinkle free, padding bony prominences, and ensuring proper lifting technique when moving patients in bed or transferring out of bed.

Risks for Pressure Injury Development

Pressure injuries may result from pressure and friction and shearing forces but may also be caused by other factors. The risk factors for pressure injury development include moisture exposure, nutrition and hydration, mobility, and level of cognition. Other factors that may contribute to pressure injuries include the following:

• advanced age
• poor skin hygiene
• loss of sensation
• fractures
• immunosuppression
• diabetes
• history of corticosteroid use
• multiple organ dysfunction
• history of previous pressure injuries
• increased body temperature
• higher weight
• significantly lower weight
• terminal illnesses
• end-of-life processes
• microvascular dysfunction

Moisture Exposure

Exposure to excessive moisture can cause skin maceration where the tissues are softened by prolonged wetting or soaking. Macerated tissue makes the skin less resistant to trauma or pathogens and more susceptible to injury. Moisture from incontinence of feces or urine or gastric tube drainage promote excoriation, the loss of the superficial layers of the skin, and is also known as denuded area. The accumulation of excretions or secretions overhydrates the skin and makes it more alkaline. The moisture exposure irritates the skin, harbors microorganisms, and makes the skin more susceptible to breakdown and infection. In fact, any substance that is excessively applied might overmoisten the skin and can lead to skin damage. People who experience incontinence should be monitored for skin breakdown. Absorbent pads may be used to aid in protecting the linens from getting soiled. The patient should be cleansed as quickly as possible after each soiling; skin barriers may be used to protect intact skin (Shi et al., 2020).

Nutrition and Hydration

Nutrition and hydration play a major role in skin health. Cells that do not get adequate nutrition are more easily damaged. Malnutrition can lead to weight loss, muscle atrophy, and a decrease in adipose tissue resulting in the reduction of padding between the skin and bony prominences. Low protein in the blood, or hypoproteinemia, leads to a negative nitrogen balance, insufficient calorie intake, edema, and electrolyte imbalances, which predispose the skin to injury. Protein is vital for wound healing as it serves multiple critical functions in the reparative process. It acts as the primary building blocks for collagen synthesis, facilitating the formation of new connective tissue essential for wound closure and tissue regeneration. Additionally, protein supports the proliferation and migration of cells involved in wound repair, such as fibroblasts and keratinocytes, enabling the formation of new tissue and closure of the wound. Moreover, protein plays a crucial role in maintaining immune function, supporting the inflammatory response necessary for clearing debris and combating pathogens at the wound site. Protein is made up of nitrogen. Negative nitrogen balance means that the body is excreting more nitrogen than is being ingested. This will delay wound healing. Deficiencies in vitamin C may lead to frail capillaries and result in inadequate circulation contributing to the development of pressure injuries. Edema and dehydration can also interfere with perfusion.

Mobility Status

Impaired mobility is a significant factor in pressure injury formation. People who have problems with mobility or are bedridden are unable to adjust themselves and may remain in one position for a prolonged period of time. People who have adequate mobility are able to move independently when they experience discomfort on an area of the body caused by pressure and also move freely in bed. People who are unconscious, have extreme weakness or pain, or have any other cause of decreased activity are unable to change positions and relieve the pressure even if their bodies sense the need to change position. Patients who require assistance in moving in bed or transferring are at risk of friction and shear injuries that may lead to pressure injuries if they are not properly lifted in the process.

Cognition Status

Cognition consists of the mental processes that take place in the brain, such as thinking, language, learning, memory, perception, and attention. Patients who have an altered mental status or have decreased awareness (e.g., unconsciousness, sedation, dementia) are at risk because they are less likely to recognize and respond to the discomfort from pressure. This means that medication or therapy that decreases a patient’s mental status can increase their risk for pressure injuries. People who are more alert are more likely to respond to increased pressure, protect their own skin integrity, and perform adequate hygiene to prevent the development of pressure injuries.

Braden Scale

A wound assessment risk can be used to evaluate a patient’s risk for developing wounds or to monitor healing. Different strategies can be employed depending on the risks various patients experience. For wounds that are more difficult to heal, providers must have reliable assessment methods to ensure appropriate and accurate communication among team members and allow for accurate assessment of changes between visits (Bates-Jenson et al., 2019).

The Braden scale is the most used pressure injury risk assessment tool in the United States and is used across many healthcare settings, including critical and acute care, long-term care, rehabilitation, and even by home-based nurses (Kennerly et al., 2022). It evaluates the relative risk of a patient developing skin breakdown and pressure injuries. The scores can be used to tailor pressure injury prevention interventions to at-risk patients (Kennerly et al., 2022).

Link to Learning

The Braden scale is a helpful tool to establish the relative risk of a patient experiencing issues with skin breakdown.

The Braden scale uses six subscales: mobility, activity, sensory perception, nutrition, friction/shear, moisture (Kennerly et al., 2022). Each of these six factors is scored on a scale from one to four, depending on the factor. After each item is decided, the ratings are added together for a possible score between six and twenty-three. The lower the score, the greater is the risk for development of a pressure injury. All patients scoring eighteen and below should be reassessed regularly, on a schedule dictated by facility and healthcare setting. Patients scoring above eighteen should be reassessed when they experience condition-related changes. The Braden scale is a tool used by nurses to identify a patient’s risk of developing pressure injuries and is typically completed on admission to a hospital or other healthcare facility as well as once per shift (Table 24.10).

Category	1 (most severe)	2	3	4
Sensory perception	Completely limited, unresponsive	Very limited, only responds to painful stimuli	Responds to verbal commands but limited communication	No impairment, responds and communicates
Moisture	Constant moisture	Frequent moisture/linen changes	Occasional moisture/extra linen change	Usually dry/routine linen change
Activity	Bedbound	Chairbound, limited walking	Short distance walking	Frequent walking
Mobility	Immobile	Very limited	Slight limitations	No limitations
Nutrition	Very poor	Likely inadequate	Adequate	Excellent
Friction, shear	Constant friction, requires assistance	Movement with minimal assistance	Independent movement	N/A

Table 24.10 The Braden Scale

Staging Pressure Injuries

Depending on the extent of damage, pressure injuries are assessed and classified as stages one through four or as deep tissue or unstageable. Stage one is the least severe of the stages. It is essential for nurses to adequately stage pressure injuries to implement appropriate interventions and assess for improvement or worsening damage.

Blanching is a part of the assessment process and can aid in identifying those at risk of pressure injury development. Normal blanching is temporary whitening or lightening of the skin around the wound site upon applying pressure. When the pressure is relieved, normal blood flow should return promptly to the area, and the skin should return to its normal color.

Prolonged pressure to an area makes it more difficult for adequate blood flow to return, thus resulting in pressure injuries. Patients who have been sitting or lying in a prolonged (e.g., two hours or more) position who are then repositioned may take sixty to ninety minutes for hyperemia (reddening of the skin) and warmth of the skin to resolve.

Stage I

A stage I pressure injury is characterized by localized nonblanchable erythema of intact skin (Figure 24.11). Darker pigmented skin may not have apparent blanching, but the color of the skin may differ from the adjacent skin. Purple or maroon skin discoloration may be indicative of deep-tissue pressure injuries and not a stage I pressure injury. The area may also be painful, soft or firm, or warmer or cooler than its neighboring tissues.

Figure 24.11 (a) In darkly pigmented skin, the area of concern is a different shade than the surrounding tissue. (b) In a light-skinned individual, an area of pink and red erythema may be seen. (CC BY 4.0; Rice University & OpenStax)

Stage II

Stage II pressure injuries are characterized by partial-thickness skin loss involving the epidermis or dermis. The wound bed is viable, moist, red or pink, and may appear as an abrasion, shallow crater, or blister (Figure 24.12). The adipose and deeper tissues are not visible at this stage, nor is slough (yellow, gray, green, tan, or brown dead tissue), eschar (hardened, black, tan, or brown necrotic tissue), or granulation tissue (delicate new reddish connective tissue) or tiny blood vessels that bleed easily but provide the framework for scar tissue development.

Figure 24.12 A stage II pressure injury is a partial-thickness loss of skin with exposed dermis. (CC BY 4.0; Rice University & OpenStax)

Stage III

Stage III pressure injuries are characterized by full-thickness skin loss where the adipose, granulation, and deeper tissues are visible and may have a presence of slough or eschar (Figure 24.13). The depth of this tissue damage will vary depending on its location on the body and amount of adipose tissue present. The ulcer presents as a deep crater with or without tunneling and undermining; however, fascia, tendon, ligament, muscle, cartilage, and bone are not exposed at this stage. Rolled or curled-under wound edges called epibole slow or stop the wound healing process and may occur at this stage.

Figure 24.13 A stage III pressure injury has necrotic tissue and epibole. (CC BY 4.0; Rice University & OpenStax)

Stage IV

Stage IV pressure injuries show full-thickness skin loss with extensive destruction; necrosis; and exposed or palpable fascia, tendon, ligament, muscle, cartilage, and bone (Figure 24.14). Slough and eschar are often visible along with epibole, undermining, and/or tunneling. The depth of this tissue damage will vary depending on its location on the body and the amount of adipose tissue.

Figure 24.14 A stage IV pressure injury extends to the bone, with necrotic tissue and epibole. (CC BY 4.0; Rice University & OpenStax)

Deep Tissue or Unstageable

Deep-tissue pressure injuries are classified as persistent, nonblanchable areas of the skin that have maroon, deep red, or purple discoloration (Figure 24.15). The affected areas of the skin may be intact or nonintact. There is a break in the epidermis that reveals a dark wound bed or blood-filled blister. With this type of injury, changes in the color of the skin are preceded by pain and temperature changes. Skin discoloration may appear differently in individuals with darker skin. For example, a bruise that may appear bluish in a lighter-skin-toned patient, may appear black in a patient with darker skin. Deep-tissue injuries are often the result of prolonged or intense pressure and shear forces at the bone-muscle interface. This wound may resolve without tissue loss or progress rapidly to expose the magnitude of tissue injury. Deep-tissue pressure injuries should not be used to describe traumatic, neuropathic, dermatologic, or vascular skin conditions.

Figure 24.15 The presence of both eschar and slough occludes the true depth of the injury and causes it to be unstageable. (CC BY 4.0; Rice University & OpenStax)

Pressure injuries are classified as unstageable if they have full-thickness skin or tissue loss and have excessive slough or eschar that obscures the extent of the damage. If slough or eschar is removed, a stage III or IV ulcer may be revealed. Stable eschar on the ischemic limb or heels should not be removed or softened. Eschar that is adherent, dry, and intact without fluctuance (tense area of skin with a wavelike or boggy feeling on palpation) and erythema is called stable eschar.

Unfolding Case Study

Unfolding Case Study #4: Part 5

Refer to Chapter 19 Oxygenation and Perfusion and Chapter 22 Activity for Unfolding Case Study Parts 1–4 to review the patient data. Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living due to weakness and increased dyspnea. She has been admitted to the telemetry unit.

Past Medical History	Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis Family history: No significant family history reported. Social history: Widowed ten years ago, currently living in an assisted care facility. No children. Current medications: Lisinopril 20 mg PO once daily Metformin 500 mg PO twice daily Metoprolol 50 mg PO once daily Aspirin 81 mg PO once daily Furosemide 40 mg PO once daily Losartan 25 mg PO once daily Ibuprofen 400 mg PO Q6 hours PRN mild arthritic pain
Nursing Notes	1500: Patient reports experiencing persistent joint pain, particularly in the shoulders and wrists, rated at 6/10 on the numerical pain scale. Patient states that pain interferes with daily activities, such as getting dressed and cooking. Patient also reports stiffness in affected joints, especially in the morning or after prolonged periods of rest, which improves with movement throughout the day. Occupational therapy referral sent per provider’s orders. Acetaminophen administered at 1415. Patient reports improvement in pain level, which she now rates as a 2/10 on the numerical scale.
Nursing Notes	1530: During shift assessment, nonblanchable redness was noted on the patient’s sacrum. When asked about it, patient reports tenderness in the area that gets worse with prolonged sitting. Patient describes the sensation as a mild “stinging” feeling.

1.

Recognize cues: What cues are most important for the nurse to recognize?

2.

Analyze cues: What other information would the nurse want to obtain from the patient at this time related to the recognized cues in the previous question?

3.

Prioritize hypotheses: What factors does the nurse hypothesize are contributing to the development of the patient’s pressure injury?