We Do have the other types of wounds that are not related to

pressure ulcer, bedsores or debicutes ulcer.You do not Need to be bedridden or wheelchair bound to have this wound.

Anyone can have this wound anytime in their life.

The most important thing is taking proper care of it.

*Remember that wound is not part of your body,so it Must heal and go away.*

Educate your patients to take care of their wound (s):

To prevent infection. (Signs of infection can be fever,increase drainge,swelling(edema) ,pus,smell,change in color of the surrounding tissues.)

To follow doctors orders.

And should not allow their wound to adhiscence.

(That is the seperation of the skin from tissue layers).

Wound can adhiscence few days after surgery.(3-11days).

I am talking about the following wounds below.

Surgical wounds/Surgical incision.

Vascular Ulcer.

Diabetic Ulcers.

Wounds due to Trauma for example bruises and contusions.

Cancer related wounds.



Skin tear due to adhesive tapes.



These Other wounds can be Classified as:

Closed wound.


Partial thickness.

Full Thickness.

The wound is bumpy red granulation,scar formation.

Fat known as adipose.

Muscles,tendon,or bone are exposed.

Rolled edges.(Epibole )

The skin is maroon or purple.

Firm to touch and non blanchable such as bruises .

Wounds due to trauma such as car accidents.

Blood filled blisters.

There could be slough,yellow ,tan or eschar.

Whereas Pressure Ulcer can be Classified as:


Pre stage 1 : This is known as blanchable.

Stage 1 :Non blanchable erythema (redness)

Stage 11.partial thickness of the loss of the dermis showing wound without slough.

Stage 111. This is the fullness tissue loss in which the subcutaneous fat may be exposed

but not the bones,tendon or muscles.Slough ,undermining and tunneling may be present.

But you can still see and able to measure the wound.The staging of stage 111

depends on the location of the wound.Please read more on that.

Stage IV. This is full thickness skin loss in which you can see the bones,

tendon and muscles.

DTPI: Deep Tissue pressure Injury. Area will be boggy,firm,painful,warm or

cooler than the adjacent skin.It is marooned or purple localized discolored

intact skin.You do not know what is in the injury,it is warm,painful,different

but the skin is intact.

Unstageable.It is named unstageable because we do not know the depth.

It is a full thickness skin loss in which the wound base is covered

with yellow slough,tan,black or eschar.We do not know the dept.

The only way we could know the depth of the wound is if all the

soughs are removed.Which might involve Sharp debridement or any other

types of debridement.

The doctor or trained physical Therapist can do Sharp debridement.

Again please follow doctors orders, and your hospital protocols,

policies and procedures.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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