The patient with a colostomy has been incorrectly applying his ostomy appliance. The continuous contact with liquid stool has caused a skin wound around the ostomy. The nurse assesses bleeding and purulent drainage that has extended into the dermis
How will the nurse classify and document this contaminated wound?
a. Acute, full-thickness, open
b. Chronic, partial-thickness, closed
c. Acute, partial-thickness, closed
d. Chronic, unstageable, open
A
The wound is acute because it developed recently. The wound is full-thickness because it involves the dermis. The wound is open because it was bleeding, so the skin must be broken. The wound is contaminated because it is exposed to stool and appears to be infected.
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Fill in the blank(s) with the appropriate word(s).