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The International Red Cross wound classification system is a system whereby certain features of a wound are scored: the size of the skin wound(s); whether there is a cavity, fracture or vital structure injured; the presence or absence of metallic foreign bodies. A numerical value is given to each feature (E, X, C, F, V, and M).
Wound assessment is a component of wound management.As far as may be practical, the assessment is to be accomplished before prescribing any treatment plan. The objective is to collect information about the patient and about the wound, that may be relevant to planning and implementing the treatment.
A wound is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. [1] [2] Wounds can either be the sudden result of direct trauma (mechanical, thermal, chemical), or can develop slowly over time due to underlying disease processes such as diabetes mellitus, venous/arterial insufficiency, or immunologic disease. [3]
The most commonly used classification is based on the depth of injury. The depth of a burn is usually determined via examination, although a biopsy may also be used. [2] It may be difficult to accurately determine the depth of a burn on a single examination and repeated examinations over a few days may be necessary. [22]
There are three (or sometimes four) degrees of burns, in ascending order of severity and depth. For more information, see Signs and symptoms. According to Jackson's thermal wound theory, there are three zones of major burn injury. Zone of coagulation is the area that sustained maximum damage from the heat source.
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Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.