The nurse assesses the surrounding skin of the client's colostomy. The client has been incorrectly applying his ostomy appliance and which caused a wound due to the continuous contact with liquid stool. The nurse notes bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound?

Question

Quizplus · Accepted Answer

The wound is classified as "Acute" because it is a recent injury resulting from improper appliance application. It is "full-thickness" because the damage extends into the dermis, indicating that all layers of the skin are affected. Lastly, it is "open" due to the presence of bleeding and purulent drainage, indicating an open wound exposed to the external environment.

The Nurse Assesses the Surrounding Skin of the Client's Colostomy