Wound Care
Wound care is the nursing practice of assessing, cleaning, treating, and dressing wounds to promote healing and prevent infection. It includes understanding wound types, healing stages, dressing selection, and recognizing signs of complications such as infection or delayed healing.
Exam Tip
Pressure injury staging: Stage 1 = non-blanchable redness (intact skin), Stage 2 = partial-thickness, Stage 3 = full-thickness (fat visible), Stage 4 = bone/tendon exposed. Follow the individualized repositioning plan. Clean from clean to dirty. Moist wound environment promotes healing. Report purulent drainage, fever, increased redness to the RN.
What Is Wound Care?
Wound care encompasses all nursing interventions aimed at promoting wound healing, preventing infection, and managing complications. Proper wound care requires assessment of the wound characteristics, selection of appropriate treatments, and ongoing monitoring of the healing process.
Types of Wounds
| Type | Description | Examples |
|---|---|---|
| Intentional | Created purposefully | Surgical incisions |
| Unintentional | Accidental injury | Lacerations, abrasions, burns |
| Open | Break in skin surface | Cuts, surgical wounds, pressure injuries |
| Closed | No break in skin surface | Contusions, hematomas |
| Acute | Recent onset, healing normally | Surgical wounds, traumatic injuries |
| Chronic | Failing to heal within expected timeframe | Pressure injuries, diabetic ulcers |
Wound Healing Phases
| Phase | Timeframe | What Happens |
|---|---|---|
| Hemostasis | Immediate | Blood clotting, vasoconstriction |
| Inflammatory | Days 1-4 | Redness, swelling, warmth, pain; WBCs fight infection |
| Proliferative | Days 4-21 | New tissue formation (granulation), wound contraction |
| Maturation/Remodeling | Weeks to months/years | Scar tissue strengthens; full strength ~80% of original |
Types of Wound Healing
| Type | Description |
|---|---|
| Primary intention | Wound edges are approximated (brought together); clean surgical incisions |
| Secondary intention | Wound left open to heal from bottom up; pressure injuries, deep wounds |
| Tertiary intention | Wound initially left open, then closed later; contaminated wounds |
Wound Assessment
| Characteristic | What to Document |
|---|---|
| Location | Anatomical site |
| Size | Length x Width x Depth (in cm) |
| Color | Red (granulation), Yellow (slough), Black (eschar/necrotic) |
| Drainage | Type (serous, sanguineous, serosanguineous, purulent), amount, odor |
| Wound edges | Approximated, rolled, undermining, tunneling |
| Surrounding skin | Color, temperature, integrity, edema |
Pressure Injury Staging
| Stage | Description |
|---|---|
| Stage 1 | Non-blanchable redness of intact skin |
| Stage 2 | Partial-thickness loss; shallow open ulcer or blister |
| Stage 3 | Full-thickness loss; subcutaneous fat may be visible |
| Stage 4 | Full-thickness loss with exposed bone, tendon, or muscle |
| Unstageable | Obscured by slough or eschar |
| Deep Tissue Injury | Dark discolored intact skin or blood-filled blister |
Key Nursing Interventions
| Intervention | Rationale |
|---|---|
| Use the ordered clean or sterile technique | Prevents infection |
| Clean wounds from clean to dirty | Prevents contamination |
| Document wound characteristics each shift | Tracks healing progress |
| Reposition on the individualized schedule | Prevents pressure injuries |
| Ensure adequate nutrition | Protein, vitamin C, and zinc promote healing |
| Keep wound moist (not wet) | Moist environment promotes healing |
| Report signs of infection | Increased redness, warmth, swelling, purulent drainage, fever |
Signs of Wound Infection
- Increased pain, redness, swelling, warmth around the wound
- Purulent (pus) drainage; foul odor
- Fever
- Elevated WBC count
- Delayed healing or wound dehiscence
Exam Alert
Wound care questions appear in the Safety and Infection Control, Basic Care & Comfort, and Physiological Adaptation categories on the NCLEX-PN. Know pressure injury stages (especially Stage 1 = non-blanchable redness). Follow the individualized repositioning plan. Clean from clean to dirty. Report infection signs to the RN immediately. Wound technique depends on the prescribed treatment and setting.
CNAs observe and report skin changes and carry out authorized preventive care. Wound assessment, staging, debridement and treatment selection require qualified clinicians. Do not remove a dressing or select a cream without authorization. Official guidance.
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Standard Precautions (Nursing)
Standard precautions are a set of infection control practices used with ALL patients regardless of diagnosis or infection status. They include hand hygiene, use of personal protective equipment (PPE), safe injection practices, respiratory hygiene, and proper handling of contaminated equipment and surfaces.
Nursing Process
The nursing process is a cyclical framework for planning, delivering and evaluating patient-centered care. ADPIE is a common way to remember assessment, diagnosis, planning, implementation and evaluation.
Focused Assessment
A focused assessment gathers targeted findings about a specific complaint, body system or change in condition. It may be the first assessment of a new concern or a reassessment after care.
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