Wound Care & Wound Healing
Key Takeaways
- Wound healing progress flows through four overlapping phases: hemostasis, inflammatory, proliferative, and maturation.
- Primary intention involves approximated surgical edges, whereas secondary intention heals from the bottom up due to tissue loss.
- Unstageable pressure injuries cannot be clinically staged because the wound bed is obscured by slough or eschar.
- Active drains like Jackson-Pratt and Hemovac require manual compression to create negative pressure suction.
- Wound evisceration is a medical emergency managed by low Fowler's positioning, sterile saline-soaked dressings, and NPO status.
Last updated: July 2026
1. Stages of Wound Healing
Wound healing is a complex biological process divided into four continuous phases:
- Hemostasis Phase: Occurs immediately after injury. Blood vessels constrict (vasoconstriction), platelets aggregate, and a fibrin clot forms to limit blood loss.
- Inflammatory Phase: Lasts 1 to 4 days. Vasodilation occurs, increasing capillary permeability to allow white blood cells (neutrophils and macrophages) to migrate to the wound bed. Macrophages clean the wound of debris, bacteria, and necrotic tissue while releasing growth factors. Clinical manifestations include localized erythema, warmth, edema, pain, and loss of function.
- Proliferative Phase: Lasts from day 4 to day 21. Fibroblasts synthesize collagen, which provides structural integrity. Granulation tissue (fragile, highly vascularized pink-to-red tissue) fills the wound bed. Epithelialization occurs as new epithelial cells migrate across the wound surface to close it.
- Maturation (Remodeling) Phase: Lasts from day 21 up to 2 years. Collagen fibers reorganize to increase tensile strength. The scar tissue changes from red and raised to flat and pale, eventually reaching approximately 80% of the skin's original strength.
2. Types of Wound Healing Intention
- Primary Intention: Occurs in clean, surgical incisions with minimal tissue loss. The wound edges are closely approximated (aligned) using sutures, staples, or adhesive glue. Healing is rapid, with minimal scarring and a low risk of infection.
- Secondary Intention: Occurs in wounds with extensive tissue loss (e.g., pressure injuries or severe trauma) or wounds left open due to infection. The edges cannot be approximated. The wound heals from the bottom up, filling with granulation tissue. This process requires a longer healing time, carries a higher risk of infection, and results in significant scarring.
- Tertiary Intention (Delayed Primary Closure): Occurs when a wound is intentionally left open for several days to resolve infection, edema, or severe contamination. Once the wound bed is clean and stable, the edges are surgically closed.
3. Pressure Injury Staging
Pressure injuries (pressure ulcers) result from localized damage to the skin and underlying soft tissue, usually over a bony prominence, due to prolonged pressure or shear forces.
Pressure Injury Stages
- Stage 1: Intact skin with non-blanchable erythema. The skin does not turn pale or white when light pressure is applied. Typically located over bony prominences (e.g., sacrum, heels).
- Stage 2: Partial-thickness skin loss involving the epidermis and dermis. Presents as a shallow, open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or ruptured serum-filled blister.
- Stage 3: Full-thickness skin loss. Subcutaneous fat (adipose tissue) may be visible, but muscle, tendon, ligament, cartilage, or bone are not exposed. Slough or eschar may be present but does not obscure the depth of tissue loss. Undermining and tunneling may occur.
- Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable muscle, tendon, ligament, cartilage, or bone. Slough or eschar may be present. Undermining and tunneling are frequently present.
- Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because the wound bed is completely covered by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black).
- Nursing Rule: Stable, dry, intact eschar on the heels serves as the body’s natural cover and should not be debrided or removed.
- Deep Tissue Pressure Injury (DTPI): Intact or non-intact skin with localized, persistent non-blanchable deep red, maroon, or purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.
4. Wound Dressings and Clinical Selection
Selecting the correct dressing depends on the wound bed's status, level of exudate, and presence of infection.
| Dressing Type | Description & Function | Clinical Indications |
|---|---|---|
| Transparent Films | Semi-permeable, adhesive films. Allow oxygen exchange but are waterproof and bacteria-proof. | Stage 1 pressure injuries; superficial wounds; securing IV lines. Contraindicated in moderate-to-heavy drainage. |
| Hydrocolloids | Occlusive dressings containing gelatin/pectin. Absorb minimal-to-moderate exudate, forming a gel to keep the wound moist. | Stage 2 or shallow Stage 3 pressure injuries with low-to-moderate drainage. Contraindicated in infected wounds. |
| Hydrogels | High-water content formulations (gels or sheets). Donate moisture to dry wound beds, facilitating autolytic debridement of necrotic tissue. | Dry wounds; sloughy wounds; necrotic wounds. Requires a secondary dressing. |
| Alginates / Hydrofibers | Highly absorbent natural fibers derived from brown seaweed. Turn into a soft gel upon contact with exudate. | Wounds with moderate-to-heavy drainage; packing deep tunnels. Requires a secondary dressing. Contraindicated in dry wounds. |
| Foams | Absorbent polyurethane sheets. Cushion the wound and absorb moderate-to-heavy exudate. | Draining wounds; Stage 2–4 pressure injuries. Can be used under compression wraps. |
5. Surgical Wound Complications
Surgical wounds require close monitoring for serious complications:
- Dehiscence: The partial or complete separation of outer wound layers.
- Evisceration: The protrusion of internal organs (viscera) through a dehisced surgical incision. This is a nursing emergency.
- Immediate Nursing Actions for Evisceration:
- Place the patient in a low Fowler's position with their knees bent (flexed) to reduce tension on the abdominal wall.
- Do not attempt to push the protruding organs back into the abdominal cavity.
- Cover the exposed organs with sterile dressings saturated with warm sterile normal saline to keep the tissue moist and viable.
- Instruct the patient to remain still, avoid coughing, and stay with them to provide reassurance.
- Maintain NPO status and notify the surgeon immediately for emergency surgical intervention.
- Monitor vital signs for signs of shock (hypotension, tachycardia).
- Immediate Nursing Actions for Evisceration:
6. Surgical Drain Management
Drains are inserted into surgical sites to remove blood, serum, or purulent material that could delay wound healing.
- Active Drains (Suction-based):
- Jackson-Pratt (JP) Drain: A closed-suction drainage system with a bulb reservoir. To function, the bulb must be compressed (squeezed) and capped.
- Hemovac Drain: A closed-suction system with a spring-loaded accordion chamber. Compressed flat to generate negative pressure.
- Nursing Care: Empty when half full (or once per shift) to maintain suction pressure. Pin the drain to the patient's gown below the level of the wound; never pin to bed linen to prevent accidental dislodgement when the patient moves.
- Passive Drains (Gravity/Capillary action):
- Penrose Drain: A soft, flexible flat latex tube. Drains directly onto dressing pads.
- Nursing Care: A sterile safety pin is placed through the drain to prevent it from slipping back into the surgical cavity. Monitor dressings and change them frequently to prevent skin maceration.
- Tube Clearance: Avoid forceful "stripping" of the tubes as it creates high negative pressure that can damage internal tissues. Gently "milk" the tubing using finger pressure if clots are blocking the flow, following institutional protocol.
Test Your Knowledge
A nurse is assessing a patient's surgical incision on the fifth postoperative day and notes that the incision edges have separated, and loops of bowel are visible protruding through the wound. Which action should the nurse take immediately?
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Test Your Knowledge
The nurse is caring for a patient with a deep sacral pressure injury. Upon examination, the wound bed is completely covered with yellow, stringy slough and thick, black necrotic tissue. How should the nurse document the stage of this pressure injury?
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Test Your Knowledge
A patient has a surgical wound with moderate-to-heavy purulent drainage. Which type of dressing is most appropriate for the nurse to apply to manage the exudate and maintain a moist wound environment?
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B
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