10.4 Wound Care Essentials for Older Adults

Wound care in older adults sits at the intersection of II-B-2 safety interventions and daily gerontological nursing skill. Thin dermis, reduced subcutaneous fat, impaired microcirculation, malnutrition, diabetes, immobility, and polypharmacy (especially systemic steroids) slow healing and raise infection risk. GERO-BC expects you to prevent, identify etiology, support healing, and know when to escalate—not to memorize every brand-name dressing.

Aging Skin and Healing Reality

Expect longer inflammatory and proliferative phases. Goals may be heal, maintain, or palliate depending on perfusion, life expectancy, and person goals. A palliative wound plan still requires odor control, exudate management, and pain relief even when closure is unlikely.

Mislabeling a venous ulcer as a pressure injury (or compressing an arterial ulcer) causes harm. When etiology is unclear, protect the wound and obtain vascular/wound-consult assessment before aggressive compression.

Assessment and Documentation

A usable wound note includes:

• Location and etiology (pressure vs venous vs skin tear, etc.)
• Stage for pressure injuries (NPIAP): Stage 1 non-blanchable erythema; Stage 2 partial-thickness; Stage 3 full-thickness adipose visible; Stage 4 fascia/muscle/bone; unstageable (obscured by slough/eschar); deep tissue pressure injury (persistent non-blanchable deep red/maroon/purple)
• Size (length × width × depth) and tunneling/undermining clock references
• Wound bed (% granulation, slough, eschar, epithelialization)
• Exudate amount/type; odor after cleansing; peri-wound maceration or dermatitis
• Pain before/during dressing changes; systemic signs (fever atypical—watch delirium, glucose rise, malaise)

Photograph per policy with consent. Reassess at each dressing change and with status change. A wound that stalls ≥2 weeks despite optimized care needs plan revision (perfusion, infection, nutrition, offloading failure, biofilm).

Moisture Balance and Dressing Logic

Modern wound care aims for moist wound healing—not wet maceration and not bone-dry desiccation (except selected stable dry eschar on ischemic heels per vascular guidance).

Practical rules of thumb:

• Dry wound → hydrate (hydrogel, moisture-donating options)
• Heavy exudate → absorb (foams, alginates, gelling fibers); protect peri-wound with barrier
• Fragile skin → silicone borders, non-adherent contact layers; avoid aggressive adhesives
• Infected / critically colonized → cleanse, increase change frequency, antimicrobial dressings per protocol, culture when indicated, systemic antibiotics for spreading cellulitis/osteomyelitis/sepsis—not for every positive swab alone
• Cavity / depth → gently fill dead space without packing too tightly

TIME/TIMERS framework guides bedside thinking: Tissue (debride nonviable when appropriate and ordered/within scope), Infection/Inflammation, Moisture balance, Edge (non-advancing edges need etiology check), Repair/Regeneration (nutrition, perfusion), Social factors (caregiver ability, cost, adherence).

Offloading, Perfusion, and Nutrition

Dressings fail if the cause continues:

1. Pressure — heels floated; turn schedules real; chair cushions used; device-related pressure checked (oxygen tubing on ears, catheters, splints)
2. Perfusion — tobacco cessation support; optimize BP/HF; arterial workup before compression; elevate venous legs when sitting
3. Nutrition — protein targets individualized (often higher in healing wounds); address dentition, appetite, and access to food; involve dietitian early for Stage 3–4 or nonhealing wounds
4. Glycemic control — hyperglycemia impairs leukocyte function; coordinate with diabetes plan without causing hypoglycemia

Infection vs Colonization

Chronic wounds are often colonized. Treat infection when there is spreading erythema, warmth, new pain, purulent increase, fever/systemic change, or probe-to-bone concern in diabetic feet. Cleanse with gentle technique; avoid cytotoxic overuse (e.g., routine harsh antiseptics on clean granulating tissue). For older adults, delirium or functional decline may be the infection “fever.”

Special Older-Adult Situations

• Anticoagulated patients — expect easy bruising and skin tears; teach gentle skin care; control bleeding with local pressure; avoid unnecessary IM injections near fragile areas
• End-of-life Kennedy terminal ulcers / skin failure — communicate expected trajectory; prioritize comfort, odor, and family education over aggressive debridement when goals are palliative
• Cognitive impairment — dressing-change trauma is high; premedicate for pain, use calm milieu, two-person assist, and distraction; secure dressings so they are harder to remove impulsively without using harmful restraints
• Home care — teach caregiver clean technique, supply logistics, and red-flag symptoms for earlier nurse visit

Interdisciplinary Escalation

Escalate early to wound/ostomy nurse, PT (mobility/offloading), dietitian, vascular surgery, infectious disease, or palliative care when wounds deepen, expose bone/tendon, show ischemia, or conflict with comfort goals. Nursing ownership remains: daily prevention, accurate staging/documentation, dressing integrity, and linking wound progress to the care-plan evaluation cycle.

Exam Pattern

GERO-BC wound items typically ask which action is priority for a Stage 1 sacral area, whether compression is appropriate, how to manage a skin tear, or which finding indicates infection needing provider notification. Choose etiology-correct, offloading-first, moisture-balanced, and dignity-preserving answers over one-size-adhesive or restraint-based “solutions.”