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Nursing Field Notes / Skin & Wound · Wound Care · Fundamentals of Nursing
🩹 SKIN & WOUND SET NG-051 Skin (foundation) NG-044 Pressure Injuries NG-080 Wound Care NG-116 Frostbite NG-182 Dermatitis NG-225 Psoriasis NG-204 Skin Cancer

Wound Care 🩹

How wounds close · the healing phases · assessment · dressings · drains · dehiscence & evisceration

NG-080 FUNDAMENTALS · SKILL ADHD-friendly visual edition

Wound care is four questions asked in order: how is this wound closing? what phase is it in? what does the bed look like? what does the bed need? Answer those and the dressing chooses itself. This page is the partner to NG-044 Pressure Injuries — that page tells you how deep, this page tells you what to do about it.

📄 Simple Nursing original — opens in Drive →

🧵 3 intentionsPrimary = edges together · Secondary = fills from the bottom · Tertiary = left open, closed later.
⏱️ 4 phasesHemostasis → Inflammatory → Proliferative → Maturation.
🔴🟡⚫ RED · YELLOW · BLACKRed = protect · Yellow = cleanse · Black = debride.
🚨 EviscerationSterile saline-moist gauze · low Fowler's, knees bent · NEVER push it back in · call surgery.
🧬

HOW WOUNDS HEAL

STEP 1 · THE BIOLOGY

Two frameworks. Intention = how the edges come together. Phase = where the wound is in time.

🧵 Primary · Secondary · Tertiary intention

HOW DO THE EDGES COME TOGETHER? PRIMARY clean surgical incision · edges approximated sutures Fast · minimal tissue loss · thin scar Lowest infection risk. Days to a few weeks. e.g. appendectomy incision, laceration repair SECONDARY edges NOT approximated · tissue lost fills from the BOTTOM up big scar Slow · granulates in · contracts · scars Highest infection risk. Weeks to months. e.g. Stage 3–4 pressure injury, deep burn TERTIARY left open on purpose, closed LATER contaminated after infection/edema clears a.k.a. delayed primary closure Open first to drain, then surgically closed. e.g. dirty abdominal wound, animal bite
🧠 1 = zip it now. 2 = it fills itself. 3 = wait, then zip it. If a question describes a wound "packed and left open, to be closed in a few days," that is tertiary.

⏱️ The four phases — with the tissue drawn at each stage

THE HEALING TIMELINE · the phases overlap, they don't queue politely ① HEMOSTASIS seconds → minutes Vessels constrict Platelets plug + clot forms Fibrin scaffold laid down You see: bleeding stops, a scab begins. Nurse: pressure, protect the clot ② INFLAMMATORY day 1 → 4–5 Vessels dilate + leak 🔵 neutrophils clean up first 🟣 macrophages take over You see: redness, warmth, swelling, pain — NORMAL now. Nurse: don't mistake it for infection (it should be settling by day 5) ③ PROLIFERATIVE day 4 → 21 Fibroblasts lay collagen New capillaries sprout Edges contract inward You see: beefy red, bumpy GRANULATION + new pink edges Nurse: keep it moist, protect it, feed protein + vitamin C ④ MATURATION day 21 → up to 2 years Collagen remodels & aligns Scar shrinks, flattens, pales Final strength ≈ 80% of the original tissue — never 100% Nurse: sun protection, scar care, watch for keloid/contracture
🧠 "Stop · Clean · Build · Polish." Stop the bleeding (hemostasis), clean the site (inflammatory), build new tissue (proliferative), polish the scar (maturation).

🍽️ What speeds healing up — and what stalls it

Helps ✅Hurts ❌
Adequate protein (collagen is protein)Malnutrition, low albumin <3.5 g/dL
Vitamin C — needed to cross-link collagen; zinc and vitamin A support repairDeficiency states, alcohol misuse
Good perfusion and oxygenationSmoking (vasoconstriction + carbon monoxide), PVD, anemia, shock
Glycemic controlHyperglycemia — impairs white cells and feeds bacteria
Moist, protected wound bedDrying out, repeated trauma from dressings, infection, foreign body
Young, healthy immune systemCorticosteroids, chemotherapy, radiation, immunosuppressants
Wound edges supported (splinting, binder)Obesity (fat is poorly perfused), coughing/straining/vomiting, tension on the wound
🧠 Collagen needs bricks (protein), mortar (vitamin C) and a delivery truck (oxygen). Take away any one and the wall doesn't go up.

⭐ Why "moist wound healing" beats a dry scab

Cells cannot migrate across a dry crust — they have to burrow underneath it. A moist wound bed with dry, intact surrounding skin heals faster and hurts less.

  • Too dry → cells die, scab forms, epithelium is slowed, dressing removal rips new tissue.
  • Too wet → the wound edges macerate (soggy, white), the wound gets bigger, and bacteria thrive.
  • The dressing's job is to balance: add moisture to a dry wound, absorb from a wet one.
🧠 "Moist in the middle, dry at the edges." Goldilocks rule for every dressing decision on this page.
🔎

ASSESS & DOCUMENT

STEP 2 · LOOK

Every dressing change is an assessment opportunity. Look before you cover it back up.

🔴🟡⚫ The wound bed — red, yellow, black

RED · YELLOW · BLACK — what the bed color tells you to do 🔴 RED = PROTECT Beefy red, moist, bumpy granulation. Healthy — this is what you want. Keep moist, cover gently, don't scrub it. 🟡 YELLOW = CLEANSE Stringy, soft, moist slough; may be creamy exudate. Irrigate, absorb, debride (autolytic / enzymatic). ⚫ BLACK = DEBRIDE Dry, leathery, adherent eschar. Dead — nothing heals under it. Debride — EXCEPT stable, dry, intact heel eschar. MIXED WOUND? Treat the worst color first. Black → Yellow → Red and document the % of each
🧠 Traffic light, backwards. Black = stop everything and debride. Yellow = slow down and clean. Red = go, just protect it.

💧 Drainage (exudate) — name it correctly

WHAT IS ON THE GAUZE? SEROUS clear / straw · thin · normal early SEROSANGUINEOUS pale pink · thin · common post-op SANGUINEOUS bright red · fresh bleeding · report PURULENT thick, opaque, yellow/green · odor

Also chart the amount (scant / small / moderate / large, or the number of saturated gauze pads, or milliliters from a drain) and odor after cleansing. A sudden increase in serosanguineous drainage from a surgical incision around post-op day 3–14 is the classic warning sign of impending dehiscence — see the Complications section.

🧠 Sero = serum (clear). Sangui = blood (red). Pus = purulent. Put the two together and you get "serosanguineous" — pale pink.

✅ The wound assessment checklist

  • Location and wound type/etiology
  • Size — length × width × depth in cm; undermining and tunnelling by the clock (12:00 = head)
  • Wound bed — % red granulation / yellow slough / black eschar; is there epithelium at the edges?
  • Exudate — type, amount, odor (assess after cleansing)
  • Wound edges — approximated? rolled? undermined? macerated?
  • Periwound skin — erythema, warmth, induration, maceration, excoriation
  • Pain — before, during and after the dressing change
  • Signs of infection, and whether the wound is progressing or stalled
🧠 Chart the wound so vividly that the next nurse could draw it without looking.

🧪 Culturing a wound — the technique that gets a valid result

  • Cleanse the wound with sterile normal saline FIRST. Culturing before cleansing just grows the surface junk.
  • Never swab pus, exudate, eschar or slough — those give you colonizing organisms, not the pathogen.
  • Swab clean, viable granulation tissue: rotate the swab over about 1 cm² for several seconds with enough pressure to express fluid from the tissue (Levine technique).
  • Label, bag, and send promptly; note antibiotics already given.
  • If both aerobic and anaerobic cultures are ordered, follow lab requirements for the anaerobic transport medium.
🧠 Clean it, then culture the living part. You are asking "what is invading the tissue?", not "what is floating in the goo?"
🩹

DRESS, CLEAN & DRAIN

STEP 3 · DO IT

Pick the dressing from what the wound needs, not from what's in the cupboard.

🩹 Dressing types, drawn — matched to the wound

MATCH THE DRESSING TO THE WOUND TRANSPARENT FILM Use: shallow, dry / minimal exudate Waterproof, breathable, you can SEE through it Promotes autolytic debridement ✗ Not absorbent — never on a draining wound HYDROCOLLOID Use: shallow, light–moderate exudate Occlusive; forms a gel; can stay 3–7 days Great for a clean Stage 2 ✗ Avoid on infected wounds; gel can smell odd HYDROGEL Use: DRY wounds — it ADDS moisture Soothing on painful wounds; rehydrates eschar Promotes autolytic debridement ✗ Not for heavy exudate — macerates edges FOAM Use: moderate–heavy exudate Absorbs and cushions; comfortable Also used prophylactically on sacrum/heels ✗ Overkill on a dry wound CALCIUM ALGINATE Use: HEAVY exudate, deep cavities, packing Seaweed-derived; turns to gel; also hemostatic ✗ Needs a cover dressing · ✗ never on a dry wound GAUZE PACKING Use: filling dead space; wet-to-dry debridement Pack LOOSELY — tight packing = more pressure ✗ Wet-to-dry is non-selective & painful — it also rips off new granulation

Two more you should be able to name: antimicrobial dressings (silver, iodine, medical-grade honey) for infected or heavily colonized wounds, and negative-pressure wound therapy ("wound vac") — a sealed foam dressing under suction that removes exudate, reduces edema and pulls the wound edges together; monitor the seal, the canister output and for bleeding.

🧠 Dry wound → add water (hydroGEL). Wet wound → soak it up (foam, ALGinate). "Gel gives, alginate absorbs."

✅ Wet-to-dry dressing change — the ordered skill, step by step

1
Prepare
Check the order. Assess pain and give analgesia 30–45 minutes before the change. Ask about latex, adhesive and iodine allergies. Explain the procedure, provide privacy, position the patient.
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2
Set up
Hand hygiene → gather supplies → open sterile field and pour sterile saline into the sterile container → place gauze/packing to soak. Have a plastic waste bag within reach.
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3
Remove the old dressing
Clean gloves. Loosen tape gently toward the wound, supporting the skin. If the gauze is stuck, moisten it with sterile saline to release it. Remove all packing and count it against what was documented as inserted. Note drainage on the old dressing, then bag it with your gloves. Hand hygiene, new gloves.
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4
Assess & measure
Wound bed color, size (L × W × D), undermining and tunnelling, exudate, odor, edges, periwound skin. Document now, while you can see it.
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5
Clean / irrigate
Clean from the least contaminated to the most contaminated area — for an incision, from the incision outward, top to bottom, one stroke per swab, then discard. Irrigate top to bottom so run-off never crosses clean tissue. Blot the surrounding skin dry.
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6
Pack
Squeeze the saline-soaked gauze until it is damp, not dripping. Pack loosely into the wound and into any undermining/tunnelling. Keep packing off the intact surrounding skin. Apply a barrier/skin prep to the periwound if ordered.
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7
Cover & secure
Dry cover dressing (ABD pad/gauze), secured with tape or rolled gauze. Date, time and initial the new dressing.
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8
Finish & document
Double-bag and dispose of waste, remove gloves, hand hygiene. Reassess pain. Chart: date/time, why, wound assessment, cleansing solution, packing used and amount, dressing applied, patient response and teaching.
🧠 "Damp not dripping, loose not stuffed, count what goes in." A retained piece of packing is a retained foreign body.

🚿 Cleaning direction — the picture that answers the question

ALWAYS CLEAN → LEAST contaminated TO MOST contaminated 12345 OPEN WOUND center → outward, in circles new swab for every circle INCISION one stroke, top → bottom new swab for every stroke

Irrigation: use warmed sterile normal saline, hold the syringe about 2.5 cm (1 in) above the wound, and irrigate from the cleanest area toward the dirtiest until the return runs clear. Standard teaching for a safe irrigation pressure is a 35 mL syringe with a 19-gauge angiocatheter (about 8 psi). Wear a gown, mask and eye protection — irrigation splashes.

🧠 One swab, one stroke, one direction — then bin it. Never go back over a clean area with a used swab.

🔪 Debridement — five ways to remove dead tissue

TypeHow it works
MechanicalPhysical removal — wet-to-dry gauze, hydrotherapy/whirlpool, irrigation, gentle scrubbing. Fast but non-selective (takes healthy tissue too), painful, can bleed.
Enzymatic (chemical)A prescribed topical enzyme ointment applied directly to the necrotic tissue only. Selective, slower, painless. Protect the surrounding skin.
AutolyticThe body's own enzymes do it, under a moisture-retentive dressing (film, hydrocolloid, hydrogel). Most selective and least painful — but the slowest. Not for infected wounds.
Surgical / sharpScalpel or scissors. Fastest and most complete; sharp debridement at the bedside is done by a qualified provider, larger excision in the OR. Used when infection or a large necrotic burden is urgent. (Tangential = shaving very thin layers until bleeding; fascial = down to fascia in deep burns.)
BiologicSterile medical-grade larvae ("maggot therapy") digest necrotic tissue only. Highly selective; used in selected chronic wounds.
🧠 "Machines rip, enzymes nibble, the body dissolves, the scalpel cuts, the maggots snack." Selectivity goes up as speed goes down.

🧪 Drains — Penrose, Jackson-Pratt, Hemovac

SURGICAL DRAINS · open vs closed PENROSE — open safety pin Flat latex tube, drains by gravity into the dressing No suction · no reservoir · estimate output by counting saturated dressings Open system = higher infection risk JACKSON-PRATT — closed bulb squeezed Compress the bulb + cap it = gentle constant suction. Empty when ½–⅔ full, then RE-COMPRESS. HEMOVAC — closed spring-loaded accordion Larger volumes. Press flat to re-establish suction.
  • Record each drain separately — label them (JP #1, JP #2), chart output in mL, color and consistency.
  • Empty when ½ to ⅔ full and re-establish the vacuum every time (a bulb that has re-expanded is not draining).
  • Secure the tubing so it doesn't pull, and keep the reservoir below the wound.
  • Report: a sudden increase in output, output that stops abruptly, a change back to bright red bloody drainage, purulence or foul odor, or a dislodged drain.
  • Expect the drainage to progress from sanguineous → serosanguineous → serous and to decrease over days.
🧠 Open drains drip; closed drains suck. A JP bulb that is popped open is doing nothing — squeeze and cap it.
🚨

WHEN IT GOES WRONG

STEP 4 · EMERGENCIES

Two words to know cold: dehiscence and evisceration. One of them is a surgical emergency.

🚨 Dehiscence vs evisceration — and exactly what you do

THE ABDOMINAL WOUND, THREE WAYS ✅ INTACT Edges approximated · layers holding ⚠️ DEHISCENCE Layers separate — the wound gapes open 🚨 EVISCERATION Organs protrude through the wound 🚨 EVISCERATION — WHAT YOU DO, IN ORDER saline gauze knees flexed LOW FOWLER'S with knees bent = takes tension off the abdomen 1 · Stay with the patient and call for help / activate the surgeon 2 · Position low Fowler's with knees flexed — reduces abdominal tension 3 · Cover the organs with sterile gauze moistened with sterile normal saline; keep it moist 4 · NEVER push the organs back in. Keep NPO · monitor for shock · prep for surgery
🧠 "Cover, curl, call — never cram." Cover with sterile saline-moist gauze, curl the patient into low Fowler's with knees bent, call the surgeon, and never push anything back inside.

🚨 Spot dehiscence coming

  • Timing: classically around post-op day 3–14, when the inflammatory phase ends and the new collagen is still weak.
  • The warning sign: a sudden increase in serosanguineous drainage from a previously drying incision.
  • The patient may describe a "popping" or "giving way" sensation, often while coughing, vomiting, straining or getting up.
  • Risk factors: obesity, malnutrition/low protein, infection, diabetes, corticosteroids, smoking, chronic cough, vomiting, straining, abdominal distension, poor surgical closure.
  • Prevention: splint the incision with a pillow for coughing, deep breathing and movement; treat nausea and constipation; support nutrition; use an abdominal binder if ordered.
🧠 "Dry incision suddenly weeping pink fluid = the wound is telling you it is about to open." Assess it now, don't wait for the next dressing change.

🚨 The other complications to name

  • Infection — increasing erythema, warmth, edema, induration, purulent drainage, odor, increasing pain, fever, leukocytosis, delayed healing. Wound infections typically declare themselves around post-op day 3–6.
  • Hemorrhage — frank bleeding, a rapidly saturating dressing, a hematoma (swollen bluish bulge under the incision). Apply pressure, mark the drainage border with the time, and escalate.
  • Fistula — an abnormal tract between the wound and another organ or the skin; look for unexpected drainage such as stool or urine.
  • Sepsis — fever or hypothermia, tachycardia, tachypnoea, hypotension, new confusion. This is the one that kills.
  • Scar problems — keloid (grows beyond the wound edges), hypertrophic scar, contracture across a joint.
🧠 Draw a line around the drainage and write the time on the tape. That is how you prove whether bleeding is increasing.

👨‍👩‍👧 Teach before discharge

  • Hand hygiene before and after touching the wound; clean technique for most home dressing changes.
  • Splint the incision with a pillow when coughing, sneezing, laughing, vomiting or standing up.
  • Ask for pain medicine early — before the pain becomes unbearable, and ideally 30–45 minutes before a dressing change.
  • Signs to report: increasing redness/swelling/warmth, thick or foul drainage, fever ≥ 38 °C (100.4 °F), increasing pain, wound edges pulling apart, or any sudden increase in drainage.
  • Eat the protein, stay hydrated, and stop smoking — nicotine constricts the very vessels the wound needs.
  • No soaking baths, hot tubs or swimming until cleared; keep the incision out of direct sun for the first year to reduce scar darkening.
🧠 Give the patient one sentence they'll remember: "If it gets redder, hotter, smellier or more painful — call."

🗺️ Where this page sits in the set

  • NG-051 — Skin: the layers, appendages and the partial- vs full-thickness rule that decides how a wound can heal.
  • NG-044 — Pressure Injuries: the partner page. Staging, risk scoring and prevention; use this page for its dressings and documentation.
  • NG-116 — Frostbite: cold-injured tissue that later needs exactly this wound care, including debridement decisions.
🧠 NG-044 answers "how deep?" · NG-080 answers "now what?"
⚡

QUICK RECALL

SAY IT OUT LOUD
🧵 1 · 2 · 3 intentionsZip it now · fills itself · wait then zip.
⏱️ Stop · Clean · Build · PolishHemostasis → inflammatory → proliferative → maturation.
🩹 Gel gives, alginate absorbsDry wound → hydrogel. Soaking wound → foam / alginate.
🚨 Cover · Curl · CallEvisceration: sterile saline-moist gauze, low Fowler's knees bent, surgeon. Never push it back.
🎯 Cover & check — 9 rapid-fire questions
Q1: A deep pressure ulcer is left open to granulate in. Which type of healing is that?
Secondary intention — the edges are not approximated, so the wound fills in from the base with granulation tissue, contracts, and heals with a large scar over weeks to months.
Q2: On post-op day 2 the incision is red, warm, slightly swollen and tender. Is this infection?
Not necessarily — this is the expected inflammatory phase (days 1 to about 4 or 5). It becomes concerning if it is increasing after day 5, or if there is purulent drainage, odor, fever or increasing pain. Wound infections typically declare around post-op day 3 to 6.
Q3: The wound bed is dry with a small amount of adherent yellow slough and no drainage. Which dressing?
A hydrogel — it adds moisture to a dry bed and supports autolytic debridement of the slough. An alginate or foam would be wrong because there is no exudate to absorb.
Q4: How do you clean a linear surgical incision?
From the least contaminated to the most contaminated area: start on the incision and move outward, wiping in single strokes from top to bottom, using a new swab for every stroke and discarding it. Never go back over a cleaned area with a used swab.
Q5: What must you do before obtaining a wound culture?
Cleanse the wound with sterile normal saline first, then swab clean viable granulation tissue — never pus, exudate, slough or eschar.
Q6: A JP drain bulb is found fully expanded and full. What do you do?
Empty it into a graduated container, measure and record the volume, color and consistency for that specific drain, then compress the bulb and recap it to re-establish suction. An expanded bulb is not draining.
Q7: A patient coughs and reports something "gave way"; the abdominal dressing is suddenly soaked with pink fluid. What is happening and what do you do?
Impending or actual dehiscence. Stay with the patient, place them in low Fowler's with knees flexed, cover the wound with sterile saline-moistened dressings, keep them NPO, monitor vital signs, and notify the surgeon immediately.
Q8: Loops of bowel are visible through the wound. Give the four actions in order.
1) Stay with the patient and call for help/the surgeon. 2) Low Fowler's with knees flexed. 3) Cover the organs with sterile gauze moistened with sterile normal saline and keep it moist. 4) Keep NPO, monitor for shock, prepare for emergency surgery. Never attempt to reinsert the organs.
Q9: Which debridement method is the most selective and least painful, and when can't you use it?
Autolytic debridement — the body's own enzymes work under a moisture-retentive dressing. It is the slowest method and should not be used on infected wounds or when rapid removal of necrotic tissue is needed.