A wound is any disruption of skin and underlying tissue. Wounds are acute (surgical incisions, trauma, burns — expected to heal in an orderly way) or chronic (pressure injuries, venous, arterial, and diabetic foot ulcers — stalled healing, usually beyond about 4–12 weeks). Pressure injuries are covered in Topic 25.

Phases of healing

Types of healing (intention)

• Primary intention — clean wound with edges approximated (sutured incision): fast, minimal scar
• Secondary intention — edges left apart; wound fills with granulation tissue from the base (pressure injuries, infected wounds): slower, larger scar, higher infection risk
• Tertiary intention (delayed primary closure) — left open for several days (contaminated wounds), then closed

Factors that delay healing

• Poor perfusion and oxygenation (peripheral artery disease, anemia, smoking)
• Malnutrition — protein, calories, vitamin C, zinc; low albumin and weight loss signal risk
• Diabetes with hyperglycemia, obesity, advanced age
• Infection, necrotic tissue, foreign bodies, pressure, excess moisture or dryness
• Drugs: corticosteroids, chemotherapy, immunosuppressants; radiation
• Edema, repeated trauma, stress

Assess at each dressing change and document consistently.

Validated tools

• PUSH tool (Pressure Ulcer Scale for Healing) — scores surface area (length × width), exudate amount, and tissue type to track healing over time
• Bates-Jensen Wound Assessment Tool — 13 items (size, depth, edges, undermining, necrotic tissue type and amount, exudate type and amount, surrounding skin color, edema, induration, granulation, epithelialization)
• Photographs per policy, taken the same way each time

• Wound culture when infection is suspected: cleanse with saline first; the Levine technique — rotate a swab over 1 cm² of viable tissue with enough pressure to express fluid; do not swab pus, slough, or eschar. Tissue biopsy is the most accurate
• Probe-to-bone test, X-ray, MRI for suspected osteomyelitis
• Ankle-brachial index (ABI) before compression for leg ulcers (arterial disease)
• CBC, glucose, HbA1c, albumin and prealbumin (inflammation lowers them — interpret with clinical picture), C-reactive protein

Principles of wound bed preparation (often summarized as TIME)

• Tissue — remove nonviable tissue (debridement)
• Infection or inflammation — treat infection; manage bacterial burden
• Moisture balance — keep the wound bed moist but not wet; protect periwound skin
• Edge — assess the edge; address nonadvancing edges

Debridement

Exception: stable, dry, intact eschar on the heel or on an ischemic limb is left in place — it acts as a natural cover. Debride if it becomes unstable, boggy, or infected.

Dressing selection

Cleansing: 0.9% sodium chloride or potable water; clean from the least contaminated to the most contaminated area (incision: center line outward; circular wound: center outward). Irrigate deep wounds at safe pressure (about 4–15 psi, e.g., a 35 mL syringe with a 19-gauge catheter). Avoid routine use of cytotoxic antiseptics (hydrogen peroxide, full-strength povidone-iodine) on clean granulating wounds.

Wound packing: fill dead space loosely (tight packing impairs blood flow); count and document pieces; leave a tail visible.

Systemic care: glucose control, nutrition (protein about 1.25–1.5 g/kg/day in adults with chronic wounds if not contraindicated), smoking cessation, perfusion (revascularization for arterial disease), compression for venous ulcers (after ABI).

Listed in priority order.

1. Surgical wound emergencies
   • Dehiscence (separation of wound edges) or evisceration (organs protrude): stay with the client, call for help, cover with sterile gauze moistened with sterile saline, place in low Fowler's position with knees flexed (reduces abdominal tension), keep NPO, monitor for shock, notify the surgeon; never reinsert organs. Coughing, vomiting, obesity, and infection increase risk — splint incisions with a pillow
   • Hemorrhage: apply pressure, monitor vital signs
2. Pain control before dressing changes (premedicate, allow time for effect)
3. Asepsis: hand hygiene; clean gloves to remove old dressing; sterile technique for fresh surgical wounds and when packing sterile cavities; clean technique acceptable for many chronic wounds per policy
4. Assess and document each change using the elements above
5. Keep a moist, not wet, environment; protect surrounding skin with barrier film or cream; manage exudate
6. Drains (e.g., closed suction bulb or spring type): keep compressed to maintain suction, empty and measure drainage, record color and amount; secure tubing
7. Suture and staple removal as ordered (often about 7–14 days, varies by site); apply adhesive strips as needed
8. Binders and splinting for abdominal wounds; heat or cold only as ordered, with time limits and skin checks
9. Nutrition, hydration, mobility, glucose control; dietitian referral

• Hand hygiene before and after touching dressings; how to change the dressing and dispose of waste
• Report increasing redness, swelling, warmth, pain, pus, foul odor, fever, or edges separating
• Splint the incision with a pillow when coughing; avoid heavy lifting per surgeon's advice
• Eat enough protein, calories, and fluids; stop smoking; keep glucose in target range
• Protect the scar from sun for up to a year; keloids are more common in people with darker skin
• Showering rules follow the surgeon's instructions (often allowed after 24–48 hours for closed incisions)

• Healing phases: hemostasis → inflammation (neutrophils first, then macrophages by days 3–4) → proliferation (granulation) → maturation up to 1–2 years
• Primary intention = edges closed; secondary = heals from the base by granulation
• Measure length (head–toe) × width (perpendicular) × depth; undermining and tunneling by clock face
• Granulation = healthy red; slough = yellow; eschar = black
• Serous clear, sanguineous red, serosanguineous pink, purulent = infection
• Maceration = white, soggy periwound skin from excess moisture
• PUSH = surface area, exudate amount, tissue type
• Moist wound healing; hydrogel for dry, alginate or foam for heavy exudate; no hydrocolloid on infected wounds
• Debride necrotic tissue — except stable dry heel eschar
• Culture with the Levine technique after cleansing
• Evisceration: sterile saline-moistened gauze, low Fowler's with knees bent, notify surgeon, do not reinsert