Wound Care and Dressing Management

Acute wounds (surgical incisions, traumatic lacerations) progress through predictable stages: hemostasis (bleeding stops within minutes), inflammation (redness, warmth, swelling for 2–3 days as immune cells clean debris), proliferation (new tissue forms, redness peaks around day 3–5), remodeling (collagen is reorganized, wound strengthens over weeks to months). Chronic wounds (pressure injuries, diabetic ulcers, venous ulcers) are stuck in inflammation and fail to progress through stages due to poor blood flow, infection, or repeated injury. Pressure injuries are staged I–IV by depth: I = nonblanchable redness; II = partial-thickness (top layer intact, lower layer shows blister or shallow ulcer); III = full-thickness (crater, subcutaneous tissue visible); IV = full-thickness with bone or tendon exposed. Diabetic ulcers on the feet are high-risk for infection and amputation, requiring frequent assessment and aggressive treatment. Venous ulcers are typically on the lower leg with surrounding hyperpigmentation and edema. Understanding the stage and cause of a wound guides treatment: an acute surgical incision heals with basic dressing changes, but a chronic pressure ulcer needs offloading, debridement, and possible advanced therapies.

Aseptic (sterile) technique is mandatory for open wounds to prevent contamination with bacteria that cause infection and delayed healing. Gather sterile supplies before you begin: open sterile packages on a clean surface, don sterile gloves or use sterile forceps. Clean the wound with normal saline (cool or at room temperature, never hot) using gentle irrigation or a syringe with a 18–20 gauge needle to create a fine spray. Do not use hydrogen peroxide or Betadine on open wounds — these are toxic to healing cells. Remove old dressing carefully; if it sticks, gently loosen with saline so you don't damage new tissue. Debride dead tissue (necrotic tissue, eschar, slough) with sterile scissors and forceps or enzymatic ointment (collagenase) — healthy tissue bleeds slightly when cut, dead tissue does not. Inspect the wound bed: healthy (pink to beefy red, moist, free of slough or eschar) vs. unhealthy (pale, dry, dark, sloughy, or foul-smelling). Apply topical agents per order (antibiotic ointment, wound cream, honey-based products for infected wounds). Never contaminate the sterile field by touching supplies with unsterile hands, letting supplies touch non-sterile surfaces, or allowing the wound to contact non-sterile items.

Gauze: basic, inexpensive, absorbs moisture; use for clean dry wounds or minor bleeding (does not adhere well to wounds with scabs, causing pain on removal). Transparent film: waterproof, allows visualization, maintains moist environment; use for shallow wounds, IV sites, or as a secondary dressing. Hydrocolloid: moist healing, forms gel when wet, absorbs exudate; use for partial-thickness wounds, pressure injuries, or leg ulcers (can be left on for 3–5 days, change if leaking). Foam: soft, absorbent, provides cushioning; use for moderate to heavy exudate, pressure relief on heels/sacrum. Alginate: calcium-alginate, converts to gel in presence of wound fluid, hemostatic; use for high-exudate wounds, bleeding wounds, or cavity wounds (string the alginate into the wound like packing). Antibiotic ointments: mupirocin for staph/strep, silver sulfadiazine for burns; apply thin layer and cover. Honey-based dressings (Medihoney): antimicrobial, absorbs exudate, deodorizes; use for infected or odorous wounds. Negative pressure wound therapy (wound vac): removes fluid and promotes granulation; use for large, complex wounds or post-surgical complications. Match the dressing to the wound characteristics: dry wound needs moisture (film or hydrocolloid), wet wound needs absorption (gauze, foam, alginate), and infected wound needs antimicrobial or negative pressure.

Stage 1 — Hemostasis and inflammation (0–3 days): bleeding stops, immune cells infiltrate, redness and swelling peak. Supported by: rest, elevation, ice if acute, pain control. Delayed by: anticoagulants, vasoconstrictors, immunosuppression. Stage 2 — Proliferation (day 3 to week 3): new collagen and blood vessels form, wound contracts, epithelial cells creep over the wound bed. Supported by: moist environment (dressings), adequate protein and vitamins (especially C and zinc), movement and circulation. Delayed by: infection, poor nutrition, ischemia, maceration (too much moisture). Stage 3 — Remodeling (weeks to months): collagen is reorganized, scar tissue matures, wound strength increases. Supported by: pressure garments, massage, patient adherence to activity restrictions. Delayed by: continued irritation, sun exposure, tension on incision. A surgical incision on a healthy patient may heal in 7–14 days for strength, but collagen remodeling continues for a year. A pressure injury on an elderly patient with poor nutrition may take months. Factors that slow healing: diabetes, poor circulation, malnutrition, immunosuppression, medications (steroids), smoking, and repeated injury (pressure, friction).

Signs of infection: purulent drainage (pus, thick and opaque, often yellow/green/brown), foul odor, increasing pain despite dressing changes, erythema (redness) spreading beyond the wound edge, warmth, edema, warmth, fever, and systemic symptoms (malaise, tachycardia, elevated WBC on labs). Bacteria count >100,000 per gram of tissue indicates infection; however, cultures are not always done for routine wound infections. Take a culture (wound swab, tissue biopsy, or drainage aspirate) if: the patient is immunocompromised, the infection is spreading (cellulitis), systemic symptoms are present, or the wound is not improving with standard care. Standard treatment for infected wounds: debride all necrotic and infected tissue, irrigate generously with saline, apply topical antimicrobials (silver sulfadiazine, honey-based dressings, iodine-based products), change dressings daily or more often, and monitor for spread. Systemic antibiotics are prescribed by the provider based on wound culture and sensitivities if available. Warn the patient that foul odor and drainage are often signs of infection, not normal healing, and to report immediately.

Pressure ulcers (bedsores) form when skin and underlying tissue are compressed between bone and a hard surface for prolonged periods, cutting off blood flow and causing tissue death. High-risk patients: immobile or bedridden (stroke, paralysis, dementia), elderly, malnourished, incontinent, or with sensory loss (diabetes, spinal cord injury). Assessment tools: Braden Scale evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear (score <12 = high risk). Prevention: regular repositioning every 2 hours (or per turn sheet), use of pressure-relief devices (foam/gel mattress overlays, alternating pressure mattresses, pillows under heels and sacrum to float them off the bed), skin inspection daily for redness that doesn't blanch, moisture management (keep skin dry, use incontinence products), adequate nutrition and hydration, and mobility assistance or passive range-of-motion exercises. For immobile patients in long-term care or hospice, turning every 2 hours may not be realistic, so priority is comfort and skin inspection. Once a pressure ulcer develops, prevention of spread and infection becomes the focus; deep Stage III–IV ulcers may require surgical consult for debridement or skin flap.

Education is key to compliance and healing. Teach: (1) Why the wound is not healing — poor blood flow, infection, poor nutrition, or repeated pressure/irritation — so the patient understands the problem. (2) How to keep the wound clean and dry at home — wash with soap and water, pat dry, apply dressing as instructed, and avoid touching the wound with unclean hands. (3) Nutrition and hydration — protein, vitamin C (citrus, vegetables), zinc (meat, nuts), and adequate fluids are essential for collagen synthesis. (4) Activity — movement and exercise improve circulation; immobility is the enemy. A bedridden patient should reposition every 2 hours, or use active range-of-motion exercises at least. (5) Pain management — chronic wound pain is real and should be managed with topical or systemic analgesics so the patient is willing to do wound care. (6) Signs of infection — pus, foul smell, increasing pain, redness spreading — and when to call the provider. Use teach-back: ask the patient to demonstrate dressing change or explain the wound care plan back to you so you know they understand. Provide written instructions with pictures if available.