Proper wound care is essential to prevent infection, promote healing, and ensure patient safety. In a clinical setting, a structured approach helps caregivers provide consistent, evidence-based care. This guide outlines best practices for assessing, managing, and documenting wounds to achieve optimal patient outcomes.
Types of Wounds
Understanding the type of wound is the foundation for proper treatment.
1. Acute Wounds:
These result from a sudden injury and heal in predictable stages. Common examples include surgical incisions, lacerations, abrasions, and punctures.
2. Chronic Wounds:
Chronic wounds fail to heal within the expected timeframe, typically four to six weeks. These include pressure injuries (pressure ulcers), diabetic ulcers, and venous stasis ulcers.
3. Pressure Injuries (Bedsores):
Caused by prolonged pressure on skin and underlying tissue, these often develop on the heels, sacrum, elbows, or hips. Pressure injuries are classified in stages:
Stage 1: Non-blanchable redness of intact skin
Stage 2: Partial-thickness skin loss
Stage 3: Full-thickness skin loss with visible fat
Stage 4: Full-thickness loss with exposed bone, tendon, or muscle
Unstageable: Wound covered with slough or eschar
Deep Tissue Injury: Purple or maroon area of discolored skin or blood-filled blister
4. Surgical Wounds:
These are intentional incisions made during surgical procedures and may be closed with sutures, staples, or adhesive strips.
5. Traumatic Wounds:
Resulting from accidents or injuries, these include cuts, abrasions, punctures, and lacerations.
6. Burns:
Classified by depth as superficial, partial-thickness, or full-thickness.
Wound Assessment
Accurate wound assessment guides treatment and ensures consistent documentation. Key elements include:
Location: Specify the exact anatomical site.
Size: Measure length, width, and depth in centimeters.
Shape: Note if the wound is round, oval, or irregular.
Edges: Describe as well-defined, undermined, or rolled.
Tissue Type:
Granulation: Red, beefy tissue indicates healing.
Necrotic: Yellow slough or black eschar suggests dead tissue.
Epithelialization: New skin growth.
Exudate: Record amount (none, scant, moderate, heavy) and type (serous, sanguineous, serosanguinous, purulent).
Odor: May indicate infection.
Surrounding Skin: Observe for erythema, edema, warmth, or maceration.
Pain: Assess severity, duration, and quality.
Principles of Wound Care
1. Infection Prevention:
Always wash hands before and after care, wear gloves and appropriate PPE, and follow sterile or clean technique per facility protocol.
2. Cleaning:
Use saline or prescribed wound cleansers. Avoid harsh antiseptics unless specifically ordered, and irrigate gently to remove debris.
3. Dressing Selection:
Choose a dressing that maintains a moist environment and matches the wound’s characteristics:
Transparent films – protect superficial wounds and allow visibility.
Hydrocolloids – suitable for partial-thickness wounds.
Foams – absorb moderate to heavy exudate.
Alginates – ideal for highly exudating wounds.
Hydrogels – keep dry wounds moist.
Gauze – versatile and often used as a secondary dressing.
4. Dressing Changes:
Follow facility protocol for frequency, observing and documenting any changes in appearance, exudate, or odor.
5. Pressure Injury Prevention:
Reposition patients at least every two hours, use pressure-relieving devices, and keep skin clean and dry. Manage moisture from incontinence or perspiration promptly.
6. Pain Management:
Administer analgesics as prescribed before dressing changes and adjust care to maintain patient comfort.
7. Nutrition and Hydration:
Adequate protein, vitamins A and C, zinc, and hydration support effective wound healing.
Documentation and Red Flags
Thorough documentation ensures communication and legal compliance. Record wound type, size, tissue characteristics, exudate, dressing type, frequency of changes, patient response, and any complications.
Seek immediate attention if there are signs of infection (redness, warmth, swelling, foul odor), systemic symptoms such as fever, rapidly enlarging wounds, or exposed bone, tendon, or muscle.
Effective wound care combines accurate assessment, infection prevention, appropriate dressing selection, and clear documentation. By following these evidence-based principles, healthcare providers can promote faster healing, reduce complications, and ensure the highest standard of patient care.