FUNDS: wounds & skin integrity

wound

break or disruption in the normal integrity of the skin & tissues that can result from injury, surgery, or infection.

intentional wounds

• surgical wounds, IV therapy, lumbar puncture

• bleeding is controlled, edges are clean

• risk of infection is lower

unintentional wounds

• gunshot wounds, stabbing

• unsterile environment

• bleeding is uncontrolled, jagged wound edges

• risk of infection higher

open wound

skin surface is broken

• getting cut; higher risk of infection

closed wound

skin surface is not broken but soft tissue is damaged

• ex: ecchymosis & hematomas

• bruising & pooling of blood underneath the surface

acute wounds

heal within days to weeks

• approximated edges: faster healing time, able to stitch evenly

chronic wounds

does not progress through the normal sequence of repair

• unapproximated edges: slower healing time

partial thickness

all or a portion of the dermis is intact

full thickness

entire dermis, sweat glands, and hair follicles are severed

unstageable

full thickness loss where the true depth cannot be determined

Incision

A clean, straight cut made by a sharp instrument (scalpel, knife). Edges are smooth and well-approximated.

Contusion

A closed wound caused by blunt force. Results in bruising, swelling, and discoloration; no break in the skin.

Abrasion

A superficial wound caused by rubbing or scraping off the top layer of skin (e.g., road rash).

Laceration

A tear in the skin with jagged, irregular edges, often caused by blunt trauma.

Puncture

A deep, narrow wound caused by something sharp (nail, needle). High infection risk due to depth.

Penetrating wound

An object enters the body and remains inside or passes through tissue (e.g., stab wound). Deeper structures often involved.

Avulsion

A wound where skin or tissue is torn away, partially or completely detached. Often traumatic and severe.

Pressure ulcers

Injuries to skin and tissue caused by prolonged pressure, usually over bony prominences (sacrum, heels). Staged 1–4.

Venous ulcers

Shallow, irregular wounds caused by venous insufficiency. Located near ankles; associated with edema and brown staining.

Typically WARM

Arterial ulcers

Deep, painful wounds caused by poor arterial blood flow. Located on toes, feet, or pressure points; pale, dry wound bed.

typically COLD

Diabetic ulcers

Wounds caused by neuropathy + poor circulation in diabetics. Often on the feet; high infection risk due to loss of sensation.

Type of Wound

Identify the category of wound because each heals differently and requires different care.

• Surgical incision – clean, intentional cut

• Pressure injury – caused by prolonged pressure

• Diabetic ulcer – caused by neuropathy + poor perfusion

• Venous stasis ulcer – caused by venous insufficiency

Knowing the type helps determine expected healing time, risk of infection, and dressing choices.

Location

The wound’s anatomical site affects:

• Blood supply

• Pressure exposure

• Mobility

• Ability to offload or position

Example: sacral ulcers heal more slowly due to pressure and moisture.

Dimensions

Size (L × W × D in cm)

Size helps track healing (wounds should shrink over time). Increasing size may indicate infection or poor perfusion.

Presence of Undermining or Tunneling

These indicate tissue destruction beneath the surface:

• Undermining: tissue erodes under wound edges

• Tunneling: a narrow path extends into deeper tissue

Document the location using a clock face (e.g., “undermining 2 cm at 3 o’clock”).
Their presence often signals infection, pressure damage, or shear injury.

Tissue Viability

Describe the types and percentage of tissue in the wound bed:

• Granulation tissue – red, moist, healthy tissue

• Slough – yellow/white, stringy, non-viable tissue

• Eschar – black/brown, thick necrotic tissue

Exudate / Drainage – COCA

Use COCA to evaluate drainage:

• Color – serous, sanguineous, purulent

• Odor – none, foul (suggests infection)

• Consistency – thin, thick, watery, creamy

• Amount – scant, moderate, large

This identifies infection, inflammation, and healing stage.

Pain

Assess pain before and after wound care.
Medicate 30–45 minutes before dressing changes to prevent trauma-related pain and improve tolerance.

Pain can indicate:

• Infection

• Poor perfusion

• Pressure

• Improper dressing application

Drains

Note the presence, type, amount, and location:

• Types: Penrose, Jackson-Pratt, Hemovac, wound VAC, etc.
  Drains remove exudate and prevent fluid accumulation that can impair healing.

Document output each shift.

Wound Closure

Look at how the wound edges are being held together:

• Staples

• Sutures

• Tissue adhesive (glue)

• Steristrips

Check for gapping, redness, or signs of impaired healing.

Wound Culture

If infection is suspected:

• Cleanse or irrigate the wound BEFORE collecting a specimen.
  This removes surface contaminants and gives a true sample.

• Requires an HCP order.

Wound cultures guide antibiotic therapy.

Open Drain — Penrose Drain

• A soft, flexible rubber tube placed in a wound.

• Allows drainage to flow passively onto a dressing (no suction).

• Used commonly for:

  • Post-op abdominal surgeries

  • Open wounds

  • Wounds with infected or contaminated drainage

• Not connected to a collection device → drainage absorbs into gauze.

• Requires frequent dressing changes to manage moisture and prevent skin breakdown.

• Higher risk of contamination because it is open to the environment.

Closed Drains —

Jackson-Pratt & Hemovac

Closed drains use a compression-based suction system to collect drainage into a sealed reservoir.

Jackson-Pratt (JP) Drain

• Used for smaller wounds or moderate drainage.

• Soft bulb reservoir.

Hemovac Drain

• Used for larger surgical wounds with more drainage.

• Larger round reservoir with stronger suction.

How Closed Drains Work

Both require the nurse to:

• Compress (“squeeze”) the reservoir before closing the cap

• This creates gentle suction to pull fluid from the wound into the reservoir

This is why they are called “closed suction drains.”

Shared Features of JP & Hemovac Drains

✔ Squeezed to create suction

The reservoir must be compressed to maintain negative pressure.

✔ Post-operative use

Common in abdominal, orthopedic, breast, and large soft-tissue surgeries.

✔ Prevent infection

Closed systems are sterile and reduce exposure to the external environment.

✔ Drain blood and fluid

Prevents fluid buildup that may lead to:

• Hematoma

• Seroma

• Infection

• Increased pain

• Delayed wound healing

Stage 1 pressure injury

non-nlanchable erythema of intact skin 

Non-blanchable: circulation is impaired (area of redness does not turn white)

• Intact skin with a localized area of non-blanchable erythema

stage 2 pressure injury

partial-thickness skin loss with exposed dermis 

• Wound bed is viable, pink, or red, moist, and may present as an intact or ruptured serum-filled blister 

• Fat and deeper tissue are not visible 

• Granulation tissue, slough, and eschar are NOT present 

Can be prevented. 

stage 3 pressure injury

full thickness skin loss

• Fat is visible and granulation tissue are often present 

• Slough and eschar may be visible 

• Undermining and tunneling may occur

Fascia, muscle, tendon, ligament, cartilage, and/or bone are NOT exposed

stage 4 pressure injury

Full-thickness skin and tissue loss 

• Exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone

• Slough and/or eschar may be visible

• Rolled edges, undermining, and tunneling often occur 

• Depth varies

Phases of wound healing 1:

Hematoma 

• Occurs immediately after injury 

• Stops the bleeding and activates the WBC to fight bacteria 

• Blood vessels constrict and platelets activate to form a fibrin clot 

phases of wound healing 2

Inflammatory 

• Lasts 2-3 days 

• Leukocytes arrive first to ingest bacteria and cellular debris 

• 24 hrs after injury the macrophages enter the area and remain for an extended amount of time to release growth factors for new epithelial cells and blood vesels 

• Exudate (plasma and blood) result in acute inflammation - heat, redness, and swelling 

• Pt may have a slight temperature, high WBC, and general malaise 

phases of wound healing 3:

Proliferation/Repair 

• Lasts for several wks 

• New tissue is built to fill the wound - fibroblasts

• Thinlayer of epithelial cells form and blood flow across the wound is reinstituted 

• New tissue is called granulation tissue forms the scar tissue development 

phases of wound healing 4:

Maturation/Remodeling 

• Final stage begins about 3 wks after the injury, can continue for months for yr 

• Collagen is making the wound stronger and makes the scar eventually become flat, thin line

Types of wound drainage

• purulent

• serous

• sanguineous

• serosanguineous

purulent drainage

made up of WBC, liquified dead tissue debris, and both dead and live bacteria 

• Thick and often has a musty or foul odor 

• Color varies, dark yellow or green

serosanguineous drainage

mixture of serum and RBC

• Light pink to blood tinged

sanguineous drainage

continuous of large numbers of RBC and looks like blood 

• Bright red is indicative of fresh bleeding, darker means older bleeding

serous drainage

composed primarily of clear, serous portion of the blood and from serous membranes

• Clear and watery

Hemorrhage –

Normal immediately after trauma; prolonged if coagulation issue or large vessels involved. Highest risk in first 24–48 hrs post-op. Internal hemorrhage signs: swelling, distention, change in drainage, or hypovolemic shock; External is visible.

Hematoma –

Localized collection of blood under tissues; appears as swelling, discoloration, warmth, pain, or a bluish mass

Infection –

2nd most common HAI. Purulent drainage indicates infection. Risk ↑ with necrotic tissue, foreign bodies, or poor blood flow. Appears 2–7 days post-op in contaminated wounds; 4–5 days post-op in surgical incisions

Fistula Formation –

Abnormal passage between internal organs, vessels, or from an internal organ to the outside of the body.

Dehiscence –

Partial or total separation of wound layers; usually abdominal. Triggered by sudden strain (coughing, vomiting, sitting up unsupported). Patient may say “something gave way.” Risk ↑ with obesity or poor nutrition

Signs of Dehiscence –

Serosanguinous drainage from a previously dry wound; feeling of pressure or sudden opening; teach splinting

Evisceration –

Total separation of wound with organs protruding; surgical emergency. Stay with patient, call for help, place in low-Fowler’s with knees bent, cover with sterile saline-soaked towels, no ice, monitor for shock, keep NPO, document.

A nurse is assessing a postoperative patient and notes bright-red, watery drainage on the dressing. Which type of drainage is this?

C. Serosanguineous

A patient arrives with a deep wound caused by a knife assault. The edges are jagged, bleeding is uncontrolled, and the environment was unsterile. How is this wound classified?

C. Unintentional and open

Which finding requires the MOST immediate intervention for risk of internal hemorrhage after abdominal surgery?

B. Firm abdominal distention and tachycardia

A nurse notes a purple-blue, tender lump under the skin near a surgical incision. What complication is most likely?

B. Hematoma

A patient states, “It suddenly felt like something gave way” after coughing following abdominal surgery. The nurse observes serosanguinous drainage on the dressing. What is the priority action?

B. Apply sterile saline-soaked gauze and call the provider

A nurse assessing a pressure injury sees a shallow open ulcer with a pink, viable wound bed. Subcutaneous fat is not visible. What stage is this?

B. Stage 2

The nurse is obtaining a wound culture. Which action is correct?

C. Cleanse or irrigate the wound before swabbing the clean tissue

A patient with a full-thickness wound has slough obscuring the wound bed, making depth impossible to determine. How is this wound staged?

C. Unstageable

A Jackson-Pratt drain is in place after surgery. Which assessment requires immediate intervention?

C. The bulb is fully expanded

A nurse finds that a patient’s abdominal contents are protruding through a surgical incision. What is the FIRST nursing action?

C. Place the patient in low-Fowler’s with knees bent

A surgical incision with clean, well-approximated edges is classified as which type of wound?

B. Intentional, acute

A patient presents with a ruptured serum-filled blister over the heel. What is the correct pressure injury stage?

B. Stage 2

Which finding indicates a stage 4 pressure injury?

A. Exposed bone

A wound with yellow, stringy tissue in the base is described as:

C. Slough

A patient with an arterial ulcer would most likely have which assessment finding?

B. Cold skin and diminished pulses

A venous ulcer is best described as:

C. Shallow, irregularly shaped wound with edema

A nurse preparing to obtain a wound culture must first:

C. Irrigate or cleanse the wound

Which phase of wound healing begins immediately after injury?

C. Hemostasis

Which phase of wound healing involves granulation tissue formation?

D. Proliferation

Which finding would alert the nurse to early wound dehiscence?

C. Sudden serosanguineous drainage

Which patient is at greatest risk for wound dehiscence?

C. Obese post-op patient

Which position is appropriate during evisceration?

C. Low Fowler’s with knees bent

What is the PRIMARY purpose of a Penrose drain?

C. Allow passive drainage onto a dressing

A Jackson-Pratt drain works by:

B. Suction created by compression

Which wound type is caused by blunt trauma and results in bruising?

B. Contusion

Which wound involves tearing of tissue from its normal position (skin flap)?

A. Avulsion

A clean but deep cut made with a scalpel is an example of:

B. Incision

A penetrating wound differs from a puncture wound because it:

C. Enters internal organs

Which wound type has the highest risk of infection?

C. Gunshot wound