NPTE - Wounds

Hemostasis Phase of Healing

Immediate (mins-hrs)

vasoconstriction, clot formation

apply pressure to control bleeding

Inflammatory Phase of Healing

0-3d

redness, swelling, p!, heat

normal signs early; avoid aggressive care

Proliferative Phase of Healing

3-21d

granulation tissue, angiogenesis, re-epithelialization

promote moist healing, protect tissue

Maturation Phase of Healing

3wks-2yrs

collagen remodeling, scar formation

scar massage, ROM, and strength exercises

Arterial ulcer

caused by ischemia (PAD)

pale wound bed, minimal drainage, round edges

found on toes, lat ankle; painful

Venous ulcer

caused by venous insufficiency

wet, irregular shape, red base, edema

found on med lower leg; compression is key

Neuropathic (Diabetic) Wound

caused by peripheral neuropathy

painless, callused edges, pressure points

found on plantar foot; often infected

Pressure injury

caused by prolonged pressure/shear

appearance depends on stage

found over bony prominences

Burn Wound

caused by heat, chemical, radiation, etc

appearance classified by depth

see burn study guide

Pressure injury stage 1

non-blanchable erythema of intact skin

Pressure injury stage 2

Partial-thickness loss, exposed dermis (blister/shallow wound)

Pressure injury stage 3

Full-thickness loss, may see fat but no tendon/bone exposed

Pressure injury stage 4

Full-thickness with exposed bone, tendon, or mm

Unstageable Pressure injury

Base covered by slough/eschar, depth unknown

Deep Tissue Injury (DTI)

Purple/maroon skin, intact but may open later

Serous exudate

clear/light yellow

normal in inflammatory phase

Sanguineous exudate

red/bloody

may indicate trauma

Serosanguineous exudate

pink/light red

normal during healing

Purulent exudate

yellow/green, thick, odorous

Infection

Inflammation (normal)

<1wk post-injury

localized redness/swelling

no foul odor

low p!

Afebrile

Infection (abnormal)

>1wk / worsens over time

spreading redness, warmth

foul odor present

increased p!

systemic signs: fever, increased WBC

Hydrocolloid

Mild-mod exudate, autolytic debridement

occlusive, keeps wound moist

Hydrogel

dry wounds, min exudate

adds moisture, soothing

Foam

mod-heavy drainage

absorptive, maintains moist environment

Alginate

heavy exudate

highly absorptive; needs secondary dressing

Transparent film

superficial wounds, stage 1-2 pressure ulcer

allows O2 in, moisture retention

Gauze

all types (usually as secondary)

inexpensive, may adhere to wound

Enzymatic Dressing

necrotic tissue

chemical debridement

Antimicrobial (silver)

infected/at-risk wounds

helps reduce bioburden

Autolytic debridement

Body’s enzymes (e.g., hydrocolloids)

use with non-infected, moist wounds

Enzymatic Debridement

topical enzymes

used with necrotic wounds, when sharp is contraindicated

Sharp Debridement

scalpel/scissors

quickest; use if urgent/large necrosis

Mechanical Debridement

wet-to-dry, irrigation

non-selective, may damage healthy tissue

Biological debridement

maggots

selective, used rarely

Red Flags

sudden increased p!/drainage

signs of systemic infection (fever, increased HR, fatigue)

new odor/color change in wound bed

skin breakdown around dressing site

pt reports feeling faint/dizzy during wound care

Boards tips pt 1

Chronic wounds often get stuck in the inflammatory phase

arterial = dry and painful

venous = wet and painless

diabetic = deep and round

Don’t remove stable eschar on heels —> body’s natural cover!

Do NOT use occlusive dressings on infected wounds unless they’re antimicrobial

Boards tips pt 2

Venous ulcers need compression therapy

Arterial ulcers need vascular referral, not compression

stage 3 pressure injuries = may expose subcutaneous fat

wound infection signs = heat, odor, pus, increased p!

Wounds need moisture, not drying out (except with maceration)

Reposition pts every 2hrs to prevent pressure injuries

For diabetic ulcers: focus on offloading and footwear

Use the Bates-Jensen / PUSH tool to document healing