Wound Care Notes

BCCNM LPN Scope of Practice: Wound Care

• LPNs can provide wound care if a treatment plan is in place.
• LPNs cannot probe, irrigate, pack, or dress tunneled wounds.
• LPNs cannot perform sharps debridement.
  • Debridement is the medical removal of dead, damaged, or infected tissue to improve healing potential.
  • Methods include surgical, mechanical, chemical, autolytic, or maggot therapy.

Wound Classification

• A wound is a disruption of the integrity and function of tissues in the body.

Acute Wound

• Heals predictably and in a timely manner.
• Usually closes in 2-4 weeks.
• Caused by surgery, trauma, or a cut.
• Goes through normal healing stages: inflammation → tissue growth → repair.
• Example: Surgical incision or paper cut.

Chronic Wound

• Takes longer to heal (often more than 4 weeks).
• Gets “stuck” in one of the healing stages (usually inflammation).
• Caused by underlying conditions like poor circulation, diabetes, inflammation, or pressure.
• More prone to infection, poor oxygen flow, and tissue breakdown.
• Example: Pressure ulcers, diabetic foot ulcers, venous leg ulcers.

Partial Thickness Wound

• Shallow wounds involving loss of the epidermis (top layer) and possibly partial loss of the dermis.

Full Thickness Wound

• Deeper wound that goes through all layers of the skin (epidermis and dermis).
• May extend into subcutaneous tissue, muscle, or even bone.

Wound Healing

Healing Process

• Primary Intention: Wound edges are clean, straight, and well-approximated (closed with sutures, staples, or glue).
  • Results in a fine scar.
• Secondary Intention: Wound edges are not closed, heals from the bottom up and sides in.
  • Results in a large scar.
• Tertiary Intention: Wound is left open initially due to infection, swelling, or contamination, then closed later once the area is clean/infection-free.
  • Results in a wide scar.
• A well-approximated wound means the edges are neatly aligned and close together.

Wound Assessment

Wound Assessment Categories:

• Location
• Type of wound
• Wound bed
• Exudate
• Periwound description
• Wound measurement

Location

• Be specific about where the wound is located on the body.
• Example: Wound located on the right anterior lower leg (shin).

Type of Wound

• Examples:
  • Incision
  • Laceration
  • Abrasion
  • Puncture
  • Pressure
  • Contusion
  • Hematoma

Wound Bed

• Granulation Tissue
  • Bright red or pink, moist, bumpy like “red velvet”.
  • Made of new blood vessels and connective tissue.
  • A sign of healing - should be protected.
• Slough
  • Soft, yellow or white, stringy or slimy.
  • Dead cells/debris - needs to be removed (debrided) to help healing.
  • Often a sign of chronic wounds or delayed healing.
  • Debridement is not within the LPN’s scope of practice.
• Eschar
  • Black, brown, or dark gray, thick, dry, leathery.
  • Dead tissue (type of necrotic tissue).
  • Can prevent healing - may need removal unless it's dry and stable (like in a heel).

Wound Measurement

• Typically measured in width, length, and depth, often using cm as the measurement.
• Deep wounds may require packing (filling a deep or open wound with a special dressing material to help it heal from the inside out) - NOT in the LPN scope.
• Wounds can also tunnel or undermine.
  • Tunneling/undermining is when a small tunnel forms under the skin, starting from the wound and going deeper into the body - NOT in the LPN scope to treat a tunneled wound.

Exudate

• Serous: Clear, watery fluid; normal in the early stages of healing.
• Sanguineous: Bright red; signifies active bleeding; common after trauma or surgery - watch for hemorrhage.
• Serosanguineous: Pink, watery fluid; mix of serous and bloody exudate.
• Purulent: Thick, yellow, green, or brown fluid; may have a foul smell; contains pus, dead cells, bacteria; indicates infection.

Exudate Documentation

• Amount: None, scant, moderate, large, copious.
• Color: Serous, serosanguineous, sanguineous, purulent.
• Consistency: Thick, thin.
• Odor: None, foul.

Periwound

• Description of surrounding skin:
  • Intact
  • Indurated: Area around wound is hard and firm.
  • Excoriated
  • Erythema
  • Macerated
  • Fragile
  • Edematous
  • Callused

Wound Assessment Activities

• Provide a wound care assessment for each wound using the categories: type of wound, wound bed, exudate, periwound description.

Wound Care Flowsheets

Braden Scale

• What Is It?
• A nursing assessment tool used to predict a patient's risk for developing pressure injuries.
  • The lower the score = the higher the risk for pressure ulcers.

Wound Assessment and Treatment Flowsheet (WATFS)

• Used for:
  • Documenting wound assessments clearly and consistently.
  • Tracking wound healing over time.
  • Guiding treatment decisions (like dressing changes or referrals).
  • Communicating with the care team about wound progress.
• Used to establish the Wound Treatment Protocol and is updated whenever there is a change to the treatment plan.
• Also used for documenting ongoing wound care, for stable wounds/wound care treatments.

Pressure Sore Review

What is it?

• Areas of damaged skin and tissue that happen when there's too much pressure on one part of the body for too long.
• This pressure reduces blood flow to the area, which can cause the skin and underlying tissue to break down.

Stages

• Stage I: Skin is not broken but is red or discolored.
• Stage II: The topmost layer of skin is broken, creating a shallow open sore. The second layer of skin may also be broken.
• Stage III: The wound extends through the second layer of skin into the fat tissue. Bone, tendon, and muscle are not visible.
• Stage IV: The wound extends into the muscle and can extend as far down as the bone.
• Unstageable
• Suspected Deep Tissue Injury
• Wound dressing depends on stage of pressure wound.
  • Stages 3+ typically requiring more extensive wound care protocols

Other Types of Wounds

Categories

• Skin tear
• Venous ulcer
• Arterial ulcer
• Diabetic ulcer
• Acute and surgical wounds
• Malignant and fungating wound

Skin Tears

• A type of wound where the top layer of skin (epidermis) is pulled away from the lower layer (dermis), or both layers peel away together.
• Usually happens when fragile skin is bumped, scraped, or pulled, often during movement or transfers.
• Can look like a flap of skin or an open wound.
• Often caused by minor trauma, like bumping into something or rough handling.
• Common in older adults or people with thin, fragile skin.
• Can bleed, bruise, or become infected if not treated properly.

Skin Tears: Classification

• Type 1: No skin loss. Linear or flap tear where the skin flap can be repositioned to cover the wound bed.
• Type 2: Partial flap loss. The skin flap cannot be repositioned to cover the whole wound bed.
• Type 3: Total flap loss. Total skin flap loss that exposes the entire wound bed.

Skin Tears: Treatment

• Using gauze pads with a cotton wrap (like Kling) or a soft, non-stick silicone dressing (ex: Mepilex Border) helps protect the wound and support healing.

Venous Ulcers

• The most common type of leg wound, making up about 80% of lower extremity ulcers.
• Usually irregular in shape and superficial.
• Often have a large amount of exudate due to surrounding tissue edema.
• Venous insufficiency is caused by weak vein walls and poor calf muscle pumping from limited ankle movement.
• Serum and red blood cells leak into the tissue, leading to brownish discoloration (hemosiderin staining).
• In chronic cases, tissue edema becomes firm and the lower legs may appear hard and woody, a condition called lipodermatosclerosis.

Venous Ulcers: Treatment

• Use normal saline, autolytic debriders, preservative-free hydrogels, and soft silicone dressings.
• Autolytic debriders are substances or dressings that help remove dead or necrotic tissue from a wound naturally, by using the body’s own enzymes to break down the tissue.
  • They create a moist wound environment, which promotes the body’s own enzymes to dissolve the dead tissue.
• Avoid dressings with preservatives, chemicals, or fragrances.
• Edema control is essential, but patients may resist compression therapy. A wound care specialist can help assess blood flow and recommend suitable compression options, as healing often requires lifestyle changes.

Arterial Ulcers

• Caused by inadequate blood flow to the lower extremity, unlike venous ulcers which are caused by poor blood return.
• Have a “punched-out” appearance, are deeper and smaller than venous ulcers.
• Commonly found on the feet, toes, or toe joints, but can appear on other lower leg areas.
• May appear necrotic (black, crusted) or have a pale wound bed.
• Legs with arterial disease often have thin, shiny, taut, and hairless skin with a translucent look.

Arterial Ulcers: Treatment

• Resistant to healing and are often considered “maintenance” wounds, where the goal is comfort and infection protection.
• The best approach for nonhealing arterial wounds is to keep them clean and dry.
• Povidone solution (10% in a 1% solution) is often used to reduce bacterial load and promote tissue drying.
• Povidone can be applied with gauze pads or painted on, then covered with a simple clean dressing, and changed daily.
• Inspect and cleanse the wound area regularly, especially between the toes, to check for hidden concerns.

Diabetic Ulcers

• Result from neuropathic changes due to diabetes.
• Sensory neuropathy causes loss of protective sensation, making it harder to feel pain or temperature changes.
• Autonomic neuropathy leads to dry skin, fissures, cracks, and calluses over pressure points (e.g., heels, ball of the foot).
• Motor neuropathy causes changes in muscle contractions, leading to high arches and hammer toes, creating additional pressure points.
• Commonly found on bony prominences on the plantar surface of the foot, over metatarsal heads, and under the heels.

Diabetic Ulcers: Treatment

• May be prophylactically treated with some form of topical antimicrobial dressing.
• If the patient reports pain at the wound site, particularly persistent pain, osteomyelitis (bone infection) should be suspected.
• May require debridement, but need to be careful as this can cause more damage than good. *If wound can heal:
  • Use moisture-retentive dressings like hydrocolloids, hydrogels, or foam dressings to keep the wound moist, promote healing, and reduce infection risk.
  • Non-stick dressings are ideal to avoid damaging fragile skin.

Other Types of Wounds

• Abrasions: A superficial wound caused by the rubbing or scraping of the skin against a rough surface.
• Lacerations: A tear or cut in the skin, often caused by a sharp object such as glass, metal, or a knife. Usually has irregular edges.
• Punctures: A wound caused by a sharp object (like a nail, needle, or animal bite) that penetrates the skin and deeper tissues. Usually a narrow deep hole.

Surgical Wounds

• Created intentionally during a surgical procedure where the skin and underlying tissues are incised to allow access to internal organs or structures.
• Typically sutured or stapled together.

Malignant Wounds

• Caused by the necrosis or ulceration of tissues due to a malignant tumor.

Fungating Wounds

• Result from the growth of cancer tissue.
• Irregular edges with necrotic tissue and may emit a foul odor due to tumor growth and tissue breakdown.