1. Rapid Summary
Wound care in nursing focuses on optimizing the physiological environment to promote tissue repair, maintain skin integrity, and prevent systemic or localized infection. The core nursing responsibilities include accurate wound staging, assessing drainage characteristics, selecting the correct dressing types based on the wound bed's moisture status, and recognizing critical surgical complications like dehiscence and eviscereation.
2. High-Yield Points/Must Know
| Critical Area | Essential Clinical Guidelines & Rationales |
|---|---|
| Wound Cleaning Direction | Always clean a wound from the least contaminated area (the center of the wound bed) to the most contaminated area (the surrounding outer skin). Use a new sterile swab for each stroke. |
| Moisture Balance | The optimal environment for wound healing is moist, not wet or dry. Dry wound beds delay cellular migration; excessively wet wound beds cause maceration (softening and breaking down of healthy surrounding skin). |
| Debridement Rule | Necrotic tissue (eschar or slough) must typically be debrided before a wound can heal. Exception: Dry, intact, stable eschar on a client's heel serves as a natural protective barrier and should not be removed or moistened. |
| Infection Prevention | Perform wound care and dressing changes using strict aseptic technique. For surgical wounds, open deep wounds, or packing, use sterile gloves and supplies. |
3. Mnemonics
Remember the MEASURE framework to document and monitor wound progression accurately:
- M - Moisture Balance: Is the wound bed dry, moist, or saturated? Choose dressings accordingly.
- E - Exudate/Drainage: Assess the amount, color, and odor of the wound output (Serous, Sanguineous, Purulent).
- A - Appearance: Evaluate the wound bed tissue color (Red = Granulation/Healthy; Yellow = Slough; Black = Eschar).
- S - Size: Measure the length, width, and depth in centimeters using a disposable measuring guide.
- U - Undermining/Tunneling: Check for lip-like erosion under the wound edges or narrow tracts using a sterile cotton swab.
- R - Re-evaluate: Regularly update the care plan based on healing trends or signs of infection.
- E - Edge: Monitor if the wound borders are clean, rolling inward, or macerated.
4. Most Tested Facts
Surgical Wound Complications:
You must be prepared to react instantly to surgical wound emergencies, which usually occur 3 to 11 days post-op:
- Dehiscence: The partial or total separation of surgical wound layers.
- Evisceration: Total separation of wound layers accompanied by the protrusion of internal visceral organs (usually loops of bowel) through the open incision. This is a medical emergency.
Emergency Evisceration Protocol (The 4 Steps):
- Call for help immediately and have someone notify the surgeon; do not leave the client's bedside.
- Place the client in a low-Fowler's position (15° to 30°) with knees bent to relax the abdominal muscles and minimize tension on the incision.
- Cover the protruding organs with sterile gauze dressings saturated in warm, sterile normal saline to prevent tissue drying and necrosis.
- Assess vital signs frequently for signs of shock (hypotension, tachycardia) and prepare the client for immediate emergency surgery. Do not attempt to push the organs back into the abdomen.
Wound Drainage Classification:
| Drainage Type | Clinical Appearance | Significance/Interpretation |
|---|---|---|
| Serous | Clear, watery, straw-colored plasma. | Normal during the early inflammatory phase of healing. |
| Sanguineous | Bright red, thick, bloody fluid. | Indicates active, fresh bleeding; expected immediately post-op. |
| Serosanguineous | Pale, pink, watery mixture of clear and red fluid. | Normal finding in surgical incisions during the first few post-op days. |
| Purulent | Thick, opaque, yellow, green, or brown fluid; often foul-smelling. | Diagnostic sign of an active infection; contains WBCs, tissue debris, and bacteria. |
5. Clinical Correlation
A 62-year-old client who underwent an exploratory laparotomy 4 days ago states, "I felt a sudden 'pop' in my stomach after I coughed, and now my shirt feels wet."
- Wrong Action: Telling the client it is normal post-op drainage, applying a tight abdominal binder over the shirt, or leaving the room to fetch an abdominal dressing kit.
- Correct Action: Suspect an abdominal evisceration. Immediately assist the client into bed in a low-Fowler's position with their knees flexed. Expose the incision area to look for protruding bowel. Open a sterile field at the bedside, saturate large gauze pads with sterile saline, and place them gently over the exposed tissue. Instruct another staff member to call the surgeon and prepare the client for the operating room.
6. Frequently Tested
- Wound Culture Technique: Never collect a wound culture sample from old drainage or old dressings.
- First, irrigate the wound with sterile normal saline to clear away residual exudate and topical medications.
- Swab the clean granulation tissue in the center of the wound bed, rotating the swab with gentle pressure to express fluid from deep within the tissue.
- Surgical Drains: Jackson-Pratt (JP) and Hemovac drains are closed-suction systems. To maintain active, negative-pressure suction, the nurse must fully compress (squeeze) the bulb or spring-loaded container before closing the drainage plug. Empty and measure the output every shift or when the container is half full.
- Pressure Injury Dressing Selection:
- Stage 1 (Intact, non-blanchable redness): Transparent film dressings to protect from friction.
- Stage 2 (Partial-thickness skin loss, blister): Hydrocolloid dressings to maintain a moist environment and insulate the wound.
- Stage 3/4 (Deep craters/exposed tissue) with heavy exudate: Alginate or foam dressings to absorb high volumes of fluid.
7. Common NCLEX Trap
- Trap: Pouring hydrogen peroxide or povidone-iodine (Betadine) directly into a clean, healing pressure injury wound bed to sterilize it.
- Reality: False. These antiseptic solutions are highly cytotoxic. They destroy fragile, newly forming healthy granulation tissue and significantly delay wound healing. Use sterile normal saline or an approved commercial wound cleanser.
- Trap: Shaving the hair around a wound or incision site with a razor prior to applying a new dressing or surgical closure.
- Reality: False. Razors cause micro-abrasions in the skin that serve as entry points for bacteria, increasing surgical site infections. If hair removal is mandatory, use electric clippers or a depilatory agent.
- Trap: Documenting a pressure injury that has healed from a Stage 3 to a Stage 2 as a "healing Stage 2 pressure injury."
- Reality: False. Pressure injuries do not down-stage as they heal. A healing Stage 3 pressure injury must always be documented as a "healing Stage 3," because the lost deep tissue is replaced with scar tissue, not the original skin layers.
8. Mini Questions
Question 1: The nurse is preparing to perform a sterile dressing change on a client's deep abdominal incision. In which direction should the nurse clean the wound bed?
A. From the outer margins of the skin inward toward the center of the incision.
B. From the center of the incision outward toward the surrounding skin.
C. From the lower edge of the wound upward to the top edge of the wound.
D. In a continuous circular motion starting from the periwound skin into the wound center.
- Answer: B
- Explanation: Wound cleaning must proceed from the area of least contamination (the center of the wound bed) to the area of highest contamination (the surrounding outer skin) to prevent dragging skin flora or bacteria back into the open wound.
Question 2: The nurse is caring for a client who is 5 days post-operative following an abdominal surgery. While turning in bed, the client reports a sensation of something "giving way" in the abdomen. The nurse inspects the surgical site and observes that the incision edges have separated, and a loop of bowel is protruding through the wound. Which action should the nurse take first?
A. Carefully push the protruding loop of bowel back into the abdominal cavity using sterile gloves.
B. Leave the room to gather an abdominal binder and emergency surgical instruments.
C. Cover the protruding bowel with sterile dressings saturated with warm, sterile normal saline.
D. Assist the client into a high-Fowler's position to maximize lung expansion.
- Answer: C
- Explanation: This scenario describes an abdominal evisceration, a critical surgical emergency. The nurse's immediate action is to protect the exposed organ from drying out and becoming necrotic by covering it with sterile dressings soaked in warm, sterile normal saline. Pushing organs back in is strictly contraindicated, the nurse must never leave the room, and the client should be placed in low-Fowler's with knees bent, not high-Fowler's.
Question 3: The nurse is obtaining a wound culture from a chronic venous stasis ulcer. Which technique demonstrates the correct protocol for obtaining this specimen?
A. Swab the thick purulent exudate pooled on the outer edges of the dressing.
B. Irrigate the wound with sterile saline and swab clean granulation tissue in the center of the wound bed.
C. Use a sterile cotton swab to scrape the dry black eschar tissue covering the wound.
D. Gather the specimen before irrigating the wound to preserve the bacterial count.
- Answer: B
- Explanation: To obtain an accurate wound culture that reflects the actual invading pathogen rather than superficial skin contaminants, the nurse must first irrigate the wound with sterile normal saline to remove debris. The swab is then pressed and rotated against healthy, clean granulation tissue in the center of the wound bed.
Question 4: The nurse is managing a Jackson-Pratt (JP) closed-suction drain for a client recovering from a mastectomy. Which action is essential for the nurse to perform to ensure the drain functions effectively?
A. Keep the drainage bulb fully inflated at all times to promote gravity drainage.
B. Tape the drainage bulb securely to the bed rail below the level of the client's chest.
C. Compress the bulb entirely before securing the drainage plug to maintain negative pressure.
D. Flush the drainage tubing with 10 mL of sterile water every 4 hours to clear clots.
- Answer: C
- Explanation: A Jackson-Pratt drain relies on a vacuum/negative pressure to pull fluid out of the surgical site. The nurse must fully squeeze/compress the bulb before sealing the plug to establish this suction mechanism. The bulb must never be pinned or taped to the bed rail (as it could pull out when the client moves) and flushing is not a routine nursing action.
Question 5: The nurse evaluates a client's sacral pressure injury and notes a deep crater with full-thickness skin loss extending down into the subcutaneous fat layer. No bone, tendon, or muscle is visible. Slough is present on the wound bed. How should the nurse stage this pressure injury?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
- Answer: B
- Explanation: A Stage 3 pressure injury is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Bone, tendon, and muscle are not exposed (which would make it a Stage 4). If slough completely covered the bed obscuring the depth, it would be unstageable, but here the depth is clearly visible.
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9. Key Takeaway Box
Key Takeaway: Wound care requires keeping the wound bed moist and the surrounding skin dry. Clean wounds from the center outward. For an evisceration emergency, do not leave the client; place them in a low-Fowler's position with knees bent, cover the tissue with sterile saline-soaked dressings, and prepare for the operating room. Always compress closed-suction drains (JP/Hemovac) to maintain negative pressure.
