Before We Start
Types of wounds and how they heal
Before you can assess or dress a wound, you need to understand what type it is — because the type determines the expected healing process and the appropriate interventions.
Acute wounds
Result from surgery or trauma. Have a defined cause and expected healing timeline. Examples: surgical incisions, lacerations, abrasions. Heal in a predictable sequence over weeks.
Chronic wounds
Do not progress through the normal healing sequence. Often result from underlying conditions (diabetes, vascular disease, immobility). Examples: pressure injuries, diabetic foot ulcers, venous leg ulcers. Require ongoing management rather than a defined endpoint.
Healing by intention
Primary intention: Wound edges are closed (sutured, stapled, glued). Clean surgical incisions. Minimal scarring expected.
Secondary intention: Wound heals from the bottom up by granulation. Open wounds, infected wounds, or wounds with tissue loss. More scarring, longer healing time.
Tertiary (delayed primary) intention: Wound is left open initially (to allow infection to clear), then closed later.
The WOUND Framework
Five steps to complete wound assessment and care
W — Wash
Hand hygiene first — always
Before touching any wound, perform thorough hand hygiene. Then don appropriate PPE — gloves for all wound care, sterile gloves for wounds requiring sterile technique.
Wound irrigation: Most wounds are cleaned with normal saline (NS) — it is isotonic and doesn't damage healing tissue. Use sufficient pressure (via syringe) to remove debris but not so much that it damages granulation tissue.
What NOT to use:
• Hydrogen peroxide — destroys granulation tissue, delays healing
• Povidone-iodine (Betadine) — toxic to fibroblasts, use only for specific indications
• Dakin's solution — only for necrotic or infected wounds, per order
Normal saline is the standard. When in doubt, use NS.
💊 Never use hydrogen peroxide on a healing wound. It feels like it's "doing something" — those bubbles mean it's destroying your patient's new granulation tissue.
O — Observe
Systematic wound assessment — document everything
Thorough observation is the most important step. You cannot treat what you haven't assessed.
Assess and document:
• Location: Anatomical site
• Size: Length × Width × Depth in centimeters. Use a measuring tape. Estimate depth with a sterile swab.
• Wound bed color: (See wound color guide below)
• Edges: Well-defined? Undermining (tissue breakdown under skin beyond wound edges)? Tunneling (channel extending into tissue)?
• Surrounding skin: Erythema (redness), warmth, induration (hardness), maceration (breakdown from moisture), peri-wound edema
• Odor: Foul or sweet odor may indicate infection or specific organisms
• Pain: At wound site during dressing change
💊 Wound color tells you the wound's status at a glance. RED = healing, protect it. YELLOW = infected/necrotic, clean it. BLACK = dead tissue, debride it. PINK = almost healed, protect it.
U — Use Sterile Technique
Sterile for surgical/acute wounds — clean for chronic wounds
Not all wound care requires sterile technique — but you must know which wounds do and which don't.
Sterile technique required: Surgical wounds (all stages), acute traumatic wounds, any wound with open body cavity, immunocompromised patients, sterile body sites
Clean technique acceptable: Chronic wounds (pressure injuries, diabetic ulcers, venous ulcers) per facility policy
Sterile technique rules:
• Open sterile supplies onto sterile field
• Sterile gloves required for all direct wound contact
• One-inch border around sterile field is contaminated
• If in doubt — treat as contaminated and restart
• Wet = contaminated (moisture wicks bacteria through dressings)
💊 Post-surgical wound dressing change = sterile technique, always. A chronic venous leg ulcer may use clean technique — but check facility policy and the specific wound/patient circumstances.
N — Note Drainage
Assess exudate — type, amount, color, and odor
Wound drainage (exudate) is one of the most important indicators of wound status and infection.
Types of drainage:
• Serous: Clear, watery, thin — normal. Small amounts expected in healing wounds.
• Serosanguineous: Pink or light red, watery — normal in early wound healing. Blood-tinged serous drainage.
• Sanguineous: Bright red, bloody — active bleeding. Expected immediately post-op; concerning if persistent or increasing.
• Purulent: Thick, yellow/green/brown, opaque — indicates infection. May be odorous. Report immediately.
Amount: Document as scant, small, moderate, or large. Use objective measurements when possible (saturated 2 gauze pads, approximately 10mL).
Signs of infection requiring immediate notification: Purulent drainage, foul odor, increasing redness/warmth/swelling beyond wound edges, fever, increasing pain.
💊 Purulent drainage + fever + increasing wound pain = surgical site infection. Notify provider immediately. Obtain wound culture before starting antibiotics.
D — Dress Appropriately
Match the dressing to the wound — one size does not fit all
Dressing selection is based on wound characteristics. The goal of all dressings is to maintain a moist wound environment while managing exudate — neither too dry nor too wet.
Common dressing types:
• Dry gauze (wet-to-dry): Mechanical debridement of necrotic tissue. Change every 8 hours. Painful — not preferred for clean healing wounds.
• Hydrocolloid: Self-adhesive, maintains moisture, protects from contamination. For low-to-moderate exudate. Change every 3–5 days. Do not use on infected wounds.
• Hydrogel: Adds moisture. For dry or minimally draining wounds. Good for partial-thickness burns.
• Alginate: Absorbs heavy exudate. Derived from seaweed. For heavily draining wounds. Becomes gel-like when wet.
• Foam: Moderately absorptive. Good cushioning. For moderate drainage.
• Transparent film: Allows visualization without removing. For superficial wounds or IV sites. Very low absorbency.
• Negative pressure wound therapy (NPWT/wound VAC): Applies subatmospheric pressure. Promotes granulation and removes exudate. Requires physician order.
💊 Key rule: keep wounds moist — but not wet. A dry wound won't heal. A macerated wound won't heal. The right dressing maintains the balance.
🏥 Clinical Scenario — Post-Op Wound Assessment
Mrs. Washington, 67 years old, post-op day 4 following abdominal surgery. You are performing a wound assessment and dressing change.
W
Wash: Hand hygiene performed. Sterile supplies gathered. Sterile gloves donned. Old dressing removed with non-sterile gloves, then sterile gloves applied for wound contact. Wound irrigated with 30mL NS via 30mL syringe from 1-inch distance.
O
Observe: Midline abdominal incision. Length 14cm. Depth approximately 0.2cm (nearly healed at surface). Wound bed: red/pink (granulating — normal at day 4). Edges well-approximated with staples intact. Surrounding skin: mild erythema 0.5cm from incision edges (expected at this stage), no induration, no warmth beyond wound margin. No odor.
N
Note drainage: Small amount serosanguineous drainage on old dressing (approximately 2cm circle). No purulence. No odor. Patient reports mild incisional pain during dressing change (4/10), denies fever or chills.
D
Dress: Non-adherent dressing applied directly to wound. Covered with gauze and secured with paper tape. Dressing date and time labeled. Patient tolerated procedure well. Educated on signs of infection to report: increasing redness, warmth, swelling, purulent drainage, fever, or increasing pain.
→
Documentation: Detailed wound assessment documented with all measurements, drainage characteristics, surrounding skin assessment, dressing applied, patient education provided, and patient response. "Wound appears to be progressing normally for post-op day 4."
📌 NCLEX Application
Wound care appears frequently on NCLEX — especially wound assessment and infection recognition.
Key NCLEX facts:
• Normal saline for wound irrigation — never hydrogen peroxide
• Red wound bed = granulating = healing → protect with moist dressing
• Yellow wound bed = slough/infection → clean and debride
• Black wound bed = necrotic eschar → debride (exception: stable heel eschar — do not debride unless ordered)
• Purulent drainage + fever = infection → notify provider, obtain wound culture BEFORE antibiotics
• Sterile technique for surgical/acute wounds
• Dehiscence (wound edges separating): cover with sterile saline-moistened gauze, notify provider immediately
• Evisceration (organs protruding): cover with sterile saline-moistened gauze, keep patient supine with knees bent, call for help, do NOT push organs back in
⚠️ The Trap — Using Hydrogen Peroxide to Clean Wounds
This is one of the most commonly tested wound care facts on NCLEX and one of the most commonly incorrect practices in clinical settings.
Hydrogen peroxide does kill bacteria. It also kills fibroblasts — the cells responsible for building new tissue and collagen. The visible bubbling is actually destroying the new granulation tissue that is supposed to fill the wound.
Standard wound cleaning solution: normal saline. Every time. For every wound that doesn't have a specific order for another solution.
If an NCLEX question asks what solution to use for wound cleaning — the answer is normal saline unless the question specifies otherwise.