Editing Nursing Skills and Procedures (section)

== Wound Care and Dressing Changes ==

=== Wound classification and healing ===
Wounds heal by primary intention when edges are approximated, as in a clean surgical incision, by secondary intention when the wound is left open to granulate, as in a pressure injury or dehisced wound, and by tertiary or delayed primary intention when a contaminated wound is left open then closed later. Phases of healing are hemostasis, inflammation, proliferation, and maturation or remodeling. Inflammation in the first several days produces warmth, erythema, edema, and serosanguineous drainage, which is expected and is not automatically infection.

Drainage terminology:
* Serous: clear, thin, watery. Expected.
* Sanguineous: bright red, fresh bleeding.
* Serosanguineous: pink and watery. Common in the first 48 hours.
* Purulent: thick, opaque, yellow, green, tan, or brown. Suggests infection.

=== Pressure injury staging ===
* Stage 1: intact skin with nonblanchable erythema. In darker skin tones look for a color change compared with surrounding skin plus warmth, firmness, or boggy texture.
* Stage 2: partial thickness loss of dermis, shallow, pink or red moist wound bed, or an intact or ruptured serum-filled blister. No slough, no granulation, no adipose visible.
* Stage 3: full thickness loss with visible adipose tissue. Slough or eschar may be present but does not obscure the depth. Undermining and tunneling may occur. Bone, tendon, and muscle are not exposed.
* Stage 4: full thickness loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone.
* Unstageable: base obscured by slough or eschar so depth cannot be determined.
* Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration, or a blood-filled blister, over intact or nonintact skin.

Application note: stable, dry, adherent eschar on an ischemic heel is not debrided. It acts as a biological cover. The nurse protects it, offloads the heel, and reports changes such as new erythema, fluctuance, drainage, or odor.

=== Dressing types and matching ===
* Gauze: inexpensive, useful for packing, requires frequent change, does not maintain moisture well.
* Transparent film such as Tegaderm: for stage 1 injuries, superficial wounds, and intravenous sites. Allows visualization and gas exchange. Not absorbent, so do not use on heavily draining wounds.
* Hydrocolloid such as DuoDERM: occlusive, keeps the wound moist, promotes autolytic debridement, used on clean stage 2 and shallow stage 3 wounds. Produces a normal odorous gel that students often mistake for infection. Not for infected wounds.
* Hydrogel: donates moisture to dry wounds, soothing, used on dry sloughy or painful wounds.
* Alginate: highly absorbent, derived from seaweed, for heavily exudating wounds, requires a secondary cover dressing.
* Foam: absorbent and cushioning, common for moderate exudate and for prophylactic sacral protection.

The governing principle is moisture balance: keep the wound bed moist and the surrounding intact skin dry. Wet-to-dry gauze performs nonselective mechanical debridement, damages new granulation tissue, and is painful. It is no longer recommended as routine care and should be questioned when ordered for a clean granulating wound.

=== Negative pressure wound therapy ===
Negative pressure wound therapy applies subatmospheric pressure through a sealed foam dressing to remove exudate, reduce edema, and promote granulation. The nurse ensures an airtight seal, monitors canister output and character, and reports a lost seal or an alarm. It is contraindicated over untreated osteomyelitis, malignancy in the wound, exposed vessels, organs, or anastomoses, and necrotic tissue with eschar. Active bleeding into the canister is an emergency.

=== Step sequence for a sterile dressing change ===
# Verify the order, assess pain, and premedicate so the analgesic peaks during the change.
# Perform hand hygiene, don clean gloves, and remove the old dressing, moistening it with sterile saline if it adheres so granulation tissue is not stripped.
# Assess the old dressing for amount, color, odor, and consistency of drainage, then discard it and the gloves and perform hand hygiene again.
# Set up the sterile field, open supplies onto it, and pour solution without reaching across the field.
# Don sterile gloves. Assess the wound bed, measure length, width, and depth, and probe for undermining and tunneling using clock terminology with 12 o'clock toward the patient's head.
# Clean from least contaminated to most contaminated, moving from the incision outward, using a new gauze for each stroke. Never return a used gauze to the wound.
# Pack loosely if ordered. Overpacking raises pressure and impairs perfusion. Packing is counted in and counted out and documented.
# Apply the new dressing, secure it, and label it with date, time, and initials.
# Reassess the patient and document findings and tolerance.

=== Complications ===
Dehiscence is separation of the wound layers. Evisceration is protrusion of viscera through the opening. If evisceration occurs, the nurse stays with the patient, positions low Fowler with knees bent to reduce abdominal tension, covers the organs with sterile gauze moistened with sterile normal saline, does not attempt to reinsert anything, keeps the patient NPO, monitors for shock, and notifies the surgeon immediately. Infection is suggested by purulent drainage, increasing pain after the third postoperative day, fever, erythema spreading beyond the incision, and leukocytosis. A wound culture is obtained from viable tissue in the wound bed after cleansing with normal saline, not from exudate or eschar, and before antibiotics are started when possible.