Part of the ICU Emergencies Hub — browse every related guide in one place.
Wound care in nursing encompasses assessment, documentation, dressing selection and application, patient education, and recognition of wound complications requiring provider intervention. Understanding wound healing physiology, pressure injury staging, and the principles behind dressing selection gives nurses the framework to apply sound clinical judgment rather than simply following orders.
Understanding where a wound is in the healing process informs appropriate dressing selection and helps nurses recognize when healing is proceeding normally versus when it is stalled or complicated.
Phase 1 — Hemostasis (minutes to hours): Platelets aggregate at the wound site; fibrin clot forms to stop bleeding. No nursing intervention accelerates this phase — the clot should be protected, not disrupted.
Phase 2 — Inflammation (1–5 days): Classic inflammatory signs (erythema, edema, warmth, pain) at the wound site are NORMAL in this phase. This is protective inflammation bringing white cells and growth factors to the wound. Distinguishing normal wound inflammation from wound infection is a critical nursing skill — infection involves purulent exudate, abnormal odor, wound margin breakdown, and systemic signs (fever, elevated WBC).
Phase 3 — Proliferation (weeks): Granulation tissue (pink-red, beefy, moist, granular texture) fills the wound bed. Epithelial cells migrate from wound margins. Healthy granulation tissue is a positive finding — it means the wound is healing. Wounds stalled in this phase may need debridement to remove devitalized tissue blocking granulation.
Phase 4 — Remodeling/Maturation (months to years): Collagen reorganizes and the scar matures. The wound reaches maximum tensile strength at approximately 80% of pre-wound tissue strength at best. Wounds that reopen during this phase (dehiscence) have lost tensile strength.
Accurate, standardized wound documentation is both a clinical care requirement and a regulatory necessity. Most facilities use a structured wound assessment format that captures all of the following:
| Assessment Element | What to Document |
|---|---|
| Location | Anatomically specific — "left lateral heel," not just "foot." Use body diagrams when available. |
| Size | Length x width x depth in centimeters. Measure perpendicular axes at widest points. Depth with sterile cotton swab if wound is open. |
| Wound bed | % granulation (pink-red, moist, granular), % slough (yellow-white, moist, devitalized tissue), % eschar (black, dry, necrotic), % epithelial tissue (new pink skin at margins) |
| Wound edges | Undermining (tissue destruction under intact skin at wound margin — measure in clock positions), tunneling (channel from wound base), wound edge attachment vs. rolled/macerated/hyperkeratotic |
| Exudate (drainage) | Amount (none/small/moderate/large), type (serous — clear; sanguineous — bloody; serosanguineous — mixed; purulent — thick/cloudy/yellow-green), odor (absent/present) |
| Periwound skin | Erythema, induration, maceration (white, soft, fragile skin from moisture), callus, warmth |
| Pain | Pain at baseline and during dressing change; scale and character |
| Stage | Definition | Key Feature |
|---|---|---|
| Stage 1 | Non-blanchable erythema of intact skin — skin intact but reddened; does not blanch with fingertip pressure for at least 1 second | Skin intact; redness does not fade when pressure applied. In darker skin tones, may appear as purple, brown, or blue discoloration rather than red. |
| Stage 2 | Partial thickness skin loss involving dermis — shallow open ulcer with pink-red wound bed, OR an intact or ruptured serum-filled blister | No slough or eschar; wound bed is moist and pink; painful; common at heels, sacrum in hospitalized patients |
| Stage 3 | Full thickness skin loss — subcutaneous fat visible; may have slough; may have tunneling or undermining; depth varies by anatomical location | Full thickness skin and subcutaneous tissue loss; bone, tendon, muscle NOT exposed (if bone visible = Stage 4) |
| Stage 4 | Full thickness skin and tissue loss with exposed bone, tendon, or muscle; often has slough or eschar; tunneling and undermining frequent | Bone, tendon, or muscle visible or directly palpable; risk of osteomyelitis; slow healing, high morbidity |
| Unstageable | Full thickness tissue loss covered by slough or eschar — cannot determine depth because wound base is obscured | Remove eschar/slough (debridement) to accurately stage; until base visible, stage cannot be assigned. Exception: stable heel eschar may be left intact as a "natural biologic cover." |
| Deep Tissue Pressure Injury (DTPI) | Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration — or epidermal separation revealing dark wound bed; often evolves rapidly | Injury originates in deep tissue layers from intense or prolonged pressure; may look superficial initially then rapidly deteriorate to Stage 3/4 over days; most common at bony prominences in patients who cannot reposition |
| Dressing Type | Best For | Clinical Note |
|---|---|---|
| Transparent film (Tegaderm, OpSite) | Intact skin at risk; Stage 1 pressure injury; superficial abrasions; IV site protection | Waterproof; semi-permeable; allows wound visualization; not for infected wounds or high exudate |
| Hydrocolloid (DuoDerm) | Stage 2 pressure injuries; partial thickness wounds; low to moderate exudate | Absorbs exudate to form a gel; provides moist healing environment; may leave brownish residue that looks like purulent drainage (it's not); change q3-7 days |
| Foam dressing (Mepilex, Allevyn) | Moderate to high exudate; Stage 2-3 pressure injuries; fragile periwound skin | Highly absorbent; gentle on wound bed; silicone-backed foams are atraumatic on removal; change when saturated or q3-5 days |
| Alginate (Algicell, Kaltostat) | High-exudate wounds; cavity wounds; wounds with tunneling; wounds with minimal necrosis | Derived from seaweed; forms a hydrophilic gel on contact with wound fluid; requires secondary dressing; daily to every-other-day change for high exudate |
| Hydrogel | Dry wound beds; necrotic tissue requiring autolytic debridement; wounds with slough | Adds moisture to dry wounds; supports autolytic debridement of slough/eschar; NOT for infected wounds or high exudate (will macerate periwound skin) |
| Silver-containing dressings | Infected wounds or high-risk wounds; critically colonized wounds | Silver is antimicrobial; appropriate for wounds with clinical signs of infection; not required for clean wounds (silver resistance is emerging; don't use prophylactically) |
| Wet-to-dry gauze | Formerly used for mechanical debridement; now largely disfavored | Drying gauze tears away granulation tissue on removal; non-selective debridement — removes healing tissue with necrotic; most wound care experts consider it outdated; WOCN does not recommend |
Wound, Ostomy, and Continence Nursing (WOC nursing or WOCN) is an advanced nursing specialty focused on the prevention and management of complex wounds, ostomies, and continence disorders. WOCNs are the primary wound care consultants in most hospital settings and long-term care facilities.
CWOCN certification: The Certified Wound Ostomy Continence Nurse (CWOCN) is offered by the Wound Ostomy Continence Nursing Certification Board (WOCNCB). Requirements: current RN licensure, completion of an accredited WOCN education program (typically 5–6 weeks didactic + clinical), and passage of the CWOCN examination. Nurses may specialize: Certified Wound Care Nurse (CWCN), Certified Ostomy Care Nurse (COCN), or Certified Continence Care Nurse (CCCN) are available as individual certifications if all three WOCN areas are not desired.
CWCN salary: $75,000–$110,000/year in hospital-based WOCN roles; consulting WOCN positions range from $85,000–$130,000+. Per diem and consulting wound care nurses are in consistent demand across acute, post-acute, and home health settings.
Related guides: Fall prevention nursing | Medication errors | Infection control nursing | Nursing diagnosis guide
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