NURS 101 Wound Care Handout.

Wound Care Handout
Stages of Wound Healing
Inflammation Stage – Begins with injury and continues for 3 – 6 days
 Vasoconstriction controls bleeding – hemostasis with clot formation
 Delivery of oxygen, nutrients, and leukocytes to wound
 Phagocytosis with actin of macrophages
Proliferation Stage – 3 – 24 days
 Capillaries grow across the wound
 Granulation tissue or collagen replaces lost tissue
 Wound edges contract
 New epithelial cells surface across the wound
Maturation Stage – from 21 days to 6 months – 1 year+
 Strengthening of collagen scar
 Return to a more normal appearance


Healing Process
Primary Intention – surgically closed incision – cut
 Little or no tissue loss with minimal scarring
 Rapid healing with low risk of infection
 Wound edges are well approximated
Secondary Intention – pressure ulcer left open to heal (may have appropriate dressing
in place)
 Loss of tissue with widely separated wound edges
 Heals by granulation
 Longer healing time with increased risk of infection
 Greater scarring
Tertiary Intention – abdominal wound initially left open until infection is resolved and
then is closed
 Deep widely separated wound edges
 May have spontaneously opened
 Extensive drainage
 Longer healing time and increased risk of infection


Factors Affecting Wound Healing (Offer Rationales for each factor)

,  Age

- As we get older, wounds heal much slower because the skin loses elasticity,
turgor, and circulation decreases

 Overall wellness

-

 Decreased leukocyte

 Anti-inflammatory medications


 Antineoplastic medications

 Malnourished patients


 Impaired tissue perfusion

 Low hemoglobin level


 Smoking

 Prolonged antibiotic use


 Wound stress

 Tissue necrosis


 Edema


Wound Assessment
Surgical incision
 Length, location, closure (staples, sutures, liquid glue)
 Wound edges – well approximated? Any visual separation?
 Drainage – color, amount, consistency, odor (from either drain or dressing)