Patients come in every day with wounds from various accidents and health conditions, while other bed bound patients unfortunately develop wounds in the clinical setting. Let’s go over various types of wounds, wound characteristics, nursing interventions, and documentation.
Types of Wounds
Wounds come in many shapes and sizes and are caused by various things. Including accidental injury, burns, diabetic complications, and pressure ulcers. While all wounds are basically the same in the sense that skin integrity has been compromised, pressure ulcers are caused from inadequately offloading pressure on bony prominences that is preventable.
Be sure to to visit Nursing Fundamentals: A Guide to Pressure Ulcers, A Guide to Diabetes, A Guide to Treating and Managing Type 1 Diabetes, and Type 2 Diabetes, and Nursing Fundamentals: A Guide to Burns, Part 1 and Part 2 for more information.
Wound Healing
Someone who is young and healthy with no other health concerns will be able to heal their wound much faster than someone who might be older and have additional health concerns. Let’s go over some additional variables that will negatively affect ones ability to heal.
- Fragile skin
- Decreased oxygenation
- Smoking
- Compromised circulation/tissue perfusion
- Dehydration
- Malnutrition
- Obesity
- Immunocompromised patients
- Chronic diseases (Diabetes or Cardiovascular issues)
- Location and stress on the wound
Color
From the color at the wound base, you can tell what stage of healing it’s in and therefore what nursing actions should be taken.
Red
If the wound appears beefy red in color, then the wound is healing nicely, and the color indicates new tissue formation. This signifies that the current treatment should be continued as the care is working.
Yellow
If the wound appears yellow in color, then this is a good indicator of puss and even slough. Which indicates that the wound is infected, and that the patient should be on some type of antibiotic.
Black
Sometime wounds will appear black in color at the edges or even at the base of the wound. If you notice the presence of black tissue, it is because the tissue is no longer being perfused adequately and is dead or dying. This tissue is called necrosed tissue and indicates to the doctor or wound care nurse that the wound needs to be debrided. Meaning cut so that the beefy red tissue underneath can grow in healthy.
Drainage
The presence or absence of drainage in a wound is another way to tell how the wound is healing.
Serous
Serous drainage is clear or slightly yellow in color and comes from the plasma portion of blood.
Sanguineous
Sanguineous fluid will be thick and appear red in color as it indicates the presence of red blood cells along with the plasma portion of blood. Bright red sanguineous drainage indicates a current bleed with fresh blood. Whereas if the drainage is dark, the bleeding might have already stopped as this color indicates dried blood.
Serosanguineous
Serosanguineous fluid will include both serous and sanguineous fluid and will be thin, like water. It will be tinged with blood.
Purulent
Purulent drainage indicates infection. It will likely have a foul smell and be yellow, tan, or brown in color. Purulent drainage includes white blood cells, bacteria, and even tissue.
Purosanguineous
Purosanguineous fluid is a mix between purulent and sanguineous fluid, indicating pus and blood.
Nursing Interventions
In order to help wounds heal, we need to provide patients with adequate fluids and a proper diet including enough protein. Make sure that the wound area is kept clean and any weight is offloaded, especially if it’s a pressure ulcer. If there are orders for antibiotics, then make sure to give it at the appropriate time.
Wound Care
If there’s an order for wound care, make sure to follow it exactly. Gather all your supplies and keep them at bedside for dressing changes. Take the old dressing off and clean however the order instructs, always moving from an area of least contamination to the most.
Be extremely gentle when providing wound care for two reasons. Firstly, because it is likely very painful for the patient. If there’s an order, you’ll want to premedicate before the dressing change to help with pain. And secondly, because the wound and any new tissue is fragile, and you wouldn’t want to cause harm to the site from cleaning friction.
Visit Nursing Fundamentals: A Guide to Pain and Patient Education: How to Effectively Manage Acute and Chronic Pain for more information on treating pain.
Documenting Wounds
When documenting wounds, be sure to note if this is the first time the wound has been documented along with the time it was found. Make a note of the location, type of wound, and size. Be sure to note what the wound looks like. Is there redness? What is the shape of the wound? Is there drainage? Does it appear to be healing?
Also be sure to document any nursing interventions. Did you change a dressing? Maybe you put in a wound consult? Or took time to educate the patient? And lastly document how the patient tolerated the dressing change or any other interventions.
And that’s it! Check out the rest of the following posts below for more information!
- Infection Control
- Identifying Sepsis and Understanding its Care and Treatment
- Intravenous Fluids
- And the entire Nursing Fundamentals Series!