Wound Care Basics for Healthcare Workers

Wound care is a fundamental skill for healthcare workers at all levels. Proper wound management promotes healing, prevents infection, reduces patient pain, and can mean the difference between a wound that resolves in weeks and one that becomes a chronic, non-healing problem requiring months of treatment or hospitalization. This guide provides comprehensive training on wound assessment, cleaning, dressing selection, infection recognition, pressure injury prevention, and documentation for healthcare support staff.

Understanding Wound Healing

Before you can care for a wound, you need to understand how the body heals itself.

Phases of Wound Healing

Phase 1 - Hemostasis (seconds to minutes):
Blood vessels constrict to reduce blood flow. Platelets form a clot. This is the body's emergency response to stop bleeding.

Phase 2 - Inflammation (1-4 days):
Blood vessels dilate, bringing white blood cells to the wound. The area becomes red, warm, swollen, and painful. This is a normal immune response, not an infection. White blood cells clean up dead tissue and bacteria.

Phase 3 - Proliferation (4-21 days):
New blood vessels grow into the wound (angiogenesis). Fibroblasts produce collagen, which forms the structural framework of new tissue. Granulation tissue (beefy red, bumpy tissue) fills the wound from the bottom up. Epithelial cells migrate across the surface to close the wound.

Phase 4 - Maturation/Remodeling (21 days to 2 years):
Collagen reorganizes and strengthens. The scar matures, becoming thinner, flatter, and lighter over time. The final scar is only about 80% as strong as the original tissue.

Factors That Impair Healing

Understanding these factors helps you identify patients at risk for poor wound healing:

• Age: Elderly patients heal more slowly due to reduced collagen production and slower immune response
• Nutrition: Protein, vitamin C, zinc, and iron are essential for wound healing. Malnourished patients heal poorly.
• Diabetes: High blood sugar impairs white blood cell function and reduces circulation to extremities
• Circulation problems: Peripheral vascular disease, venous insufficiency, and arterial disease all impair blood flow to wounds
• Medications: Steroids, chemotherapy, and immunosuppressants slow healing
• Smoking: Nicotine constricts blood vessels and reduces oxygen delivery to tissue
• Infection: Active infection keeps the wound in the inflammatory phase and prevents progression
• Moisture imbalance: Too much moisture (maceration) or too little (desiccation) both impair healing
• Pressure: Continuous pressure on a wound reduces blood flow and prevents healing
• Obesity: Adipose tissue has poor blood supply

Types of Wounds

Acute Wounds

• Abrasion: Skin scraped or rubbed away (road rash, carpet burn). Typically shallow, painful, and heals well with proper care.
• Laceration: A cut or tear, often from a sharp object. May be deep with irregular edges. May require sutures or staples.
• Puncture: A small, deep hole from a pointed object (nail, thorn, animal bite). High infection risk because bacteria are pushed deep into tissue.
• Avulsion: Skin or tissue torn partially or completely away. May require surgical repair.
• Surgical incision: A clean, deliberate cut with sutured or stapled closure. Heals by "primary intention" (edges are held together).
• Burn: Tissue damage from heat, chemicals, electricity, or radiation. Classified by depth: first degree (superficial, red skin), second degree (partial thickness, blisters), third degree (full thickness, white or charred).

Chronic Wounds

Chronic wounds are wounds that do not progress through normal healing phases in the expected timeframe (usually 30 days). Common types:

• Pressure injuries (pressure ulcers, bedsores): Caused by prolonged pressure on the skin, typically over bony prominences.
• Venous stasis ulcers: Caused by poor venous return in the lower legs. Typically located on the inner ankle, shallow, irregularly shaped, with a lot of drainage.
• Arterial ulcers: Caused by poor arterial blood flow. Typically located on the toes, feet, or outer ankle. Deep, well-defined edges, pale wound bed, minimal drainage. Very painful.
• Diabetic foot ulcers: Caused by a combination of neuropathy (loss of sensation), poor circulation, and immune dysfunction. Often located on the bottom of the foot. The patient may not feel pain because of neuropathy, which makes these ulcers dangerous.
• Skin tears: Common in elderly patients with fragile skin. The epidermis separates from the dermis, creating a flap.

Wound Assessment

Accurate assessment is the foundation of effective wound care. Assess and document at every dressing change.

What to Assess

Location: Use anatomical terminology. "2 cm wound on the medial aspect of the left ankle" is better than "wound on the leg."

Size: Measure in centimeters.

• Length: longest measurement head to toe
• Width: widest measurement side to side (perpendicular to length)
• Depth: gently insert a sterile cotton-tipped applicator into the deepest point and measure against a ruler

Wound bed appearance:

• Red/pink (granulation tissue): Healthy. Beefy red, bumpy tissue. This is the wound healing.
• Yellow (slough): Devitalized tissue. Soft, moist, yellow or tan. Needs to be removed for healing to progress.
• Black (eschar/necrotic tissue): Dead tissue. Hard, dry, black or brown. Must be removed (debrided) for healing, unless it is a stable eschar on a heel (which may be left intact per physician order).
• Mixed: Wound beds often have multiple tissue types. Describe the percentage of each: "60% red granulation, 30% yellow slough, 10% black eschar."

Drainage (exudate):

• Amount: None, scant, small, moderate, large, or copious
• Type: Serous (clear, straw-colored), sanguineous (bloody), serosanguineous (pink, blood-tinged), purulent (thick, opaque, may be yellow, green, or brown)
• Odor: Normally minimal. A foul odor may indicate infection or necrotic tissue.

Wound edges:

• Well-defined or irregular?
• Attached or detached (undermining)?
• Rolling under (epibole)? This prevents wound closure.

Surrounding skin:

• Color: Redness (erythema) may indicate inflammation or infection
• Temperature: Warm to touch may indicate inflammation or infection
• Moisture: Maceration (white, soggy skin from excess moisture) indicates the wound is too wet
• Integrity: Is the surrounding skin intact or breaking down?

Undermining and tunneling:

• Undermining: Tissue destruction under the wound edges. Documented using the clock method: "Undermining extends 2 cm from 2 o'clock to 5 o'clock."
• Tunneling: A narrow channel extending from the wound into surrounding tissue. Document the location and depth: "Tunnel at 3 o'clock, 3 cm deep."

Pain: Ask the patient to rate wound pain (0-10 scale). Note whether pain is constant, increases with dressing changes, or occurs at specific times.

Wound Cleaning

General Principles

• Use sterile or clean technique as specified by the care plan
• The standard wound cleansing solution is normal saline (0.9% sodium chloride)
• Do NOT use hydrogen peroxide, Betadine (povidone-iodine), or alcohol on open wounds unless specifically ordered by the physician. These products are cytotoxic - they kill healthy cells along with bacteria and delay healing.
• Clean from the center of the wound outward, or from the cleanest area to the dirtiest
• Use gentle pressure. High-pressure irrigation (using a syringe with an 18-gauge needle or commercial wound irrigation device) is effective for removing debris but should only be done as ordered.

Step-by-Step Wound Cleaning

1. Wash your hands. Put on clean gloves.
2. Remove the old dressing carefully. If it sticks, moisten it with normal saline and wait a moment before pulling.
3. Observe the old dressing: how much drainage? What color? Any odor? These observations are part of your assessment.
4. Discard the old dressing and soiled gloves. Wash your hands. Put on new clean gloves (or sterile gloves if the care plan requires sterile technique).
5. Pour normal saline over the wound or irrigate gently with a syringe. Let the fluid run across the wound and collect on the pad beneath.
6. Using gauze moistened with saline, gently wipe from the center of the wound outward. Use a new piece of gauze for each wipe. Do not go back and forth with the same piece.
7. Pat the surrounding skin dry with clean gauze. Excess moisture on the surrounding skin causes maceration and skin breakdown.

Dressing Types and Selection

The right dressing creates the optimal environment for healing: moist (not wet, not dry), protected from contamination, and undisturbed.

Dressing Selection Guide

Gauze:

• The most versatile and widely available dressing
• Can be used wet (saline-moistened) for packing wounds or dry as a cover
• Requires frequent changes (may dry out and stick to the wound bed)
• Good for packing deep wounds with dead space
• Often used as a secondary (outer) dressing over other primary dressings

Transparent film (Tegaderm, OpSite):

• Clear, adhesive, waterproof
• Allows you to monitor the wound without removing the dressing
• Best for: shallow wounds, skin tears, IV sites, Stage 1 pressure injuries
• Not for: wounds with moderate to heavy drainage (traps moisture)

Hydrocolloid (DuoDERM):

• Waterproof, adhesive outer layer with a gel-forming inner layer
• Promotes moist healing
• Can stay in place for 3-7 days
• Best for: partial-thickness wounds, light to moderate drainage, Stage 2 pressure injuries
• Not for: infected wounds, wounds with heavy drainage

Foam (Mepilex, Allevyn):

• Absorbent, cushioning, non-adherent
• Comes in adhesive and non-adhesive varieties
• Can stay in place for 3-7 days
• Best for: moderate to heavy drainage, pressure injuries, under compression wraps
• Good for fragile skin because foam dressings are gentle to remove

Alginate (Kaltostat, Aquacel):

• Made from seaweed derivatives
• Extremely absorbent (absorbs 15-20 times its weight)
• Forms a soft gel when it contacts wound fluid
• Best for: heavy drainage, deep wounds, packing material
• Not for: dry wounds (it needs moisture to work)

Hydrogel (Intrasite, SAF-Gel):

• Water-based gel that donates moisture to the wound
• Available as sheets, tubes, or impregnated gauze
• Best for: dry wounds, wounds with necrotic tissue (helps soften eschar), painful wounds (cooling effect)
• Not for: wounds with heavy drainage

Silver dressings (Aquacel Ag, Silvercel):

• Contain antimicrobial silver
• Best for: wounds with confirmed or suspected infection, high-risk wounds
• Used as ordered by the physician or wound care nurse

Collagen dressings:

• Contain bovine or porcine collagen to promote cellular growth
• Best for: chronic wounds that have stalled in the healing process
• Used as ordered by the wound care team

Dressing Application - General Steps

1. Select the dressing appropriate for the wound (per the care plan).
2. Cut the dressing to size. It should overlap the wound edges by at least 1 inch (2.5 cm) on all sides.
3. If packing a deep wound, moisten the packing material with saline and gently place it into the wound. Fill the dead space but do not pack tightly (tight packing increases pressure and impairs blood flow).
4. Apply the primary dressing (the one that contacts the wound).
5. Apply a secondary dressing (cover dressing) if needed. Secure with tape or a wrap.
6. Label the dressing with the date, time, and your initials.
7. Document the wound assessment and the dressing change.

Pressure Injury Prevention and Staging

Staging System

Stage 1: Intact skin with a localized area of non-blanchable redness (erythema). When you press on it, it stays red instead of turning white. This is the earliest warning sign.

Stage 2: Partial-thickness loss of skin. The wound bed is pink or red and moist. May appear as an intact or ruptured blister. No slough or eschar.

Stage 3: Full-thickness skin loss. Subcutaneous fat may be visible. Bone, tendon, and muscle are NOT visible. Slough and/or eschar may be present. Undermining and tunneling may occur.

Stage 4: Full-thickness skin and tissue loss. Bone, tendon, or muscle is exposed. Slough and/or eschar are often present. Undermining and tunneling are common.

Unstageable: The wound bed is covered by slough and/or eschar, making it impossible to determine the true depth. Once the necrotic tissue is removed, the wound can be staged.

Deep Tissue Pressure Injury (DTPI): Intact or non-intact skin with a dark area (purple or maroon) or a blood-filled blister. This indicates damage to underlying tissue from pressure and/or shear.

Prevention Strategies (Detailed)

Prevention is far better than treatment. A Stage 4 pressure injury can take months to heal and may require surgery.

Repositioning:

• Turn bed-bound patients every 2 hours. Use a turning schedule.
• For wheelchair-bound patients, reposition every 1 hour. Teach weight shifts every 15 minutes.
• Use a 30-degree lateral position to offload the sacrum.
• Do not position the patient directly on the trochanter (hip bone).
• Use pillows or foam wedges between bony prominences (knees, ankles).
• Float the heels off the bed using a pillow under the calves (heels are the second most common pressure injury location).

Skin assessment:

• Check all bony prominences at every turn: sacrum, coccyx, ischial tuberosities, heels, elbows, shoulder blades, back of head, ears.
• Look for redness, discoloration, warmth, induration (hardening), or open areas.
• In dark-skinned patients, stage 1 pressure injuries may appear as darker than surrounding skin, purple, or boggy. Use touch and temperature to assess.

Moisture management:

• Keep skin clean and dry.
• Use incontinence briefs and change them immediately after soiling.
• Apply a moisture barrier cream to the perineal area and buttocks for incontinent patients.
• Assess for excessive sweating and address the cause.

Nutrition:

• Ensure adequate caloric intake, especially protein (1.25-1.5 g/kg/day for at-risk patients).
• Vitamin C and zinc supplementation may be ordered for wound healing.
• Adequate hydration is essential.

Support surfaces:

• Use a pressure-redistribution mattress for at-risk patients (foam, alternating pressure, or low-air-loss).
• Use a wheelchair cushion for patients who spend significant time in a chair.
• Do not use donut-shaped cushions (they concentrate pressure at the edges).

Other measures:

• Minimize friction and shear during repositioning (use a draw sheet to lift, do not drag).
• Keep bed linens smooth and wrinkle-free.
• Manage pain (a patient in pain may not reposition themselves).
• Encourage mobility when possible. Even small amounts of movement help.

Signs of Wound Infection

Report these signs to the nurse or physician immediately:

Local Signs of Infection

• Increasing redness spreading outward from the wound edges
• Increased swelling or induration around the wound
• Increased warmth to touch
• Purulent drainage (thick, opaque, yellow, green, or brown)
• Foul odor
• Increased pain at the wound site
• Wound bed changes from red to dark or gray
• Wound stopped progressing or is getting larger despite appropriate care
• New undermining or tunneling

Systemic Signs of Infection

• Fever (temperature above 100.4 degrees F / 38 degrees C)
• Chills
• Increased heart rate
• Elevated white blood cell count (will be on lab results)
• Red streaks extending from the wound toward the heart (lymphangitis - this is urgent)
• Confusion or altered mental status (especially in elderly patients)
• General malaise (feeling unwell)

When to Call Immediately

• Red streaks from the wound
• Fever with wound deterioration
• Foul-smelling, copious purulent drainage
• Rapid increase in wound size
• Patient becomes acutely confused or lethargic

Wound Care Documentation

Document at every dressing change. Include:

1. Date and time of the dressing change
2. Wound assessment: location, size (L x W x D in cm), wound bed appearance (% of each tissue type), drainage (amount, type, color, odor), wound edges, surrounding skin condition, presence of undermining or tunneling
3. Pain: patient's pain level before, during, and after the dressing change
4. Cleaning method: what solution was used, how it was applied
5. Dressing applied: type of primary dressing, type of secondary dressing, how it was secured
6. Patient response: how the patient tolerated the procedure
7. Comparison to previous assessment: is the wound improving, stable, or deteriorating?
8. Notifications: did you report any findings to the nurse or physician?
9. Your name, credentials, and signature

Scope of Practice Reminders

As a healthcare support worker, you may perform wound care tasks as delegated and trained. Always follow the care plan. Common scope boundaries:

Typically within scope:

• Simple non-sterile wound cleaning
• Applying clean dressings
• Measuring wounds
• Documenting observations
• Reporting changes to the nurse

Typically outside scope (requires nurse or wound care specialist):

• Debridement (removing dead tissue)
• Packing deep or tunneling wounds
• Applying negative pressure wound therapy (wound VAC)
• Changing dressings on central line sites
• Irrigating deep wounds under pressure
• Making decisions about dressing type changes

When in doubt, ask. Wounds are complex, and the consequences of incorrect care can be severe.