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Wound - Adult Health Nursing

Note: The medical library does not contain a dedicated adult health nursing textbook. The content below is drawn from the closest authoritative equivalents - Bailey & Love's Short Practice of Surgery (28th ed.), Schwartz's Principles of Surgery (11th ed.), and Mulholland & Greenfield's Surgery (7th ed.) - which cover all core wound topics taught in adult health nursing programs.

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Definition

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Classification of Wounds

By Etiology (Bailey & Love, 28th ed.)

By Bacterial Contamination (CDC Surgical Wound Classification)

By Depth

• Epidermal
• Dermal (superficial or deep)
• Full-thickness (subcutaneous/fascial/muscle involvement)

By Complexity

• Simple
• Complex (significant soft-tissue loss, open fracture/joint, visceral involvement)
• Complicated (infection, necrosis, haematoma, gas gangrene, compartment syndrome)

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Phases of Wound Healing

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Phase 1: Hemostasis (Minutes to Hours)

• Immediately follows injury
• Damaged blood vessels constrict (vasoconstriction via catecholamines, prostaglandins)
• Platelets aggregate and degranulate, releasing:
  • Platelet-derived growth factor (PDGF)
  • Transforming growth factor-beta (TGF-β)
  • Vascular endothelial growth factor (VEGF)
  • Fibronectin, serotonin, platelet-activating factor (PAF)
• Coagulation cascade activated → fibrin clot forms
• Fibrin clot acts as scaffold for incoming inflammatory cells
• Result: bleeding controlled, healing initiated

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Phase 2: Inflammation (Days 1-4)

• First cells to arrive; peak at 24-48 hours
• Primary role: phagocytosis of bacteria and debris
• Release cytokines (TNF-α, IL-1) and proteases (collagenases)
• Stimulated by: complement factors, IL-1, TNF-α, TGF-β

• Derived from circulating monocytes
• Peak at 48-96 hours; remain until healing complete
• Central regulators: release TGF-β, VEGF, IGF, EGF, lactate
• Direct fibroblast proliferation, angiogenesis, and matrix synthesis
• Essential to successful healing - without macrophages, healing fails

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Phase 3: Proliferation / Fibroplastic Phase (Days 3 - Weeks 3-4)

• Fibroblasts migrate into the wound and produce collagen (initially type III, later type I)
• Collagen synthesis requires: oxygen, vitamin C (cofactor for prolyl hydroxylase), iron, amino acids
• Ground substance laid down: glycosaminoglycans and proteoglycans

• Pink, granular tissue formed in early proliferative phase
• Composed of new capillaries (angiogenesis), fibroblasts, and provisional matrix

• New blood vessels form to supply oxygen and nutrients to the healing wound

• Begins within 24 hours of injury
• Marginal basal cells migrate across the wound surface
• Complete in <48 hours for approximated incisions; longer for open wounds
• Re-establishes the epidermal barrier

• Myofibroblasts (fibroblasts with actin microfilaments) cause wound edges to pull inward
• Particularly prominent in wounds healing by secondary intention

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Phase 4: Maturation and Remodeling (Weeks to Months - up to 1 Year)

• Collagen type III replaced by stronger collagen type I
• Matrix metalloproteinases (MMPs) break down and reorganize collagen
• TGF-β increases new collagen transcription AND inhibits breakdown
• Wound progressively becomes avascular and acellular
• Tensile strength increases over months but never reaches that of uninjured tissue
• Scar remodeling continues for 6-12 months

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Types of Wound Healing (Intention)

• Bailey & Love, 28th ed.: "Primary healing is also known as healing by first intention. This occurs when there is direct approximation of the wound edges and is the aim of treatment."

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Factors Affecting Wound Healing

Local Factors

• Skin tension
• Hypoxia and ischaemia
• Vascular insufficiency
• Lymphoedema
• Contamination and infection
• Presence of foreign bodies
• Radiotherapy

Systemic Factors

• Advancing age
• Obesity
• Malnutrition (especially protein, vitamin C, zinc deficiency)
• Smoking (reduces tissue oxygenation)
• Diabetes mellitus (impairs neutrophil function, microvascular disease)
• Immunocompromised states (HIV/AIDS)
• Medications: corticosteroids, immunosuppressants, chemotherapy

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Abnormal Wound Healing

Hypertrophic Scars

• Excess collagen in a parallel arrangement
• Do NOT extend beyond original wound boundary
• Eventually regress spontaneously
• More common in: high-tension areas, wounds crossing tension lines, deep dermal burns, wounds healing by secondary intention >3 weeks

Keloid Scars

• Excess collagen in a disorganised arrangement
• Extend beyond original wound boundary
• Do NOT regress spontaneously - difficult to treat
• Genetic predisposition; more common in darker skin pigmentation
• Can result from relatively minor trauma

Chronic / Non-healing Wounds

• Failure to progress through normal healing phases
• Causes: persistent infection, ischaemia, pressure, underlying disease (diabetes, venous insufficiency)
• Examples: pressure ulcers, venous leg ulcers, diabetic foot ulcers

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Wound Management Principles

Tetanus-Prone Wounds (Bailey & Love, 28th ed.)

• Puncture injuries in contaminated environments
• Bites
• Compound fractures
• Wounds containing foreign bodies
• Burns/wounds with systemic sepsis
• High-risk: heavy contamination (soil/manure), surgical delay >6 hours, extensive devitalized tissue

Debridement

• Removes all devitalized tissue and foreign material
• Non-viable tissue excised until healthy bleeding occurs at wound edges
• Methods: surgical, mechanical, enzymatic, autolytic (moist dressings), biological (maggot therapy)

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Wound Assessment (Nursing)

1. Location - anatomical site
2. Size - length × width × depth (cm)
3. Wound bed - color: red (granulating), yellow (slough), black (necrotic)
4. Exudate - amount, color, consistency, odor
5. Wound edges - attached/unattached, rolled/undermined
6. Periwound skin - erythema, maceration, induration
7. Signs of infection - erythema, warmth, purulent discharge, odor, fever, increased pain
8. Pain - at rest and during dressing changes

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• Bailey and Love's Short Practice of Surgery, 28th ed., Chapter 3 (Wound Healing & Management)
• Schwartz's Principles of Surgery, 11th ed., Chapter 9 (Wound Healing)
• Mulholland and Greenfield's Surgery, 7th ed., Chapter on Wound Management

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WOUND - Adult Health Nursing

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1. DEFINITION

• It is a break in the epithelial integrity of the skin, with or without involvement of deeper structures (dermis, subcutaneous tissue, muscle, bone, viscera)
• Wounds may be intentional (surgical incisions) or unintentional (traumatic injuries)
• A wound that fails to progress through normal healing in an orderly, timely manner is classified as a chronic wound

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2. TYPES OF WOUNDS

A. By Mechanism / Etiology

B. By Skin Integrity

C. By Bacterial Contamination (CDC Classification) - Bailey & Love

D. By Duration

Chronic wound examples: pressure ulcers, venous leg ulcers, diabetic foot ulcers, arterial ulcers

E. By Depth

• Superficial - epidermis only
• Partial-thickness - epidermis + superficial dermis
• Full-thickness - epidermis + dermis + subcutaneous tissue
• Deep - involves fascia, muscle, tendon, bone, or viscera

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3. ETIOLOGY

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4. CLINICAL MANIFESTATIONS

Local Signs

Signs of Wound Infection (NERDS/STONEES Criteria)

• N - Non-healing wound
• E - Exudate increasing
• R - Red/bleeding wound bed
• D - Debris (slough/tissue) on wound
• S - Smell/odour from wound

• S - Size increasing
• T - Temperature elevated (local and systemic)
• O - Os (bone) exposed
• N - New areas of breakdown
• E - Erythema/oedema
• E - Exudate (purulent)
• S - Smell

Systemic Manifestations (if infected)

• Fever (>38°C), chills, rigors
• Tachycardia, tachypnoea
• Elevated WBC (leukocytosis)
• Fatigue, malaise
• Sepsis/septic shock in severe cases

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5. PATHOPHYSIOLOGY

Normal Wound Healing - Four Overlapping Phases

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Phase 1: Hemostasis (0 - Hours)

• Tissue injury → vasoconstriction → platelet aggregation and degranulation
• Platelets release: PDGF, TGF-β, VEGF, fibronectin, serotonin
• Coagulation cascade activated → fibrin clot formed
• Fibrin clot = physical barrier to blood loss AND scaffold for healing cells

Phase 2: Inflammation (Hours - Day 4)

• Vasodilation and increased vascular permeability
• Classic signs: Rubor (red), Tumor (swelling), Calor (heat), Dolor (pain)
• Neutrophils (PMNs): First responders; peak 24-48 hours; phagocytose bacteria and debris; release cytokines (TNF-α, IL-1) and proteases
• Macrophages: Peak 48-96 hours; phagocytosis + regulation of repair; release TGF-β, VEGF, EGF, IGF; essential to coordinated healing

Phase 3: Proliferation (Day 3 - Week 3-4)

• Fibroblasts proliferate and synthesize collagen (type III initially, then type I) and ground substance
• Granulation tissue forms: pink, vascular, granular tissue filling the wound bed
• Angiogenesis: New capillary formation supplies oxygen and nutrients
• Epithelialization: Marginal basal cells migrate across wound surface; begins within 24 hours; complete in <48 hours for closed incisions
• Wound contraction: Myofibroblasts pull wound edges inward (prominent in secondary intention healing)
• Collagen synthesis requires: oxygen, vitamin C, iron, zinc, protein

Phase 4: Maturation and Remodeling (Weeks - 12 Months)

• Collagen type III → replaced by stronger type I collagen
• Matrix metalloproteinases (MMPs) continuously remodel collagen
• TGF-β controls balance of synthesis vs. degradation
• Scar becomes progressively avascular and acellular
• Tensile strength reaches 50% at 3 weeks, 80% at 3 months - never achieves 100% of unwounded tissue
• Scar remodeling continues 6-12 months

Chronic Wound Pathophysiology

• Persistent inflammation → proteases (MMPs) overwhelm new tissue formation
• Biofilm formation → impairs host defenses
• Ischaemia/hypoxia → cells cannot sustain proliferation
• Healing remains "stuck" in inflammatory phase

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6. DIAGNOSTIC MEASURES

Laboratory

Imaging

Wound-Specific Assessment Tools

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7. COMPLICATIONS

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8. PROGNOSIS

• Simple acute wounds in healthy adults: heal well within 2-4 weeks
• Chronic wounds (venous ulcers): 40-70% healed at 24 weeks with optimal care
• Diabetic foot ulcers: 5-year recurrence rate >50%
• Infected wounds with sepsis: mortality increases significantly (septic shock mortality 20-40%)

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9. MANAGEMENT

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A. MEDICAL MANAGEMENT

1. Wound Irrigation and Cleaning

• Warm normal saline is the standard irrigant
• High-pressure irrigation (20 mL syringe, 19G needle) for contaminated wounds
• Antiseptic solutions (Betadine, chlorhexidine) used with caution - cytotoxic to healing cells at full strength

2. Debridement (Bailey & Love, 28th ed.)

3. Wound Dressings (Pfenninger & Fowler's)

4. Pharmacological Treatment

5. Advanced Medical Therapies

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B. SURGICAL MANAGEMENT

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PRE-OPERATIVE ORDERS

PHYSICIAN'S ORDERS - PRE-OPERATIVE

Patient Name: _______________  Date: ____________  Time: ______
Diagnosis: Wound requiring surgical intervention
Procedure: Wound debridement / Wound exploration / Wound closure / Skin graft

1. NOTHING BY MOUTH (NPO)
   - NPO after midnight (or 6 hours before procedure for solids,
     2 hours for clear liquids per anaesthesia guidelines)

2. LABORATORY INVESTIGATIONS
   - CBC with differential
   - BMP (Basic Metabolic Panel): BUN, Creatinine, Electrolytes
   - Fasting blood glucose / HbA1c (if diabetic)
   - PT / INR / aPTT
   - Blood group and crossmatch / type and screen
   - Serum albumin / Pre-albumin
   - Blood cultures x2 (if signs of systemic infection)
   - Wound swab for C&S

3. IMAGING
   - X-ray of affected area (if foreign body or fracture suspected)
   - Doppler ultrasound (if vascular compromise suspected)

4. IV ACCESS
   - Insert peripheral IV line (18G or 16G)
   - IV fluids: Lactated Ringer's / Normal Saline 0.9% at 
     ___ mL/hr (maintenance rate)

5. MEDICATIONS
   - Antibiotic prophylaxis: Cefazolin 2g IV 30-60 minutes 
     before incision (adjust dose: 3g if weight >120 kg)
   - (If penicillin allergy: Clindamycin 900 mg IV OR 
     Vancomycin 15-20 mg/kg IV)
   - Continue home medications EXCEPT:
     • Hold anticoagulants (as per physician order)
     • Hold metformin 24-48 hours pre-op
     • Hold ACE inhibitors / ARBs on day of surgery

6. TETANUS PROPHYLAXIS
   - Review immunisation status
   - Tetanus toxoid 0.5 mL IM if indicated
   - Tetanus immunoglobulin (TIG) 250 IU IM if high-risk wound
     and incomplete immunisation

7. ANAESTHESIA CONSULT
   - Anaesthesiology review required

8. SKIN PREPARATION
   - Clip hair (do not shave) in operative field as needed
   - Do NOT apply skin prep until in OR

9. CONSENT
   - Informed consent obtained and signed

10. PRE-OP CHECKLIST
    - Allergy identification band applied
    - Surgical site marked by surgeon
    - Remove jewellery, nail polish, prosthetics
    - Patient identification confirmed x2 (name + DOB)

Physician Signature: _____________  Time: ______

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SURGICAL (OPERATIVE) NOTE

OPERATIVE / SURGICAL NOTE

Date: ____________  Time of procedure: _______ to _______
Surgeon: _______________  Assistant: _______________
Anaesthesiologist: _______________
Anaesthesia type: [ ] General  [ ] Regional  [ ] Local  [ ] MAC

PATIENT: _______________  DOB: _______________
MRN: _______________

PRE-OPERATIVE DIAGNOSIS:
  Wound: [specify type, location, size, classification]
  e.g., Contaminated traumatic wound, right forearm, 8 x 3 cm
        Full-thickness; devitalized tissue; no vascular compromise

POST-OPERATIVE DIAGNOSIS:
  [Same / or revised findings]

PROCEDURE PERFORMED:
  e.g., Wound exploration, debridement, and primary closure
        / Split-thickness skin graft / Flap coverage

ESTIMATED BLOOD LOSS (EBL): ___ mL
FLUIDS ADMINISTERED: ___ mL (type: ___)
URINE OUTPUT: ___ mL
SPECIMEN SENT: [ ] Wound culture  [ ] Tissue biopsy  [ ] None

PROCEDURE IN DETAIL:
  - Patient positioned: _______________
  - Surgical site prepped with ___ (e.g., 2% chlorhexidine 
    in 70% isopropyl alcohol) and draped in sterile fashion
  - Tourniquet applied at ___ mmHg / not used
  - Wound explored: extent of injury - [describe layers 
    involved: dermis / subcutaneous / fascia / muscle / 
    tendon / bone; neurovascular status]
  - Non-viable tissue identified: [colour, texture, amount]
  - Debridement performed: [surgical excision of ___ cm² 
    of devitalized tissue until healthy bleeding margins 
    obtained]
  - Wound irrigated with [saline/betadine] x ___ litres 
    under pressure
  - Haemostasis achieved: [electrocautery / ligation / 
    pressure]
  - Repair of structures: [tendons, vessels, nerves if 
    applicable]
  - Wound closed: [primary / secondary / tertiary intention]
      - Deep layers: Vicryl [size] interrupted sutures
      - Subcutaneous: Vicryl [size]
      - Skin: [nylon / staples / Steri-Strips / skin glue]
  - Drain placed: [ ] Yes - type ___ at ___ location
                  [ ] No
  - Dressing applied: [specify type]
  - Tourniquet released; circulation confirmed distal to wound

COMPLICATIONS: None / [list if any]
PATIENT CONDITION: Stable / [note any concerns]
PLAN: [Post-op wound care, follow-up, further procedures]

Surgeon Signature: _______________  Date: _______________

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POST-OPERATIVE ORDERS

PHYSICIAN'S ORDERS - POST-OPERATIVE

Patient Name: _______________  Date: ____________  Time: ______
Procedure Performed: _______________
Post-op Diagnosis: _______________

1. VITAL SIGNS
   - Every 15 minutes x 4, then every 30 min x 2, then 
     every 1 hour x 4, then every 4 hours (or per unit 
     protocol)
   - Notify physician if:
     • Temperature > 38.5°C or < 36°C
     • HR > 100 or < 60 bpm
     • SBP > 160 or < 90 mmHg
     • SpO2 < 94%
     • Increasing pain / wound drainage

2. MONITORING
   - Continuous cardiac/SpO2 monitoring until stable
   - Intake and output every 4 hours
   - Blood glucose monitoring every 4-6 hours 
     (especially if diabetic)

3. ACTIVITY
   - Bed rest for ___ hours post-op
   - Elevate affected limb above heart level (if applicable)
   - Ambulate when fully recovered from anaesthesia 
     (with assistance x first time)
   - No weight bearing on ___ extremity until further 
     assessment

4. DIET
   - Clear liquids when fully awake and bowel sounds present
   - Advance to regular diet as tolerated
   - High-protein diet encouraged to promote wound healing

5. IV FLUIDS
   - Continue IV [NS / LR] at ___ mL/hr
   - D/C IV fluids when tolerating oral intake

6. WOUND CARE
   - Leave initial dressing intact for 24-48 hours 
     unless saturated/soiled
   - Inspect wound every shift: note colour, temperature, 
     exudate type and amount, odour, surrounding skin
   - First dressing change: _____ (date/time) by surgeon/
     nurse per protocol
   - Wound care orders: [specify dressing type, frequency]
   - NPWT settings if applicable: ___ mmHg continuous/
     intermittent
   - Drain care: measure output every shift; document colour 
     and character
   - Remove drain when output < 30 mL/24 hours (or per 
     surgeon order)

7. MEDICATIONS
   a. Pain Management:
      - Morphine / Hydromorphone PCA: [dose/lockout settings]
        OR
      - Ketorolac 15-30 mg IV every 6 hours x 5 doses, then
      - Paracetamol (Acetaminophen) 1 g IV/oral every 6 hours
      - Ibuprofen 400 mg oral every 8 hours with food
   
   b. Antibiotics:
      - Continue Cefazolin 1g IV every 8 hours x [24-48 hours
        for prophylaxis] OR [5-7 days for established infection]
      - (Adjust based on culture and sensitivity results)
   
   c. DVT Prophylaxis:
      - Enoxaparin 40 mg SC every 24 hours (start 12-24 hrs 
        post-op when haemostasis confirmed)
        AND
      - Sequential Compression Device (SCD) to lower 
        extremities while in bed
   
   d. GI Protection:
      - Omeprazole 20 mg oral/IV daily (while on NSAIDs or 
        stressed patient)
   
   e. Anti-emetics:
      - Ondansetron 4 mg IV every 6 hours PRN nausea

   f. Glycaemic Control:
      - Target blood glucose 140-180 mg/dL
      - Insulin sliding scale / basal-bolus insulin as ordered

   g. Nutritional Supplements:
      - Vitamin C 500 mg oral twice daily
      - Zinc sulfate 220 mg oral daily (if deficient)
      - Ensure/Boost supplement with meals if intake inadequate

8. SUTURE / STAPLE REMOVAL
   - Facial wounds: Day 5-7
   - Scalp: Day 7-10
   - Trunk / extremities: Day 10-14
   - Over joints: Day 14
   - Contaminated/complex wounds: per surgeon review

9. FOLLOW-UP
   - Wound clinic/outpatient review in ___ days
   - Remove drain on Day ___
   - Physiotherapy referral if joint/function involved
   - Occupational therapy if hand/upper limb involved

10. DOCUMENTATION
    - Document wound assessment each shift
    - Photograph wound at baseline and with each major change
    - Report signs of infection, dehiscence, or unusual 
      drainage to physician immediately

Physician Signature: _______________  Time: ______

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10. NURSING MANAGEMENT

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A. NURSING ASSESSMENT

1. Health History

• Mechanism and time of injury (hours since wound occurred)
• Previous wounds, surgeries, or skin conditions
• Tetanus immunisation status
• Allergies (especially to antiseptics, adhesives, latex)
• Current medications (steroids, anticoagulants, immunosuppressants)
• Past medical history: diabetes, vascular disease, connective tissue disorders, malignancy
• Smoking, alcohol, and nutritional status
• Psychosocial factors: living situation, ability to perform self-care

2. Physical Assessment

• Vital signs (temperature, HR, BP, RR, SpO2)
• Pain assessment: PQRST (Position, Quality, Radiation, Severity 0-10, Time/triggers)
• Neurovascular assessment distal to wound: pulses, capillary refill, sensation, movement
• Nutritional assessment: weight, BMI, dietary intake, albumin level
• Mobility and function: activity level, ability for self-care
• Psychosocial: anxiety, coping, body image concerns

3. Priority Nursing Diagnoses

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B. NURSING INTERVENTIONS

1. Wound Care

• Perform dressing changes using aseptic/clean technique per hospital protocol
• Irrigate wound with normal saline; use pressure irrigation for contaminated wounds
• Apply appropriate dressing based on wound type and exudate level
• Protect periwound skin from maceration (use skin barrier/zinc oxide)
• Document wound appearance, measurements, and changes each shift
• Photograph wound with patient consent at baseline and regularly

2. Infection Prevention

• Strict hand hygiene before and after wound care
• Maintain sterile/aseptic technique for surgical wounds
• Monitor for SSTI signs every shift; report early indicators promptly
• Administer antibiotics on time; monitor for therapeutic effects
• Teach patient to avoid touching wound; hand hygiene education

3. Pain Management

• Assess pain before, during, and after dressing changes
• Pre-medicate 30-60 minutes before dressing changes (oral analgesia)
• Use non-pharmacological methods: positioning, distraction, relaxation
• Report uncontrolled pain (may indicate wound complication)

4. Nutritional Support

• Collaborate with dietitian for high-protein, high-calorie diet
• Offer protein supplements (Ensure, Boost) if oral intake inadequate
• Ensure adequate vitamin C and zinc intake
• Monitor albumin and pre-albumin levels as healing markers
• Maintain blood glucose <180 mg/dL in diabetic patients

5. Patient and Family Education

6. Complications Monitoring and Reporting

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C. EVALUATION / EXPECTED OUTCOMES

• Wound dimensions decrease progressively (>30% reduction in 4 weeks = positive indicator)
• Wound bed: progressive granulation tissue formation
• Exudate decreasing in amount; no purulent discharge
• No signs of infection (afebrile, WBC normalizing, wound margins non-erythematous)
• Pain well-controlled (VAS/NRS ≤ 3/10)
• Patient and family demonstrate correct wound care technique
• Patient maintains adequate nutritional intake
• Wound completely closed within expected timeframe

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