Wound Care
Pressure Injury Staging
| Stage | Description | Appearance |
|---|---|---|
| Stage 1 | Non-blanchable erythema | Intact skin; red/pink; does not blanch with pressure |
| Stage 2 | Partial thickness | Shallow open ulcer; pink wound bed; may present as intact or ruptured blister |
| Stage 3 | Full thickness | Subcutaneous fat visible; no bone/tendon; slough may be present |
| Stage 4 | Full thickness with bone/tendon | Exposed bone, tendon, or muscle; slough/eschar may cover extent |
| Unstageable | Obscured by slough/eschar | Full thickness but base cannot be assessed until slough/eschar removed |
| Deep Tissue Injury (DTI) | Suspect deep tissue damage | Intact skin; purple/maroon; may evolve to thin blister over dark wound bed |
Wound Assessment
MEASURE mnemonic:
- Measure — length × width × depth
- Exudate — amount, type, color
- Appearance — wound bed, tissue type
- Suffering — pain assessment
- Undermining — tunneling, sinus tracts
- Re-evaluate — document changes
- Edge — wound margins, condition
Wound Bed Colors
| Color | Tissue Type | Action |
|---|---|---|
| Red | Granulation | Protect; moist environment |
| Yellow | Slough | Debride; absorb exudate |
| Black | Eschar | Debride (unless dry, stable heel) |
| Pink | Epithelializing | Protect; support healing |
Dressing Selection
| Dressing Type | Indications | Key Points |
|---|---|---|
| Transparent film | Stage 1–2; minimal exudate; IV sites | Waterproof; allows visualization; not for infected wounds |
| Hydrocolloid | Stage 2–3; light to moderate exudate | Absorbs; forms gel; promotes autolytic debridement |
| Hydrogel | Dry wounds; necrotic tissue | Donates moisture; cooling; may need secondary dressing |
| Foam | Moderate to heavy exudate; Stage 2–4 | Absorbent; cushioning; various thicknesses |
| Alginate | Heavy exudate; cavity wounds | Highly absorbent; forms gel; requires secondary dressing |
| Collagen | Chronic wounds; stalled healing | Supports granulation; scaffold for healing |
| Silver | Infected or at-risk wounds | Antimicrobial; use per facility protocol |
| Negative Pressure (VAC) | Complex wounds; surgical; high exudate | Promotes granulation; reduces edema; requires training |
Wound Healing Phases
- Hemostasis — Immediate; clotting, vasoconstriction
- Inflammatory — 1–4 days; vasodilation, neutrophils, macrophages
- Proliferative — 4–21 days; granulation, epithelialization, contraction
- Maturation/Remodeling — 21 days–2 years; collagen remodeling, scar strength
Braden Scale Interventions
Score 15–18 (low risk): Routine care; repositioning; skin checks
Score 13–14 (moderate risk): Increase repositioning; pressure redistribution surfaces; nutritional support
Score 10–12 (high risk): Advanced support surfaces; frequent repositioning; heel offloading; consider specialty mattress
Score 9 or below (very high risk): Aggressive interventions; low-air-loss or air-fluidized bed; wound care consult; comprehensive plan