WOUND CARE NURSING NOTES

Wound Care Nursing Notes


1. Definition

Wound care involves the assessment, cleaning, treatment, and monitoring of wounds to promote healing, prevent

infection, and maintain skin integrity.



2. Types of Wounds

- Open Wound: Break in the skin (cuts, abrasions, punctures).

- Closed Wound: Damage under the skin (e.g., contusions).

- Acute Wound: Heals within expected timeframe (e.g., surgical incision).

- Chronic Wound: Fails to heal normally (e.g., pressure ulcers).



3. Phases of Wound Healing

1. Hemostasis - Immediate vasoconstriction and clotting.

2. Inflammation - Vasodilation, WBC infiltration, edema.

3. Proliferation - Granulation tissue formation, angiogenesis.

4. Maturation - Scar tissue strengthens and reorganizes.



4. Wound Assessment Checklist

- Location & Size

- Wound Bed (color, necrotic tissue)

- Exudate (type, amount)

- Edges (rolled, macerated)

- Periwound Skin (redness, swelling)

- Pain

- Signs of Infection



5. Types of Wound Drainage

- Serous: Clear or slightly yellow fluid.

- Sanguineous: Bright red, indicates bleeding.