How wounds heal and why the phase changes your answer
Wound healing proceeds through predictable phases, and the exam expects you to distinguish normal progress from complication. Haemostasis occurs immediately as vessels constrict and clots form. The inflammatory phase follows for roughly three days, producing warmth, redness, mild oedema and serosanguineous drainage — findings that are expected rather than infectious at this stage. The proliferative phase builds granulation tissue over the following weeks, and the maturation phase remodels collagen for up to a year.
Because early inflammation looks like early infection, item writers rely on timing and character. Redness and warmth on day two with scant serosanguineous drainage are normal. Increasing pain after day three, purulent or foul-smelling drainage, spreading erythema, fever and rising white cell count indicate infection. Recognising that difference prevents both false alarms and missed complications.
Healing intention also matters. Primary intention describes a clean surgical incision approximated with sutures or staples, healing quickly with minimal scarring. Secondary intention describes a wound left open to granulate from the base upward, as with a pressure injury, which takes longer and scars more. Tertiary intention describes a wound intentionally left open for a period, often due to contamination, and closed later.
- •Days 1–3: inflammation with expected warmth and serosanguineous drainage
- •Increasing pain after day 3 suggests infection, not healing
- •Primary intention: approximated edges; secondary: granulation from the base
- •Serous is clear, sanguineous is bloody, purulent is infected
Pressure injury staging without second-guessing
Stage the injury by the deepest tissue you can actually see. Stage 1 is intact skin with localised non-blanchable erythema; in darker skin tones look for changes in temperature, firmness or colour compared with surrounding tissue rather than redness. Stage 2 is partial-thickness loss of dermis presenting as a shallow open ulcer with a pink-red bed, or an intact or ruptured serum-filled blister. There is no slough and no granulation tissue.
Stage 3 involves full-thickness loss where subcutaneous fat may be visible, but bone, tendon and muscle are not exposed. Undermining and tunnelling are common. Stage 4 shows full-thickness loss with exposed bone, tendon or muscle, and carries a high risk of osteomyelitis. Two additional descriptors complete the system: unstageable, where slough or eschar obscures the base so depth cannot be determined, and deep tissue pressure injury, a persistent non-blanchable deep red, maroon or purple discolouration of intact skin.
Two rules resolve most staging questions. First, if you cannot see the base, you cannot stage it. Second, pressure injuries are never reverse-staged; a healing stage 4 is documented as a healing stage 4, not a stage 2, because the lost tissue is replaced with scar rather than original structures.
| Stage | Key finding | Wound bed | Nursing focus |
|---|---|---|---|
| Stage 1 | Non-blanchable erythema, intact skin | No open area | Offload pressure, protect, reposition |
| Stage 2 | Partial-thickness loss or serum blister | Pink-red, moist | Moisture-retentive dressing |
| Stage 3 | Full-thickness, fat visible | May have slough, tunnelling | Debride as ordered, fill dead space |
| Stage 4 | Bone, tendon or muscle exposed | Often necrotic | Assess for osteomyelitis, complex care |
| Unstageable | Base obscured by slough or eschar | Not visible | Debridement unless stable heel eschar |
| Deep tissue | Persistent deep purple discolouration | Intact or blistered | Offload and monitor closely |
Choosing dressings and managing drainage
Dressing selection follows one principle: keep the wound bed moist and the surrounding skin dry. A dry wound needs moisture added, a heavily exuding wound needs moisture absorbed, and a wound with necrotic tissue needs debridement. Transparent films suit stage 1 and superficial wounds, hydrocolloids suit stage 2 with light exudate, hydrogels rehydrate dry wound beds, foams and alginates absorb moderate to heavy drainage, and alginates also assist with minor bleeding.
Wet-to-dry gauze provides mechanical debridement but damages new granulation tissue, so it is reserved for wounds requiring debridement rather than clean granulating wounds. Negative pressure wound therapy accelerates granulation and manages exudate, and requires an airtight seal; a loss of seal with an audible leak is the finding to correct.
Drain management is a related tested skill. Closed suction drains such as Jackson-Pratt and Hemovac must be compressed after emptying to re-establish suction, output is measured and documented each shift, and a sudden increase in bright red output or an abrupt stop in previously heavy drainage both warrant reporting. Irrigation is performed from the cleanest to the dirtiest area, and swabbing moves from the incision outward.
- •Moist wound bed, dry peri-wound skin
- •Hydrogel adds moisture; alginate and foam absorb it
- •Wet-to-dry is debridement, not routine care for granulating wounds
- •Recompress bulb drains after emptying to restore suction
Prevention, the Braden scale and surgical wound emergencies
Prevention questions centre on risk assessment and repositioning. The Braden scale scores sensory perception, moisture, activity, mobility, nutrition, and friction and shear, with lower total scores indicating higher risk. Reposition at-risk clients on a schedule, use pressure-redistributing surfaces, keep the head of bed at or below thirty degrees when tolerated to limit shear, lift rather than drag during transfers, and keep skin clean and dry with barrier products for incontinence.
Nutrition is a recurring correct answer that candidates undervalue. Adequate protein, calories, vitamin C and zinc are essential for collagen synthesis and wound healing, and albumin or prealbumin levels help identify clients at risk. A poorly nourished client will not heal regardless of dressing choice.
Two surgical emergencies must be recognised instantly. Dehiscence is separation of wound layers, often heralded by a sudden give sensation and an increase in serosanguineous drainage. Evisceration is protrusion of viscera through the opening. The response is the same opening sequence: stay with the client, place them in low Fowler position with knees slightly flexed to reduce abdominal tension, cover the site with sterile gauze moistened with normal saline, keep the client nil by mouth, monitor for shock and notify the surgeon immediately. Never attempt to push organs back in and never use dry gauze.
- •Lower Braden score means higher pressure injury risk
- •Protein, vitamin C and zinc drive collagen formation
- •Head of bed at 30 degrees or less reduces shear
- •Evisceration: sterile moist saline gauze, low Fowler, knees bent, call surgeon