Wound Assessment, Care, and Dressing Techniques

Wound care is a fundamental nursing skill tested extensively in the DOH (UAE) examination. The UAE has a high burden of diabetic foot ulcers, pressure injuries in elderly patients, and traumatic wounds from road traffic accidents (a significant public health issue in the Emirates). Nurses must demonstrate competence in wound assessment using evidence-based classification systems, selecting appropriate dressing products based on wound characteristics, and performing dressing changes using aseptic technique. Understanding wound healing phases, factors affecting healing, and infection prevention measures is essential for both safe clinical practice and examination success.

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🟢 Lite — Quick Review (1h–1d)

Rapid summary for last-minute revision before your exam.

Wound Healing Phases — Memorise in Order:

1. Haemostasis (immediate) — clot formation, vasoconstriction
2. Inflammatory phase (Days 1–3) — redness, warmth, swelling; WBCs clear debris
3. Proliferative phase (Days 3–21) — granulation tissue, angiogenesis, collagen deposition
4. Remodelling/Maturation (3 weeks–2 years) — collagen fibres reorganise; scar matures

Signs of Wound Infection (Acronym: RIPE):

• Redness (erythema extending >1 cm from wound edge)
• Inflammation (persistent warmth and swelling)
• Pain (increasing or new pain)
• Exudate (purulent discharge; increased volume or change in character)

Dressing Selection Quick Guide:

Wound Type	Dressing
Dry, superficial	Gauze (passive)
Moderate exudate	Alginate, foam
Heavy exudate	Hydrocolloid, high-absorbency
Necrotic (eschar)	Hydrogel, enzymatic debridement
Infected	Antimicrobial (silver, honey dressings)

⚡ Exam Tip: Normal saline (0.9% NaCl) is the preferred wound irrigation solution in UAE practice. Antiseptic solutions (povidone-iodine, chlorhexidine) can be cytotoxic to granulation tissue — use only on initially contaminated wounds and rinse thoroughly with saline afterwards.

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🟡 Standard — Regular Study (2d–2mo)

Standard content for students with a few days to months.

1. Wound Classification

Wounds are classified by several characteristics:

A. By Cause (ETIOLOGY)

• Surgical (elective) — clean, sharp incision; edges approximated; heal by primary intention
• Traumatic — contaminated potential; road traffic accidents are a leading cause in UAE
• Pressure injury — tissue necrosis from prolonged pressure (>capillary pressure of 32 mmHg)
• Diabetic foot ulcer — neuropathic, ischaemic, or neuro-ischaemic; major cause of amputation in UAE diabetic population
• Burns — thermal, chemical, electrical; UAE has significant burns incidence in expatriate workers in industrial settings

B. By Depth

• Superficial (epidermis only) — heals quickly, minimal scarring
• Partial-thickness (dermis) — deeper partial-thickness burns
• Full-thickness (subcutaneous tissue, muscle, bone) — requires longer healing; often needs surgical intervention

C. By Healing Intention

• Primary intention — surgical wound, edges approximated; minimal tissue loss; heal quickly with minimal scar
• Secondary intention — wound left open to heal from base; tissue loss; fills with granulation tissue; longer healing; larger scar (e.g., pressure ulcers, infected traumatic wounds)
• Tertiary/delayed primary intention — wound initially left open (dirty/contaminated) then closed surgically after 3–5 days

D. By Contamination Status

• Clean — no infection, no break in technique
• Clean-contaminated — controlled break in technique (e.g., surgical wound)
• Contaminated — traumatic wound, fresh surgical wound with major break
• Dirty/infected — established infection; organisms present

2. Pressure Injury Staging (NPUAP/EPUAP/PPPIA — Internationally Recognised)

Pressure injuries are a major quality indicator in UAE healthcare facilities and a key test area:

Stage	Description
Stage 1	Non-blanchable erythema; skin intact; localised red area, typically over bony prominence
Stage 2	Partial-thickness skin loss; shallow open ulcer; red-pink wound bed; no slough
Stage 3	Full-thickness skin loss; subcutaneous fat visible; granulation tissue; slough may be present
Stage 4	Full-thickness tissue loss; muscle/bone/tendon visible; slough or eschar may be present
Unstageable	Full-thickness tissue loss; base of wound covered by slough (yellow, tan, grey) or eschar (brown, black) — cannot stage until debrided
Deep Tissue Pressure Injury	Intact skin with non-blanchable deep red, maroon, or purple discolouration; localised area of persistent non-blanching deep discolouration

Risk Factors in UAE patients: Immobility (post-operative, elderly), diabetes (neuropathy and microvascular disease), stroke, spinal cord injury, advanced age, malnutrition, incontinence.

Braden Scale — Used to predict pressure injury risk. Score 6–23 (lower = higher risk):

• Sensory perception, moisture, activity, mobility, nutrition, friction/shear
• Score ≤12 = high risk; initiate prevention protocol immediately

3. Aseptic Technique and Dressing Procedure

Key principle: Aseptic technique prevents wound contamination by microorganisms. It is used for all open wounds and any procedure that breaches skin or mucous membranes.

Setting up a sterile field:

• Open the outer packaging away from the sterile field (do not lean over sterile area)
• Use the inner surface of the sterile package as the sterile field
• Place items on sterile field without contamination
• Anything that falls off the sterile field is considered contaminated

Wound irrigation:

• Use sterile syringe (30–50 mL) and catheter tip
• Irrigate with sterile normal saline under pressure (squeeze bottle or syringe without needle at 4–15 PSI)
• Irrigate until all visible debris and exudate are removed
• Use gauze to wipe from clean area outward

Applying a dressing:

1. Explain procedure to patient; obtain consent
2. Perform hand hygiene; don non-sterile gloves
3. Remove old dressing (note exudate colour, volume, odour — document)
4. Don sterile gloves
5. Clean wound with saline using irrigation technique
6. Pat dry surrounding skin (not the wound bed itself)
7. Apply appropriate dressing (size should cover wound without overlapping healthy skin)
8. Secure with tape or bandage
9. Position patient comfortably
10. Document: wound appearance, dimensions (length × width × depth using sterile probe), exudate, dressing applied

Common Mistake: Using cotton balls to clean wounds — cotton fibres can be left behind in the wound. Use gauze only.

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🔴 Extended — Deep Study (3mo+)

Comprehensive coverage for students on a longer study timeline.

4. Wound Exudate (Drainage) — What Each Type Indicates

Type	Description	Indicates
Serous	Clear, pale yellow, thin	Normal in early healing; inflammatory
Sanguineous	Bloody, red	Acute trauma; deep tissue injury; do NOT confuse with haemarthrosis
Serosanguineous	Pink/red, thin	Mixed; normal in early proliferative phase
Purulent	Thick, yellow/green/brown, malodorous	Infection — culture and sensitivities required

Foul odour is a strong indicator of anaerobic infection — notify physician immediately.

5. Diabetic Foot Ulcers — A UAE Priority

Diabetes mellitus affects approximately 17% of the adult UAE population, making diabetic foot care a critical nursing competency. The IWGDF (International Working Group on the Diabetic Foot) classification system is used in UAE facilities:

PEDIS Classification:

• Perfusion (foot ischaemia assessment)
• Extent (ulcer size)
• Depth (tissue loss)
• Infection
• Sensation (neuropathy assessment using monofilament test)

The Wagner Classification:

• Grade 0: No ulcer; pre-ulcerative lesion
• Grade 1: Superficial ulcer
• Grade 2: Deeper ulcer, involving tendon/bone
• Grade 3: Deep ulcer with abscess/osteomyelitis
• Grade 4: Forefoot gangrene
• Grade 5: Whole foot gangrene

Nursing Responsibilities in Diabetic Foot Care:

• Inspect feet daily (use mirror if patient cannot see plantar surface)
• Never walk barefoot (even at home — stepping on something can cause injury)
• Wash and dry feet daily, especially between toes
• Apply moisturiser to feet but NOT between toes
• Cut toenails straight across (or podiatry referral)
• Report any redness, blister, cut, or non-healing wound immediately
• Offloading (reducing pressure on ulcer site) is critical — total contact casts or felted foam dressings

6. Burns Classification and Initial Management

Burns are a significant injury type in the UAE due to industrial accidents, cooking fires, and scalding injuries.

Classification by Depth (Parkland Formula area):

• Superficial (1st degree): Erythema, dry, painful; only epidermis; heals in 3–7 days; no scarring
• Superficial partial-thickness (2nd degree shallow): Blisters, moist, very painful; heals in 10–14 days; minimal scarring
• Deep partial-thickness (2nd degree deep): Blisters, mottled, less painful (nerve damage); heals in 3–4 weeks; scarring
• Full-thickness (3rd degree): Leathery, charred, painless (nerve destruction); requires grafting

Rule of Nines (for adults):

• Head and neck = 9%
• Each upper limb = 9%
• Each lower limb = 18% (anterior 9%, posterior 9%)
• Anterior trunk = 18%
• Posterior trunk = 18%
• Perineum/genitals = 1%

Parkland Formula (for fluid resuscitation in burns): 4 mL × Body weight (kg) × %TBSA burned = Total fluid for first 24 hours

• Give 50% in first 8 hours (from time of burn), 50% in next 16 hours
• Use Ringer’s Lactate (Hartmann’s solution) — NOT plain saline

Initial Burn Management (ABCDE approach):

• Airway: With C-spine protection (smoke inhalation risk)
• Breathing: High-flow oxygen; assess for carbon monoxide poisoning
• Circulation: IV access; fluid resuscitation
• Disability: AVPU; assess for head injury
• Exposure: Remove jewellery and burned clothing; assess %TBSA

Exam Watch: A question about a burns patient with singed nasal hairs and carbonaceous sputum should immediately trigger concern for inhalation injury and airway compromise — prepare for possible intubation early.

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