16. CCA Study Notes: Wound Healing, Complications, Drainage, and Observation

The Big Picture

A wound goes through several stages as the body repairs damaged tissue. Healing takes time, and different wounds heal in different ways.

Complications can interfere with healing. Some problems, such as heavy bleeding, shock, a wound opening, or abdominal organs coming through a wound, are emergencies.

When helping with wound care, you should report your observations to your supervisor and record them according to employer policy.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

Jump to:

Course Notes: Key Ideas You Need to Know

The Three Phases of Wound Healing

Wound healing takes place in three phases. Each phase has its own timing and changes.

1. Inflammatory Phase

The inflammatory phase lasts 3 days.

During this phase:

• Bleeding stops.
• A scab forms over the wound and helps prevent microbes from entering.
• Blood supply to the wound increases.
• The blood brings nutrients and substances needed for healing.

Because blood supply increases, the wound area may show signs of inflammation. These include redness, swelling, heat or warmth, pain, and some loss of function.

2. Proliferative Phase

The proliferative phase lasts from day 3 to day 21.

Proliferate means to multiply rapidly. During this phase, tissue cells multiply to repair the wound.

3. Maturation Phase

The maturation phase lasts from day 21 to 1 or 2 years.

During this phase, scar tissue gains strength. At first, the scar may look red and raised. Over time, it becomes thinner and paler than the surrounding skin.

Three Types of Wound Healing

Wounds can heal by primary intention, secondary intention, or tertiary intention.

Primary Intention

Primary intention is also called first intention or primary closure.

With primary intention, the wound edges are held together using:

• sutures, also called stitches
• staples
• clips
• adhesive strips

Secondary Intention

Secondary intention is also called second intention.

It is used with contaminated and infected wounds. The wound is cleaned, dead tissue is removed, and the wound edges are not brought together.

Instead, the wound remains open or gaping while it heals naturally.

Secondary-intention healing:

• takes longer
• forms a larger scar
• carries a high risk of infection

Tertiary Intention

Tertiary intention is also called third intention or delayed intention.

The wound is left open for a period before it is closed. This method combines features of secondary and primary intention.

Infection and poor circulation are common reasons for using tertiary intention.

Factors That Affect Wound Healing

Many factors can affect healing and increase the risk of complications.

These include:

• the client’s age
• general health
• nutritional status
• lifestyle
• the type of wound
• the location of the wound

Clients with diabetes have an increased risk of infection.

Healing may also be slower in a client who:

• is very old
• has circulatory disease or diabetes
• smokes
• has a poor diet

Certain medications can affect healing. Warfarin and heparin will prolong bleeding and may delay healing.

What Supports Wound Healing

Wound healing depends on good blood circulation to the wound and good nutrition.

Nutrition should include:

• fluids, which are needed for tissue hydration
• protein
• vitamin C, which is needed for tissue growth and repair

The wound must also be protected from infection.

A doctor may prescribe antibiotics to prevent an infection from developing.

Hemorrhage

Hemorrhage is excessive blood loss within a short period.

If the bleeding does not stop, death results.

Hemorrhage can be internal or external.

Internal Hemorrhage

Internal hemorrhage occurs when bleeding takes place inside tissues or body cavities. You cannot see the bleeding directly.

Internal hemorrhage leads to a hematoma, which is a collection of blood under the skin and tissues.

A hematoma may cause the area to look:

• swollen
• reddish-blue
• grey

Signs of internal hemorrhage include:

• shock
• vomiting blood
• coughing up blood
• loss of consciousness

External Hemorrhage

External bleeding is visible.

You may see:

• bloody drainage
• dressings soaked with blood

Shock can occur with external hemorrhage as well as internal hemorrhage.

Shock

Shock occurs when the organs and tissues do not receive enough blood supply.

Signs and symptoms include:

• low or falling blood pressure
• a rapid, weak pulse
• rapid respirations
• cold, moist skin
• pale or greyish skin
• restlessness
• thirst

Confusion and loss of consciousness eventually occur.

What to Do for Hemorrhage and Shock

Hemorrhage and shock are emergencies.

Notify your supervisor immediately and assist as requested.

When you have contact with blood:

• follow Standard Practices
• gloves should always be worn
• gowns, masks, and eye protection are necessary when blood splashes or splatters are likely

Wound Infection

Wound contamination can happen during or after an injury or surgery.

Trauma often produces contaminated wounds. Surgical wounds can also become contaminated during or after surgery.

An infected wound contains a large amount of bacteria and shows signs of infection. It is also called a dirty wound.

An infected wound has drainage and is painful and tender to the touch.

The client may also have a fever.

Dehiscence

Dehiscence is the sudden separation of wound layers along a surgical suture line.

The separation may involve only the skin or may affect deeper tissues, as is usually seen in abdominal wounds.

Stress can be placed on the wound by:

• coughing
• vomiting
• abdominal distension

The client often describes a sensation of the wound popping open.

Evisceration

Evisceration occurs when a wound separates and abdominal organs protrude ⓘ through the opening.

The causes are the same as those of dehiscence.

Dehiscence and Evisceration Are Surgical Emergencies

Tell your supervisor at once if you see dehiscence or evisceration.

A nurse will cover the wound with a large sterile dressing saturated ⓘ with sterile saline. The client will need emergency medical care.

Observing a Wound

Physicians and nurses routinely observe wounds and their drainage for healing and complications.

A support worker also makes certain observations when helping with wound care.

CCA action: You should report your wound observations to your supervisor.

Record your observations according to employer policy.

What to Observe

Wound Location

Check:

• where the wound is located
• whether more than one wound is present

A client may have several wounds following surgery or trauma.

Wound Appearance

Observe:

• whether the wound is red or swollen
• whether the area around it feels warm
• whether sutures, staples, or clips are intact or broken
• whether wound edges are closed or separated
• whether the wound has broken open
• the size of the wound

Drainage

Observe:

• whether drainage is present
• how much drainage is present
• whether it is clear
• whether it is bloody
• whether it is watery and blood-tinged
• whether it is thick and green, yellow, or brown

Odour

Notice whether the wound or its drainage has an odour.

Surrounding Skin and Tissues

Observe:

• whether the surrounding skin is intact
• the colour of the surrounding skin
• whether surrounding tissues are swollen
• redness
• swelling
• purulence
• other observations that need to be reported and documented

Wounds Hidden Under Casts or Dressings

In an acute-care setting ⓘ, a client may have a wound that you cannot see because it is inside a cast or under a large, bulky dressing.

You are still responsible for observing the wound area and reporting your observations.

If blood seeps through a newly applied cast or dressing, you must report it to the nurse.

You may be instructed to mark the outline of the blood seepage through the cast or dressing. If so, report any further drainage.

The client will also be monitored for signs of blood loss, including:

• low blood pressure
• a high pulse rate

Wound Drainage

During an injury and the inflammatory phase of healing, fluid and cells escape from tissues.

The amount of drainage can be small or large. It depends on:

• the size of the wound
• the location of the wound
• whether bleeding is present
• whether infection is present

The nurse is responsible for changing dressings.

The CCA needs to observe wound drainage and report any type of drainage to the nurse.

Depending on the employing agency and the CCA’s provincial scope of practice, the CCA may also be shown how to:

• measure the amount of drainage
• document the amount of drainage

Four Major Types of Wound Drainage

Serous Drainage

Serous drainage is clear, watery fluid.

The fluid found in a blister is serous fluid. Serum ⓘ does not contain blood cells or platelets.

Sanguineous Drainage

Sanguineous drainage is bloody drainage.

Both the amount and colour are important.

Hemorrhage is suspected when large amounts are present.

• Bright red drainage means fresh bleeding.
• Darker drainage means the bleeding is older.

Serosanguineous Drainage

Serosanguineous drainage is thin and watery with a blood tinge.

Think of it as drainage that has both a watery and bloody appearance.

Purulent Drainage

Purulent drainage is thick drainage that is:

• green
• yellow
• brown

It may also have a foul odour.

Purulent drainage may indicate an infection.

Why Drainage Needs to Leave the Wound

Drainage must leave the wound for healing to occur.

When drainage becomes trapped inside the wound:

• the tissues underneath swell
• the skin surface may heal while deeper tissues remain open
• infection and other complications can occur

When a large amount of drainage is expected, the physician will insert a drain.

Open and Closed Drainage Systems

Penrose Drain

A Penrose drain is a rubber tube that allows drainage to flow onto a dressing.

It is an open drain. Because it is open, it can act as a portal of entry for microbes.

Closed Drainage Systems

Closed drainage systems prevent microbes from entering the wound.

A drain is placed in the wound and attached to suction.

Examples include:

• Hemovac
• Jackson-Pratt

Other drainage systems may be used depending on the wound’s type, size, and location.

How Nurses Measure Drainage

A nurse can measure drainage in two ways.

By Looking at Dressings

The nurse notes the number and size of dressings containing drainage and describes the amount and type.

The nurse considers:

• whether the dressing is saturated
• whether drainage covers only part of the dressing
• which part contains drainage
• whether drainage has passed through some or all layers

By Measuring Collected Drainage

When a closed drainage system is used, the nurse measures the drainage in the collecting receptacle ⓘ.