Wound care and dressing changes: a guide for nursing students

Wound care is one of the most frequently performed nursing skills across every clinical setting — medical-surgical floors, intensive care units, long-term care, and home health alike. Where wound assessment focuses on gathering information about a wound, wound care is the procedural side: selecting the right dressing, preparing the wound bed, performing the dressing change safely, and knowing when to escalate. This guide covers wound healing phases, wound bed preparation, dressing selection logic, dressing change technique, and the NCLEX-tested concepts that nursing students most commonly get wrong.

Quick reference: what every dressing change involves

• Hand hygiene before and after the procedure
• PPE selection based on wound type and drainage characteristics
• Removal of old dressing with wound assessment documented
• Wound irrigation when indicated (normal saline preferred, 8–15 psi)
• Dressing selection matched to wound characteristics
• Periwound skin protection
• Accurate documentation

Wound healing phases

Understanding the phases of wound healing is foundational to every wound care decision. Dressing selection, irrigation technique, and assessment findings all depend on knowing what phase a wound is in and what changes are normal for that phase.

Table 1 — Wound healing phases

Phases overlap — a wound does not cleanly exit one phase before entering another. A wound showing both granulation tissue (proliferative) and localized erythema (inflammatory) is not unusual. Infection can stall the wound in the inflammatory phase indefinitely.

Wound bed preparation: the TIME framework

The TIME framework (Tissue, Infection/Inflammation, Moisture, Edge) is the evidence-based approach to wound bed preparation. It provides a systematic structure for identifying the barriers preventing a wound from healing and guides intervention selection.

T — Tissue (non-viable or deficient)

Non-viable tissue — slough (yellow/tan, soft) and eschar (black/brown, hard) — prevents healing by blocking granulation tissue formation and providing a medium for bacterial growth. Debridement removes non-viable tissue.

Types of debridement:

• Autolytic: The body’s own enzymes and moisture soften and liquefy necrotic tissue. Achieved by maintaining a moist wound environment with hydrocolloid or hydrogel dressings. Slow but atraumatic. Appropriate for lightly infected or clean wounds. Contraindicated in immunocompromised patients when faster debridement is needed.
• Enzymatic: Topical enzymatic agents (e.g., collagenase/Santyl) selectively break down collagen in necrotic tissue. Faster than autolytic. Requires a physician or advanced practice order.
• Mechanical: Physical removal via wet-to-dry dressings, wound irrigation, or hydrotherapy. Wet-to-dry is non-selective — it removes both necrotic and viable tissue and is largely falling out of favor in modern wound care.
• Surgical/sharp: Scalpel or scissors debridement by a physician, surgeon, or certified wound care specialist. Fastest method; appropriate for large necrotic wounds or urgent infection control.

Critical exception: dry, stable eschar on a heel should NOT be debrided unless vascular status has been assessed and confirmed to be adequate. The National Pressure Injury Advisory Panel (NPIAP) specifies that stable heel eschar may serve as a protective cover. Debridement without adequate arterial perfusion can convert a stable wound into an ulcer that will not heal.

I — Infection/Inflammation

Infection stalls wound healing and must be identified early. Two frameworks help differentiate wound bioburden levels:

• NERDS criteria (superficial infection): Non-healing wound, Exudate increase, Red and bleeding granulation tissue, Debris (slough/eschar), Smell/odor
• STONEES criteria (deep/spreading infection): Size increasing, Temperature elevated (periwound >3°F above surrounding skin), Os (probes to bone), New satellite lesions, Erythema/edema, Exudate increase, Smell

A wound meeting 3 or more NERDS criteria may benefit from topical antimicrobials. A wound meeting 3 or more STONEES criteria requires systemic treatment and physician notification.

M — Moisture imbalance

Moist wound healing — first demonstrated by Winter in 1962 — is the standard of care. Winter’s research showed that epithelial cell migration across a wound surface occurs 50% faster in a moist environment compared to a dry one. However, excess moisture (maceration) softens and breaks down periwound skin, creating new tissue damage.

Moisture balance means:

• Maintaining adequate moisture at the wound surface to support cell migration
• Absorbing excess exudate to protect periwound skin
• Preventing both desiccation (drying out) and maceration (over-wetting)

E — Edge (non-advancing or undermining)

Wound edges that are not advancing inward despite adequate wound bed preparation may indicate rolled edges (epibole), undermining, or tunneling that requires intervention. Undermining (destruction of tissue beneath intact wound edges) and tunneling (sinus tract extending from wound) both require measurement at each dressing change — measured in centimeters using the clock-face method.

Dressing selection

The foundational principle: match the dressing to the wound. Dressing selection is driven by wound depth, exudate level, presence of infection, wound bed tissue type, and periwound skin integrity. No single dressing suits all wounds at all stages.

Table 2 — Dressing type quick reference

The NCLEX differentiator students most commonly miss:

• Hydrogel donates moisture — it is used on dry, necrotic wounds that need rehydration
• Hydrocolloid maintains moisture — it seals in the wound’s own moisture for partial-thickness wounds with low exudate
• Alginate absorbs moisture — it is used on heavily exudating wounds; using it on a dry wound will desiccate the tissue

Memorize the direction of moisture transfer: hydrogel adds water in, alginate draws water out, hydrocolloid keeps water in.

Dressing change procedure

Sterile vs. clean technique

Sterile technique is required for:

• Surgical wounds in the early post-operative period (generally first 24–48 hours post-op)
• Immunocompromised patients
• Wounds with exposed deep structures (bone, tendon, hardware)
• Invasive procedures (wound debridement, packing deep wounds)
• Institutional policy may specify sterile technique for particular wound types

Clean technique is acceptable for:

• Chronic wounds (pressure injuries, venous leg ulcers, diabetic foot ulcers) in non-immunocompromised patients
• Home care settings (evidence supports clean technique for most chronic wound dressing changes)
• Long-term care settings per institutional protocol

When in doubt: check facility policy and the physician/wound care order.

Step-by-step dressing change

1. Gather supplies before entering the room. Interrupting a dressing change to retrieve supplies increases contamination risk. Know the current dressing type and what you are replacing it with before you start.

2. Perform hand hygiene. Two moments at minimum: before putting on gloves, and after removing the soiled dressing.

3. Explain the procedure to the patient. Administer prescribed analgesics 20–30 minutes before the procedure when significant pain is anticipated.

4. Position the patient for access to the wound with adequate lighting. Preserve dignity — expose only what is needed.

5. Don appropriate PPE. Non-sterile gloves for removal of the soiled dressing. Sterile gloves if sterile technique is required for application.

6. Remove the old dressing carefully. Moisten adherent dressings with normal saline to reduce trauma to fragile healing tissue. Fold the soiled surface inward.

7. Assess the wound before cleaning. Observe and document size, wound bed tissue type and percentage, exudate amount and character, odor, periwound skin condition, and any tunneling or undermining. This is the assessment moment — findings should be documented before the wound is cleaned.

8. Wound irrigation when indicated. Normal saline is the preferred irrigant for most wounds — it is isotonic and does not damage healing tissue. Povidone-iodine, hydrogen peroxide, and Dakin’s solution are cytotoxic to fibroblasts and epithelial cells; avoid routine use.

Correct irrigation technique: use a 35 mL syringe with a 19-gauge angiocatheter (needle removed). This combination delivers irrigation fluid at approximately 8–15 psi — sufficient to dislodge surface bacteria and debris without traumatizing tissue. Below 8 psi is ineffective. Above 15 psi causes tissue damage.

9. Apply the new dressing per wound care order and dressing type instructions. Ensure the dressing covers the entire wound with appropriate margins. Secure without causing pressure or impairing circulation.

10. Remove gloves and perform hand hygiene.

11. Document in the medical record (see documentation section below).

Wound assessment during dressing changes

Every dressing change is an assessment opportunity. The findings you document during a dressing change are the primary data source for tracking wound trajectory.

Table 3 — Wound assessment documentation during dressing changes

Wound culture collection

Culture swabs are indicated when wound infection is suspected but not yet confirmed — not routinely on every wound. Collect before starting antibiotics when possible.

Levine technique is the validated method for wound culture collection:

1. Irrigate the wound first with normal saline to remove surface contaminants and debris
2. Using a sterile culture swab, rotate the swab over a 1 cm² area of the wound bed with sufficient pressure to extract tissue fluid
3. Collect from viable-appearing wound tissue — avoid eschar, obvious pus, or wound edges
4. The Levine technique reliably samples deeper tissue fluid rather than surface contaminants

The older “Z-stroke” method (zigzagging swab across wound surface) is less reliable and no longer recommended. Avoid collecting from eschar: bacteria on the eschar surface are surface colonizers and do not reflect the organism causing deep tissue infection.

Table 4 — Wound culture technique and infected wound signs

Moisture balance and periwound skin protection

Periwound skin breakdown is a preventable complication of wound care. Chronic exudate contains proteolytic enzymes and inflammatory mediators that macerate and erode skin within the wound margin. Once the periwound skin breaks down, the wound effectively enlarges.

Prevention strategies:

• Skin barrier wipes or sprays (liquid skin protectant/film-forming barrier): applied to periwound skin before placing absorbent dressings. Creates a thin protective film that resists moisture and adhesive trauma.
• Zinc oxide-based barrier creams: appropriate for highly exudating wounds; applied to periwound skin (not wound bed). Do not use in the wound bed — zinc oxide impairs visualization and may interfere with healing.
• Dressing selection: an appropriately absorbent dressing that does not allow saturation and leakage is the primary defense against maceration. A dressing saturated with exudate for 12+ hours before change will macerate the surrounding skin regardless of barrier products applied.

Maceration appears as white, softened, wrinkled periwound skin. If present, increase dressing change frequency, reassess absorbency of current dressing type, and apply barrier protection.

Negative pressure wound therapy

Negative pressure wound therapy (NPWT), commonly known by the brand name VAC (vacuum-assisted closure), applies controlled sub-atmospheric pressure to a wound via foam or gauze interface covered by an airtight adhesive drape connected to a suction canister.

Mechanism: negative pressure removes exudate, reduces edema in periwound tissue, mechanically stimulates cell proliferation, and draws wound edges together (macro-deformation). The result is improved granulation tissue formation and faster wound contraction.

Indications:

• Large acute or chronic wounds not responding to conventional dressings
• Surgical wound dehiscence or post-surgical open wounds
• Wounds with significant tunneling or undermining
• Diabetic foot ulcers — see diabetes mellitus nursing for specifics on diabetic wound management
• Split-thickness skin graft bolsters

Contraindications:

• Malignant wounds (stimulation of cell proliferation is harmful)
• Exposed vessels, nerves, or organs
• Non-debrided necrotic wounds (negative pressure over undebrided eschar is ineffective and may cause harm)
• Untreated osteomyelitis
• Fistulas with unknown tracking

Nursing responsibilities with NPWT: monitor the seal for air leaks (audible alarm), track canister fill, assess periwound skin under the drape at each dressing change, maintain prescribed pressure settings, and document exudate character and volume in the canister.

Special wound types and relevant considerations

Surgical wounds

Post-surgical wound management begins in the PACU. Initial dressings are typically placed by the surgeon in the OR; the first dressing change is usually at 24–48 hours post-operatively unless ordered sooner. Sterile technique applies. Monitor for dehiscence (wound separation), evisceration (protrusion of abdominal organs through wound), and signs of surgical site infection. For a full overview of post-operative nursing priorities, see post-operative nursing.

Pressure injuries

Pressure injuries frequently require ongoing wound care management beyond assessment and staging. The wound care principles here — dressing selection, moisture balance, debridement — apply directly to pressure injury management. See pressure injury nursing for staging criteria and prevention protocols.

Infected wounds and isolation

When wound infection involves organisms requiring transmission-based precautions (MRSA, VRE, C. diff), wound care must be performed within the appropriate isolation framework. MDRO-infected wound drainage is a primary transmission vector. For a review of isolation category requirements and PPE selection, see infection control and isolation precautions.

Topical wound medications

Topical antimicrobials (silver sulfadiazine, mupirocin, bacitracin, metronidazole gel for odor) are ordered medications — they require a physician or advanced practice order. Documentation follows the same MAR documentation principles as any other medication. For general medication administration principles, see safe medication administration.

Documentation requirements

Accurate wound care documentation is a legal record of care and the basis for treatment decisions by all subsequent providers. Documentation after each dressing change must include:

• Date and time
• Wound location (anatomical description)
• Wound dimensions (L × W × D in cm)
• Wound bed: tissue type and percentages
• Exudate: amount, color, consistency
• Odor (present or absent; character if present)
• Periwound skin condition
• Tunneling/undermining if present (depth + clock-face location)
• Irrigant used and volume
• Dressing applied (type, size, any topical agents)
• Patient response/pain score
• Patient or family education provided
• Any changes in wound status and whether provider was notified

Wound care is a routine part of the head-to-toe assessment handoff — document findings before end of shift so the oncoming nurse has a baseline. Any significant deterioration (new purulence, expanding erythema, fever, new wound dehiscence) requires immediate provider notification and documentation of that notification.

NCLEX high-yield review

Wound healing phases — most tested questions:

• Which cells dominate the inflammatory phase? Neutrophils first, then macrophages.
• What signals a wound has stalled? Plateau in size, excessive exudate without progress, persistent eschar beyond 3 weeks without debridement.
• When does collagen remodeling begin? The maturation phase starts at 21 days and continues for up to 2 years.

Dressing selection — the three distinctions students miss:

• Hydrogel: dry wound — donates moisture
• Hydrocolloid: partial-thickness low-exudate wound — maintains moisture, promotes autolytic debridement
• Alginate: heavy-exudate or bleeding wound — absorbs moisture, hemostatic

Wound irrigation:

• Preferred irrigant: normal saline (0.9% NS)
• Correct pressure range: 8–15 psi
• Correct equipment: 35 mL syringe + 19-gauge angiocatheter (needle removed)
• What to avoid: povidone-iodine and hydrogen peroxide in wound beds (cytotoxic to fibroblasts)

Heel eschar:

• Do NOT debride stable, dry heel eschar without first confirming adequate vascular perfusion

Wound culture:

• Use Levine technique: rotate swab over 1 cm² of viable wound tissue with pressure
• Collect from viable tissue, not from eschar or pus

Sterile vs. clean technique:

• Sterile: new surgical wounds (first 24–48 hours), immunocompromised patients, exposed deep structures
• Clean: chronic wounds in non-immunocompromised patients

Key takeaways

Wound care competence comes down to a systematic approach and decision-making logic. Perform hand hygiene at every step transition. Match the dressing to the wound — the direction of moisture transfer (donate, maintain, or absorb) is the core principle. Irrigate with normal saline at 8–15 psi when indicated. Protect the periwound skin actively. Document findings before the wound is cleaned, so the baseline is captured. Know when to notify the provider: expanding erythema, fever, probing to bone, or any wound that has stopped progressing despite appropriate care.

For wound assessment technique (staging, measuring, and documenting wound characteristics), see wound assessment. For pressure injury-specific wound care, see pressure injury nursing. For diabetic foot ulcer management, see diabetes mellitus nursing.