Wound Care cheat sheet

Wound care is a multi-disciplinary approach service that must involve all other pertinent subspecialty in order to heal and prevent recurrence of
the wounds (Ulcers).

Wound care consults are mostly; pressure ulcer, leg ulcer, or abdominal wounds.

Chronic wounds are defined as wounds, which have failed to proceed through an orderly and timely reparative process to produce anatomic
and functional integrity over a period of 3 months.

Pressure ulcer:

1) Stage 1; Non blanch able redness ( Erythema) over a pressure point with intact skin. No skin break down.
TX: Off loading protocol using pillows and Air mattress ( order, Turn – Q-Mattress) + Cushioning using Mepilex ( Foam wound dressing)

Free text nurse order: continue Off loading protocol using pillows and Air mattress ( order Turn – Q-Mattress) + Cushioning using Mepilex (
Foam wound dressing). Continue pressure ulcer prevention protocol. Continue reposition the patient on different sides every 2 hours using 30
degree technique.

2) Stage 2; Skin break down over a pressure point with red wound bed . No slough

-It is a partial thickness wound that include epidermis and dermis but not through the dermis layer.

Tx: The same off loading protocol and nurse free text order as above + Hydrogel or hydrocolloid or Mepilex ( foam dressing).

3) Stage 3; Full- thickness tissue loss with s/c fat visible but not through the s/c fascia.

Bone, tendon , or muscle is not exposed.

TX: The same off loading protocol and nurse free text order as above plus;

Excisional debridement of necrotic tissues if it is > 30 % of the size of the wound. If patient is not a surgical candidate you can always use
collagenase ointment for enzymatic debridement as your secondary choice, Or hydrogel/ hydrocolloid for autolytic debridement. You can also
use wound vac dressing on clean and viable wound base to promote granulation tissue. Wound vac setting at 125 mmhg continuous
treatment at low intensity.

4) Stage 4; Full thickness tissue loss with exposed bone, tendon, or muscle.
Slough or Eschar may be present on some parts of the wound bed. Undermining & tunneling often present.

TX: The same treatment as it was mentioned for stage 3.

5) Suspected Deep Tissue injury: A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage
of underlying soft tissue from pressure and/or shear.
It may be difficult to detect in dark skin patient. It may evolve and become covered by thin eschar in a very short time.

TX: Off loading protocol + Cushioning + monitoring for getting better or worse.

6) Unstageable pressure ulcer; Full –Thickness tissue loss in which the base of the ulcer is covered by slough ( yellow, tan, gray,
green, brown) and /or Eschar ( tan, brown, or black).
Tx: Excisional sharp debridement of Escher anywhere in the body. The only exception to the debridement roles is when Escher is dry stable (
Hard like a rock) on the heels. But once the eschar started to become soft and and showed sign of infection, debridement is indicated then.

Leg Ulcers;

70%-90% of leg ulcers are venous stasis ulcers. 10%-30% could be arterial ulcers, unusual ulcers

( vasculitis, Calciphylaxis, Pyoderma gangrenosun) or traumatic wounds (such as the one on the anterior tibia area,; infected hematoma).

-Obtain a culture swab after cleaning and irrigating the wound with normal saline.

-Recommend venous duplex to R/O DVT and venous mapping to R/O chronic venous insufficiency.
-Recommend Arterial duplex to R/O PAD and get to obtain the patient’s ABI ( ankle Brachial index),

-Recommend an X- Ray of the tibia and fibula to R/O bone involvements (osteomyelitis).

-Recommend Lesion biopsy to R/O skin cancer, vasculitis, Calciphylaxis, Pyoderma gangrenosun in case of chronic/none-healing ulcer for 3-6
months.

Tx. In case of positive DVT, wait for three days after the medical team treats the DVT then do compression therapy.

- Do local wound care according to the condition of the wound bed (Base characteristics)

-Excisional debridement of necrotic/ infected leg ulcer. If the patient is not a surgical candidate; order, collagenase ointment for
enzymatic debridement. That is to be applied to the ulcer daily

• -Excisional debridement is contraindication in case of Pyoderma gangrenosun because of a phenomena called Pathergy –
Paradoxical response to debridement (may get worse) particularly in proximity to the areas debrided.

-Do compression therapy ( such as Unna’s Boot + ACE bandage) in case of negative DVT, and ABI = >0.9- 1.3. Compression therapy
is not indicated for ABI < 0.8 unless under close supervision and with a very reliable and compliant patients.

-Apply silver dressing as an antimicrobial wound dressing before applying the Unna’s Boot. Change the Unna’s boot every 3-7 days
depending on the amount of the wound exudates.

- Write in the free text nurse order;

Keep the legs elevated above the heart level

Remind the patient about the calf muscle exercises (Press on the gas pedal, release the gas pedal) to help in the venous system
returned.

Recommend Vascular consults for all patients with chronic/ none- healing leg ulcers, Venous stasis ulcers, arterial ulcers ( ABI< 0.8 –
0.5 ) for possible revascularization.

Recommend Podiatry consults for diabetic foot ulcers.

Abdominal Wounds;

Type of Abdominal Wounds:

• Infected surgical wound; fascia is intact. Apply wound vac, and IV antibiotic as per the culture sensitivity

• Dehisced Wound; fascia is not intact. Call the attending physician to notify him that the Fascia is not intact.

• Eviscerated Wound; Abdominal content is outside the abdominal wound edges. Cover the exposed bowel with moist gauze or stile
towel and send the patient back to the OR as soon as possible.

TX; F/U wound culture taken during examination; Antibiotic as per ID recommendations

Excisional sharp debridement of necrotic/ infected wound, then apply wound vac the following day.

General recommendations for patients who have wounds/Ulcers;

• - Control bacterial burden of wound

• Monitor for signs of infection.

• Debride all necrotic tissue.

• No topical antibiotics due to risk of developing resistant organisms.

 • Topical antimicrobial dressing for infected wounds/ulcers ; eg Silver dressing; ( Acticoat, Silver alginate, Aquacel AG) Iodosorb gel (
Cadexomer iodine ). Methylene blue(Hydrofera Blue)

• Use systemic antibiotic only in presence of spreading cellulites, sepsis , or osteomyelitis

• Provide moist wound environment and control exudates with Alginate, Foams, moist plain packing.

• Prevent further injury; relief pressure by changing body position Q2 hrs. Using; Low air loss mattress

• Support repair process;

• Protein and calories( protein 1.25- 1.5 g/kg/d: calories 30-35 calories/kg/d)

• Vitamin &mineral supplement e.g; 500 mg of Vit. C, MVI 1 tab daily, and 220 mg zinc sulphate daily for 2 weeks.

• Avoid exposure to cold

Wound care nurse orders:

-Order; Dressing changes to be done by the nursing staff daily and as needed; example sacral ulcer

Clean and irrigate sacral ulcer with normal saline.

Tap it lightly to dry.

Apply 0.3 cm of collagenase ointment on an oil emulsion and then apply it to sacral ulcer.

Cover it with dry gauge.

Then seal the area with bordered gauze

Continue off-loading protocol using pillows and air mattress ( supreme air mattress to patient who can move a little bit. Turn Q mattress to
patient who do not move at all)

Continue pressure ulcer prevention protocol.

Continue repositioning the patient on either side Q 2 hours using the 30 degree technique.

-For patients who have wound vac ; Maintain wound vac at 125 mmhg continuous at low intensity.

Please notify the surgical resident on call in case of any wound vac malfunction.

In case of malfunction more than 2 hours please remove the wound vac dressing and apply wet- to dry daily dressing changes.

-Order; Albumin and peralbumin

- Order; 500 mg of Vit. C, MVI 1 tab daily, and 220 mg zinc sulphate daily for 2 weeks.

LOCAL WOUND MANAGEMENT PRINCIPLES

Regardless of the specific wound type, general local wound management principles exist for a wide variety of chronic wounds.4 The TIME

acronym, promoted by the Wound Healing Society,

The letter “T” refers to tissue, denitrifying specific tissue deficits as well as the presence of devitalized or necrotic tissue.

The letter “I” characterizes inflammation or infection within and surrounding the wound site.
The letter “M” reflects the state of moisture balance, ranging from maceration to desiccation.

The letter “E” describes the quality of the wound edge, often heaped up, nonadvancing, and hyperkeratotic in the chronic wound setting, while

also describing the extent of reepithelialization.15