Wound Care


Undermining: space under the skin.

Tunnel: Depth (hidden), use probe

Maceration: Softening from fluid excess

Desiccation: dry wound

Wound Prevention:

Risk for pressure ulcer:

  1. Q 2 hr turn

  2. 30/30 rule:

  3. Surface support: 

    1. foam, water, gel mattress

    2. Low air loss mattress for stage 3-4

    3. No donut

    4. For heel, floatation, wt distribution in calf

4. Moisturizing soap. Not too hot or too long in bath or shower

5. Moisture control / prevention

  1. Toileting program, scheduled

  2. Foley 

  3. Moisture barrier

  4. Topical antifungal for folds

  5. Wick or diaper

Wound assessment:


  • Measure

  • Exudate

  • Appearance

  • Suffering

  • Undermining

  • Re-evaluate

  • Edge 

      M: Measure – depth, length , width

           E : Exudate : include   Color and Consistency.

                                                  Quantity: Dry (no exudate), small, moderate,large (uncontrolled)

           A : Appearance :          Green – infection

                                                       Pale : epilthelialized

                                                       Yellow : slough

                                                       Red : granulation

                                                       Black : necrotic

           S : Suffering

           U : undermining

           R : Re-evaluate

           E : Edge – peri-wound assessment

Infection Clues : If not getting better. Better, then gets worse. Pain

Inability to heal : reinjury. Poor edema control. Exudate. Infection. Moisture balance


              Pain control:     

                             Topical- EMLA cream : lidocaine, prilocaine.

Morphine infused hydrogel (compounded) 8 mg MS in 8 mg hydrogel (or metronidazole gel can be used as carrier)

                                   No wet to dry , no tapes              

Pain Quantify: (PQRST)

                             P – Palliative factors. Provoking factors

                             Q – Quality

                             R – Region

    S- Severity

    T – time, temporal

              Odor control ( bacterial load)

o   Topical metronidazole

o   Activated charcoal dressing , traps and prevents odor locally

o   Silver impregnated dressing

o   Meta honey

o   Room deodorizers : kitty litter, coffee ground, oils. Remove old dressing from room


              Protect wound bed

                             Non adherent dressing

                             Manage incontinence

              Exudate control – heal better in some but not too much moisture.

o   Transparent dressing. Provides moisture if wound is not moist or dry. Waterproof. Maceration if left too long.

o   Hydrocolloid dressing. for light exudate. Occlusive, waterproof. Not good for odor, not good for undermining, not good for too much exudate.

o   Hydrogel. Limited absorption. For dry wound.

o   Allgenate. For moderate to heavy exudate. Forms a gel. Could desiccate if not enough exudate.

o   Foam dressing. For multiple varieties of wounds. May use for dry wounds. 


Types of wound

  • Pressure ulcers (decubs). Not only caused by pressure (causing ischemia and hypoxia in addition to pressure trauma) , but also by friction and shearing (breaking up layers of skin and separating them). Deep fat and muscle are compromised first but skin changes are seen earlier. 

  • Malignant

  • Venous stasis/edema

  • Arterial

  • Diabetic

Pressure ulcers:


  • I. Intact skin. epidermis only,  non-blanchable. 

  • II. Partial thickness skin loss. Through epidermis and into dermis, shallow open ulcer with red-pink base and no slough.

  • III. Full thickness skin loss. SubQ fat may be visible, slough may be present, may have tunneling.

  • IV. Full thickness skin loss with visible muscle, tendon or bone. Slough or eschar may be present in some parts of the wound bed and tunneling often exists.

  • Unstageable. Full thickness skin loss where base of the wound is covered by slough (yellow, tan, green, brown, gray) or eschar (tan, brown, black).


  • size (L, W,D)

  • tunneling

  • color

  • odor (? anerobic infection)

  • exudate 

  • necrotic tissure

  • surrounding area


  1. Debridement: 

    1. autolytic dressing. gentle, debriding. May take longer

    2. enzymes. Santyl (collagenase), or Papain (Accuzyme)

    3. mechanical.  hydrotherapy, pressure irrigation, magots, wet-to-dry (DON’T DO, painful)

    4. surgical. Makes chronic wounds into acute wounds to start physiologic healing

  2. Cleaning. 

    1. Antiseptics (Iodine base, peroxides, Dakin solution), may delay healing.

    2. Water

    3. NS

  3. Dressing

    1. Foams. Polyurethane pads, semi-occlusive, good for exudate, some pain relief.

    2. Alginates. autolytic, both hemostatic and bacteriostatic ( good for exudates, bleeding wounds, infected wounds). Made out of seaweed.

    3.  Hydrogel.  autolytic. either gel or solid, hydrates, good  for dry wounds and cooling.

    4.  Hydrocolloid.  Wafer or gelatin, decrease friction or shear. non-absorbant, not good for exudate.

    5.  Transparent films. 

    6. Gauze.

    7. Silver.  antimicrobial, can be placed on alginate.

  4. Infected wounds

    1. Topical anti-septic:  Dakin solution

    2. antimicrobials. anerobes (metronidazole powder, silver sulfadiazine).  Areobes ( neomycin, polymixin, bacitracin)

    3.  Deep infection/sepsis.  consider systemic antibiotics.

  5. Malodorous wounds

    1. Dressing.  alginate. Activated charcoal dressing , traps and prevents odor locally. Silver impregnated dressing, Meta honey

    2. ventilation

    3. Absorbers.  kitty litter, ground coffee, charcoal, candle flames. oils. Remove old dressing from room

    4. Alternative smells. vanilla, vinegar.

    5. Topical metronidazole

  6. Pain management

    1. narcotics before dressing changes

    2. can sometimes give topical morphine, methadone, dilaudid, lidocaine.

    3. Morphine infused hydrogel (compounded) 8 mg MS in 8 mg hydrogel (or metronidazole gel can be used as carrier).