Skip to content

Wounds − Adapted from Dr. Duggan’s Geriatrics Guide

  • To do when admitting a patient with wounds:

    • Document ALL wounds that are present on admission. This affects reimbursement

  • Use the Haiku app on your cell phone to document images of wounds in chart

  • Wound Service hours are Monday through Friday, 6 AM - 2 PM

    • If there is an urgent/emergent wound need (i.e. needs surgical eval or management), consult the appropriate surgical service

    • While awaiting consultation, initiate topical wound care orders (detailed below)

  • Consider contributing factors: nutritional, pressure-offloading equipment, wound supplies, PT/OT, home health nursing

Types of wounds

  • Arterial wound - Calciphylaxis

  • Venous leg wound - Fistula

  • Diabetic foot wound - Abscess

  • Vasculitis - Skin tear

  • Pyoderma gangrenosum - Pressure injury

  • Fungating lesion - Ischemic ulcers / gangrene

Vascular Wound Etiologies

  • Arterial: located on distal ends of digits, shallow, well-defined borders, pale/necrotic wound bed, minimal exudate due to poor blood flow, cramping pain or a constant deep ache

  • Diabetic: plantar surface of foot, callused wound margins; usually painless due to neuropathy

  • Venous: located on medial malleolus or gravity dependent areas, irregular edges, ruddy red with yellow slough and copious exudate

Pressure Injury Staging

stages of pressure sores

Feature Deep Tissue Injury Stage 1 Stage 2 Stage 3 Stage 4
Skin Consistency Boggy Boggy Variable N/A N/A
Skin color/nature of lesion Non-blanching purple or maroon, may appear as blood-filled blister Non-blanching erythema Abrasion, blister, or shallow crater Variable

Variable.

If eschar, must be removed in order to stage, or is unstageable
Depth Epidermis intact Epidermis intact Through surface of epidermis and outer dermis SQ tissue to, but not through, fascia Full-thickness loss w/ destruction, necrosis, or damage to muscle, bone, supporting structures

Non-Acute Wound Consult Guidelines

  • Order “Inpatient Consult to Adult Wound" for these wound types: diabetic foot wounds*, venous, arterial, pressure injuries (consult required for DTI, stage 3, 4, and unstageable), IV infiltrate, skin tears, moisture-associated dermatitis, calciphylaxis, vasculitis, pyoderma gangrenosum, fungating lesion, abscess*, surgical wounds*, or wound VAC

  • *Diabetic foot wounds: if pt being followed by podiatry, order "Inpatient Consult to Podiatry"

  • *Abscess: if chronic due to IBD, consult colorectal surgery

  • *Surgical wounds: if pt has VUMC surgeon, consult the respective surgical service

  • Order "Inpatient Consult to Adult Ostomy / Fistula / Tube" for ostomy, trach, PEG, associated needs or complications (etc)

Acute Wound Consult Guidelines

  • Abscess, hematoma, or osteomyelitis with overlying wound – whom to consult for drainage/debridement:
    • Face – Face
    • Chest/Sternum – CT surgery
    • Breast – General surgery
    • Spine – Spine
    • Arm (hand to elbow) – Hand
    • Lower leg (foot to knee) – Ortho
    • Labial – OB/GYN
    • Scrotal – Urology
    • Buttock, thigh (knee to hip), arm (elbow to shoulder) – EGS consult
    • Perirectal/Rectal acute abscess – EGS; (chronic due to IBD – Colorectal Surgery)
  • Necrotizing Fasciitis – whom to consult for URGENT/EMERGENT surgical eval:
    • Genitalia – Urology
    • Buttocks, perineum, abdomen – EGS
    • Upper extremity (shoulder to hand) – Hand
    • Lower extremity (hip to toes) – Ortho

Wound Care (order while awaiting consultant recs)

  • Superficial wounds
    • Stage 1 or 2 pressure injuries, moisture-associated skin damage, or skin tears
      • Order “Adult Skin Care Guidelines” and use the order set to guide you
  • Shallow Stage 3 pressure injuries (i.e., <1cm deep) or diabetic foot ulcers
    • Order “Wound Care”: Frequency 2x weekly and prn; Cleanse with NS; protect periwound with Mepilex foam (type in comments)

  • Painful superficial wounds with no infection (i.e. vasculitis, PG, calciphylaxis)

    • Order “Wound Care”: Frequency 2 times daily; Cleanse with NS; Apply Vaseline; Protect periwound with Xeroform and dry gauze (type in comments)
      • If wound is on the hand, arm, foot, or lower leg consider wrapping in Kerlix
      • If wound is on the trunk (i.e., abdomen or buttocks), consider covering with an ABD pad and secure with medipore tape

  • Infected superficial wounds

    • Odor alone does NOT indicate infection; wounds with necrotic tissue may have odor
    • Order “Wound Care”: Frequency 2 times daily; Cleanse with NS, Apply Silvadene; Protect periwound with Xeroform and dry gauze (type in comments)
      • If wound is on hand, arm, foot, or lower leg consider wrapping in a Kerlix
      • If wound is on the trunk (i.e., abdomen or buttocks), consider covering with an ABD pad and secure with medipore tape

  • Medication order required: Silvadene q12h; in Admin Inst put “per wound care orders”

  • Deep wounds (i.e., stage 3, 4, or deep diabetic foot wound (all >1cm deep))

    • Order “Wound Care”: Frequency 2 times daily; Cleanse with NS, pack with Dakin’s 0.025% (1/20 strength) soaked continuous Kerlix roll; Protect periwound with ABD pad & medipore tape (type in comments)
    • If wound care is painful, consider changing to daily dressing changes
    • Medication order required: Dakin’s 0.025% solution q12h; in Admin Inst put “per wound care orders”

  • Deep tissue injury

    • Medication order required: Venelex (balsam peru-castor oil) ointment q4h; in admin instructions put location to apply ointment and put “no dressing”

  • Fungating mass

    • Order “Wound Care”: Frequency 2 times daily; Cleanse with baby shampoo and water, NS, Metrogel (type in comments); Protect with Xeroform, ABD pad, medipore tape
    • Medication order required: metrogel q12h; in Admin Inst put “per wound care orders”

  • Wound VAC

    • Vanderbilt surgeon – consult Vanderbilt provider to provide care
      • Ensure connected to VUMC wound VAC. Pt shouldn't use home unit while admitted
      • Order “nursing communication” to “Obtain wound VAC hospital machine and canister from service center to connect pt to hospital machine.”
      • Wound VAC should not be left without suction for more than 2 hours
      • Settings: 125 mmHg continuous

  • Non VUMC surgeon (i.e., gets wound care at outside hospital/wound care center)

    • Discontinue wound VAC as soon as possible
    • Remove all of the clear plastic drape just like you would remove tape
    • Remove all of the sponge just like you would remove gauze packing
    • Examine the wound to ensure no residual sponge by gently probing site
    • Rinse with saline, initiate care based wound type as above

  • Leg wrap

    • Ex: Unna's boot, ACE and 2, 3, or 4 layer compression
    • Remove by cutting the wrap off
    • Assess the wound and order dressing based on type of wound as above
    • Order ACE bandage wrapped toe-to-knee. Remove q12h to assess skin