managing-wound-care

# Managing Wound Care

Guides wound assessment, classification, and treatment selection with documentation requirements.

## Why This Skill Exists

Surgical wound management is a significant clinical and financial burden. The CDC estimates that surgical site infections (SSIs) account for 20% of all healthcare-associated infections, affecting 2-5% of surgical patients. Chronic and complex wound management costs the US healthcare system over $25 billion annually. Accurate wound classification drives treatment selection, reimbursement coding, and quality reporting. CDC wound classification (Clean, Clean-Contaminated, Contaminated, Dirty) determines SSI surveillance requirements, while the ACS NSQIP tracks wound complications as a primary quality outcome.

Improper wound assessment leads to delayed recognition of infection, inappropriate dressing selection, prolonged healing, and preventable readmissions. Joint Commission standards require documentation of wound assessment at admission and with every dressing change. This skill standardizes wound assessment methodology, classification, treatment selection, and documentation to meet clinical and regulatory requirements.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the wound type (surgical incision, traumatic laceration, pressure injury, chronic ulcer)? **Default: surgical incision**
2. What procedure created the wound (if surgical) and on what date? **Default: [VERIFY]**
3. What was the CDC wound classification at the time of surgery? **Default: Class I (Clean)**
4. What is the current wound status (intact, dehisced, infected, granulating)? **Default: intact with staples/sutures**
5. Are there any patient factors affecting healing (diabetes, immunosuppression, malnutrition, smoking, steroids, radiation history)? **Default: none**
6. What is the current wound care regimen? **Default: dry sterile dressing**
7. Has the wound been cultured? If yes, what organisms? **Default: no**
8. Is there exposed hardware, mesh, or prosthetic material? **Default: no**

### Documents to Request

- Operative report (for wound classification and closure method)
- Wound care nursing assessments with measurements
- Wound photographs (if available)
- Culture and sensitivity results
- Current dressing and treatment orders
- Nutrition assessment (albumin, prealbumin, BMI)
- Vascular assessment (ABI, duplex) if lower extremity wound

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## Step 1: Wound Assessment and Classification

### CDC Surgical Wound Classification (assigned at time of operation)

| Class | Definition | SSI Rate |
|---|---|---|
| I — Clean | No entry into GI, GU, or respiratory tract; no inflammation; no break in aseptic technique | 1-3% |
| II — Clean-Contaminated | Controlled entry into GI, GU, or respiratory tract without unusual contamination | 5-8% |
| III — Contaminated | Open traumatic wound <4h, major break in sterile technique, gross GI spillage, entry into infected biliary or urinary tract | 10-15% |
| IV — Dirty/Infected | Old traumatic wound with devitalized tissue, existing infection, perforated viscus | 25-40% |

### Wound Bed Assessment (for open or healing wounds)

Document using the TIME framework:

| Component | Assessment | Example |
|---|---|---|
| **T** — Tissue | Viable (granulation, epithelial) vs. non-viable (slough, eschar, necrotic) | 60% granulation, 30% slough, 10% eschar |
| **I** — Infection/Inflammation | Signs of infection (erythema, warmth, purulence, odor, increasing pain) | 2 cm periwound erythema, no purulence |
| **M** — Moisture | Excessive exudate vs. desiccated wound bed | Moderate serous drainage |
| **E** — Edge | Advancing (healing) vs. undermined/non-advancing | Edges advancing, no undermining |

### Wound Measurements
- Length x Width x Depth in centimeters (measure greatest length in head-to-toe direction, greatest width perpendicular to length)
- Tunneling: depth and clock position (e.g., "2 cm tunnel at 3 o'clock")
- Undermining: depth and extent by clock position

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## Step 2: Wound Classification for Healing Trajectory

Categorize the wound by healing intention:

| Type | Description | Management Focus |
|---|---|---|
| **Primary intention** | Edges approximated with sutures, staples, or adhesive | Protect closure, monitor for SSI, remove closures per timeline |
| **Secondary intention** | Wound left open to granulate | Moist wound healing, debridement of non-viable tissue, packing |
| **Tertiary intention (delayed primary)** | Wound left open initially, closed after infection controlled | Pack open, culture, IV antibiotics, close at 3-5 days |

**Surgical incision staple/suture removal timelines** (adjust for patient factors):

| Location | Removal Timeline |
|---|---|
| Face | 3-5 days |
| Scalp | 7-10 days |
| Trunk/abdomen | 7-10 days |
| Extremity | 10-14 days |
| Over joints | 14 days |
| Retention sutures | 14-21 days |

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## Step 3: Dressing Selection by Wound Characteristics

Match dressing type to wound bed and drainage level:

| Wound Characteristic | Primary Dressing | Secondary Dressing | Change Frequency |
|---|---|---|---|
| Clean, sutured, minimal drainage | Non-adherent gauze or adhesive strip | Tape or transparent film | Remove at 24-48h per ERAS, then open to air |
| Moderate drainage, granulating | Foam dressing (polyurethane) | Tape border | Q 2-3 days |
| Heavy drainage | Calcium alginate or hydrofiber | Foam or gauze overlay | Daily to Q2 days |
| Slough/necrotic tissue | Hydrogel (autolytic debridement) | Gauze or foam | Q1-3 days |
| Dry eschar (stable) | Leave intact if heel, vascular assessment | Dry gauze | Monitor only |
| Tunneling/undermining | Alginate rope or hydrofiber ribbon | Cover dressing | Q1-2 days |
| Exposed tendon/bone | Negative pressure wound therapy (NPWT) | Sealed NPWT drape | Q48-72h per protocol |

**Negative Pressure Wound Therapy (NPWT) indications:**
- Deep surgical wounds healing by secondary intention
- Dehisced abdominal wounds
- Skin graft bolster
- Complex wounds with undermining and heavy drainage
- Settings: typically -125 mmHg continuous for acute wounds

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## Step 4: Infection Surveillance and Management

Monitor all surgical wounds for SSI using CDC NHSN definitions (see managing-surgical-site-infections skill for full protocol):

**Daily assessment checklist:**
- [ ] Periwound erythema (measure in cm from wound edge)
- [ ] Warmth compared to surrounding tissue
- [ ] Wound drainage character (serous, serosanguinous, purulent)
- [ ] Odor
- [ ] Pain trajectory (improving vs. worsening)
- [ ] Wound edge integrity (intact, separating, dehiscing)
- [ ] Systemic signs (fever, leukocytosis, tachycardia)

**When to obtain wound culture:**
- Purulent drainage
- Cellulitis progressing despite empiric antibiotics
- New systemic signs without other source
- Chronic wound failing to progress for >2 weeks
- Use tissue biopsy or Levine technique (rotate swab over 1 cm^2 of clean wound bed with sufficient pressure to express tissue fluid) — NOT a superficial swab of wound surface

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## Step 5: Nutrition Optimization and Healing Support

Wound healing requires adequate nutrition. Assess and optimize:

| Parameter | Target | Intervention |
|---|---|---|
| Albumin | ≥3.0 g/dL | High-protein supplements (1.25-1.5 g protein/kg/day) |
| Prealbumin | ≥15 mg/dL | Monitor Q weekly as acute marker |
| Caloric intake | 30-35 kcal/kg/day | Nutrition consultation |
| Vitamin C | Adequate | 500 mg BID supplementation for deficiency |
| Zinc | Adequate | 220 mg daily for deficiency |
| Glucose control | <180 mg/dL | Per ADA surgical patient guidelines |

Document nutritional assessment at wound care initiation and reassess weekly.

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the wound classified by CDC class, healing intention, and current status?
2. Does the dressing selection match the wound bed characteristics and drainage level?
3. Is the wound measurement documented with length, width, depth, tunneling, and undermining?
4. Are infection surveillance criteria being applied at each assessment?
5. Has nutritional status been assessed and optimization initiated?

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## Quality Audit

- [ ] CDC wound classification documented from operative report
- [ ] Wound measurements recorded in cm (L x W x D) with tunneling/undermining
- [ ] TIME framework assessment documented
- [ ] Healing intention documented (primary, secondary, tertiary)
- [ ] Dressing type matches wound characteristics
- [ ] Dressing change frequency ordered and documented
- [ ] Wound photograph obtained at baseline and with significant changes
- [ ] Infection surveillance documented at each assessment
- [ ] Culture obtained appropriately (tissue biopsy or Levine technique, not superficial swab)
- [ ] Nutritional assessment completed with albumin/prealbumin
- [ ] Staple/suture removal timeline documented
- [ ] NPWT settings documented if applicable (pressure, mode, sponge type)
- [ ] Patient education on wound care provided and documented
- [ ] Wound care plan communicated at transitions of care (discharge, transfer)

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## Guidelines

1. Remove surgical dressings at 24-48 hours per ERAS guidelines — prolonged occlusive dressings over clean, closed incisions do not reduce SSI and may delay recognition of wound problems.
2. Never culture a wound by superficial swab — this grows colonizing organisms, not pathogens. Use tissue biopsy or the Levine technique on a cleansed wound bed.
3. Moist wound healing is the standard of care for open wounds — dry gauze packing ("wet-to-dry") is considered outdated and causes tissue damage during removal.
4. Always measure wounds quantitatively (cm) at each assessment; subjective terms like "looks better" are insufficient.
5. Document wound photographs with a ruler and date stamp at baseline, weekly, and with any significant change.
6. For patients with diabetes, maintain glucose <180 mg/dL during the wound healing period — hyperglycemia impairs neutrophil function and collagen synthesis.
7. Smoking cessation is the single highest-impact modifiable factor for wound healing — document counseling and cessation status.
8. When transitioning wound care across settings (hospital to home, SNF, or home health), provide a detailed wound care plan including dressing type, change frequency, supply list, and criteria for urgent reassessment.