managing-wound-care

name	managing-wound-care
language	en
description	Guides wound assessment, classification, and treatment selection with documentation requirements. Use when managing surgical wounds, classifying wound types, or selecting wound care protocols.
tags	["management","surgery","surgical","treatment"]
metadata	{"author":"casemark","practice_areas":["General Surgery","Surgical Subspecialties"],"document_types":["Management Report"],"skill_modes":["Management","Coordination"]}

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.