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 a an urgent/emergent wound need (e.g. 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, and home health nursing.

Types of wounds

  • Abscess
  • Arterial wound
  • Calciphylaxis
  • Diabetic foot wound
  • Fistula
  • Fungating lesion

 

  • Ischemic ulcers / gangrene
  • Pressure Injury
  • Pyoderma gangrenosum
  • Skin tear
  • Vasculitis
  • Venous leg wound

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

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 patient is followed by podiatry, order "Inpatient Consult to Podiatry"
    • Abscess: if chronic due to IBD, consult Colorectal Surgery
    • Surgical wounds: if patient has a VUMC surgeon, consult the respective surgical service
  • Order "Inpatient Consult to Adult Ostomy / Fistula / Tube" for ostomy, trach, PEG, associated needs or complications (etc.)

Pressure Injury Staging

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 look like blood blister non-blanching erythema abrasion, blister, or shallow crater variable Variable. If eschar, must be removed to stage, or is unstageable
Depth epidermis intact non-blanching erythema epidermis intact SQ tissue to, but not through, fascia full-thickness w/ destruction, necrosis, or damage to muscle, bone, supporting structures

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 patient 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
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